Acute Cardiac Failure

Presentation

Dyspnoea, orthopnea, paroxysmal nocturnal dyspnoea, pink frothy sputum

History

Dyspnoea - onset, aggravating and relieving factors. Normal exercise tolerance.
Any changes to medications? Recent pneumonia or infections?
Does the patient have any risk factors for developing vascular disease - Hypertension, hypercholesterolaemia, obesity, diabetes, previous acute coronary event/stroke, smoker, lifestyle/occupation, family history of ischaemic heart disease?
PMHx - previous MI, COPD, pneumonia, valvular disease. Consider risk factors for adult respiratory distress syndrome that may present similarly - trauma, pneumonia, shock, post-op
Medications - cardiac or respiratory medications

Vital signs / observations

Tachypnoea
Tachycardia
Hypoxic

Examination

Distressed, pale, sweaty - leaning forward gasping for breath
pitting cold hands and feet, oedema in ankles and/or sacrum may suggest right heart failure
Signs of heart failure? - raised JVP, basal crepitations, 3rd heart sound
Wheeze, fine inspiratory basal crackles

Bedside tests

ECG - exclude arrhythmias and acute STEMI/NSTEMI. ECG may show previous MI, LV hypertrophy or strain

Laboratory investigations

FBC, U&E, CRP, BNP, glucose, lactate, cardiac markers

Look for signs of anaemia, infection or MI in blood results

Consider ABG if patient acutely unwell - may show hypoxia

Radiological investigations

CXR - cardiomegaly, signs of pulmonary oedema. shadowing (usually bilateral), small fusions at costophrenic angles and fluid in the lung fissures and Kerley B lines (linear opacities)

Urgent echo - poor LV function/ejection fraction

Management

Immediate management

Continually monitor pulse oximeter, BP and ECG

Sit the patient upright and give 15l/min of oxygen.
Gain IV access and treat any arrhythmia present on ECG
If attack is severe consider contacting anaesthetics early as CPAP and ICU may be required

Diamorphine 2.5-5mg IV slowly caution in liver failure and COPD.
Furosemide 40-120mg IV slowly

Further treatment guided by blood pressure:
systolic >100 Give 2 sprays of sublingual GTN followed by an IV nitrate infusion starting at 4mg/h and increase by 2mg/h every 10 mins with the aim to keep systolic >100
systolic <100 Cardiogenic shock likely - contact senior help as ionotropes likely needed. Do not give nitrates.
wheezing Treat following COPD guidelines
No improvements Furosemide up to 120mg total and consider CPAP. Monitor urine output and consider HDU/ICU.

If failure to improve with the following treatment then consider alternative diagnosis: hypertensive heart failure, aortic dissection, pulmonary embolism and pneumonia

After patient is stabilised daily weights and fluid restriction.

Optimise treatment for heart failure. Link to chronic heart failure.
Oral bumetanide may be used over oral furosemide for diuresis due to more predictable absorbtion in the gut in the presence of bowel oedema. Monitor U&Es during diuresis. Consider the addition of a thiazide diuretic.
Most patients will already be on beta blockers - continue treatment unless heart rate below 50.
Offer ACE inhibitor and an aldosterone antagonist

Prior to discharge

Aim to reduce modifiable risk factors such as smoking, obesity, control of diabetes, blood pressure and cholesterol.

Follow up

Review in out-patient by specialist heart failure team within 2 weeks of persons discharge from hospital

Complications

Prognosis

If admission is needed for heart failure, 5 year mortality is about 75%. Poor prognosis following acute attack

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