16 Congestive cardiac failure
Salient features
Examination
• Signs of fluid retention: raised JVP, lung crepitations, pitting leg oedema, tender hepatomegaly
• Signs of impaired perfusion: cold clammy skin, low BP
• Signs of ventricular dysfunction: displaced left ventricular apex, right ventricular heave, third or fourth heart sound, functional mitral or tricuspid regurgitation, tachycardia
Diagnosis
Be prepared to discuss mortality in heart failure depending on the NYHA functional class (see p. 3).
How would you investigate this patient?
• Chest radiography (Fig. 16.1). Presence of pulmonary oedema on chest radiograph suggests that left ventricular end-diastolic pressure is 25 mmHg (normal ~7 mmHg).
• ECG to look for underlying cause, e.g. ischaemia or infarction, left ventricular hypertrophy, arrhythmia, other causes of pathological Q waves. Monitoring with 24-Holter can identify ventricular arrhythmias.
• Echocardiogram detects valvular disease and determines whether LV function is globally impaired (e.g. idiopathic dilated cardiomyopathy) or whether there is segmental wall motion abnormalities (e.g. in ischaemic heart disease). Ejection fraction can be estimated and usually treatment is initiated when ejection fraction is ≤40. Doppler echocardiography allows determination of diastolic dysfunction.
• Exercise testing is useful to identify ischaemic heart disease.
• Cardiopulmonary exercise testing is useful to determine functional capacity before cardiac rehabilitation and to determine eligibility for cardiac transplantation.
• Blood tests can identify associated disease: renal, liver and electrolyte disturbances (common); metabolic causes (e.g. haemochromatosis, hypocalcaemic cardiomyopathy, thyroid heart disease, anaemia, heavy metal poisoning), amyloid (serum electrophoresis, rectal biopsy), sarcoid (serum ACE).
• Coronary angiography is used to identify ischaemic heart disease.
• Ventricular biopsy for specific myocarditis, especially viral, and to exclude infiltrative diseases such as cardiac sarcoidosis and amyloidosis.
• Radionuclide ventriculography or echocardiography to quantitate severity of systolic dysfunction (ejection fraction).
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