Investigations & Management

By: Siti Nurulismah Bt Che Haron

Diagnosis
Framingham criteria Simultaneous presence of at least 2 major criteria or 1 major criterion plus 2 minor criteria.

Framingham criteria
Major
PND Acute pulmonary edema

Minor
Nocturnal cough Dyspnea on ordinary exertion Bilateral ankle edema Tachycardia (HR >120/min) Hepatomegaly Pleural effusion Decrease in vital capacity by 1/3rd

JVP Hepatojugular reflux

S3 gallop Crackles in lung fields

Cardiomegaly on CXR CVP (>160 cmH2O at RA)

Weight loss >4.5 kg in 5 days in response to Rx of HF

Quiz
For Framingham criteria: simultaneous presence of at least . or plus ..

ECG
No specific changes AF Tachy / bradyarrhythmias Previous MI Cardiac ischemia Ventricular hypertrophy

Plasma BNP
Secreted by ventricular myocardium Closely related to LV pressure Reflect myocyte stretch Highest in decompensated heart failure Diagnosis of HF if BNP >100ng/L

CXR

Alveolar oedema (Bats wing)

Dilated prominent upper lobe vessel

Kerley B line

Pleural Effusion

Cardiomegaly

Echocardiogram
Resting LV size and function Absence/presence of LV dysfunction To detect valvular disease, pericardial or myocardial disease

Acute management
Sit the patient upright O2 100% IV access and monitor ECG. Treat any arrhythmias Ix whilst continuing treatment

Diarmorphine 2.5 to 5mg IV slowly.

Furosemide 40-80mg IV slowly

GTN spray 2 puffs SL or 2 X 0.3mg tablets SL

Necessary ix, examination and history

If BP 100mmHg, start nitrate infusion

If patient is worsening: further dose of furosemide, ventilation or increase nitrate infusion. Alternatively, venesect 500mL blood

If SBP <100mmHg treat as cardiogenic shock

Management outline
Confirm diagnosis Ascertain the severity of symptoms and presenting features Determine the etiology of HF Identify the exacerbating factors and any concomitant illness Estimate prognosis Anticipate complications Counsel patient and relatives Choose appropriate management Monitor progress and manage accordingly

Chronic management
Change in lifestyle: smoking. Salty foods. Weight and nutrition. Treat the cause Treat exacerbating factors Avoid exacerbating factors Drugs

Quiz
Following is/are true regarding heart failure: A. Framingham criteria can be used to diagnose HF B. Hepatomegaly is the major point in Framingham criteria C. CXR in HF will shows dilated prominent lower lobe vessels D. The higher the BNP, the lower the cardiovascular mortality E. Usage of Digoxin is absolutely contraindicated in heart failure

References
Oxford Handbook of Clinical Medicine Oxford American Handbook of Cardiology

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