When Should I Call An Ambulance
If you have any of the symptoms below, call triple zero immediately and ask for an ambulance. If calling triple zero does not work on your mobile phone, try calling 112.
- chest pain thats severe or worsening, or has lasted longer than 10 minutes
- chest pain that feels heavy, crushing or tight
- other symptoms, such as breathlessness, nausea, dizziness or a cold sweat
- pain in your jaw or down your left arm
Epidemiology Aetiology Pathophysiology And Natural History Of Heart Failure
Approximately 12% of the adult population in developed countries has HF, with the prevalence rising to 10% among persons 70 years of age or older. There are many causes of HF, and these vary in different parts of the world . At least half of patients with HF have a low EF . HF-REF is the best understood type of HF in terms of pathophysiology and treatment, and is the focus of these guidelines. Coronary artery disease is the cause of approximately two-thirds of cases of systolic HF, although hypertension and diabetes are probable contributing factors in many cases. There are many other causes of systolic HF , which include previous viral infection , alcohol abuse, chemotherapy , and idiopathic dilated cardiomyopathy .
HF-PEF seems to have a different epidemiological and aetiological profile from HF-REF., Patients with HF-PEF are older and more often female and obese than those with HF-REF. They are less likely to have coronary heart disease and more likely to have hypertension and atrial fibrillation . Patients with HF-PEF have a better prognosis than those with HF-REF .
Systolic Vs Diastolic Dysfunction
As many as 40 percent of patients with clinical heart failure have diastolic dysfunction with normal systolic function.32 In addition, many patients with systolic dysfunction have elements of diastolic dysfunction. With systolic dysfunction, the pumping ability of the ventricle is impaired. With diastolic dysfunction, ventricular filling is defective.
Ventricular diastolic function depends on the pressure-to-volume relationship in the left ventricle. Decreased compliance of the left ventricular wall leads to a higher pressure for a given diastolic volume. The end result is impaired ventricular filling, inappropriately elevated left atrial and pulmonary venous pressure, and decreased ability to increase stoke volume. These dysfunctions lead to the clinical syndrome of heart failure.
Findings suggestive of diastolic dysfunction on the two-dimensional echocardiogram are left ventricular hypertrophy, a dilated left atrium, a normal or nearly normal ejection fraction and reversal of the normal pattern of flow velocity across the mitral valve .
Two-dimensional echocardiogram showing a four-chambers view of the heart in a patient with systolic dysfunction. Note dilated LV.
Two-dimensional echocardiogram showing a four-chambers view of the heart in a patient with systolic dysfunction. Note dilated LV.
X = suggestive the number of Xs reflects the relative weight = not suggestive.
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How Do You Assess A Patient With Heart Failure
10 Steps to Assess Volume Status in Congestive Heart Failure
Third And Fourth Heart Sounds
A double apical impulse can represent an auscultated third heart sound . Just as with the displaced point of maximal impulse, a third heart sound is not sensitive for heart failure, but it is highly specific .14 Patients with heart failure and left ventricular hypertrophy can also have a fourth heart sound . The physician should be alert for murmurs, which can provide information about the cause of heart disease and also aid in the selection of therapy.
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Considerations On The Use Of Anticoagulants In Covid
Many cardiac patients or patients with other CV history will have an indication for anticoagulation. Table 16 lists the possible interactions of COVID-19 therapies with VKAs, NOACs, LMWHs and UFH. The table includes information that was derived from several drug interaction sites, which have been referenced. Drug SmPCs often do not contain information for older drugs and/or drugs with a narrow spectrum of indications . Antimalarial drugs have a P-glycoprotein inhibiting effect, which may affect NOAC plasma levels. COVID-19 patients on oral anticoagulation may be switched over to parenteral anticoagulation with LMWH and UFH when admitted to an ICU with a severe clinical presentation.
We would like to rephrase here also the conventional dose reduction criteria for NOACs, for those patients in whom oral treatment for stroke prevention in AF patients, can be continued. For more details, including the assessment of renal function and other considerations in patients taking a NOAC, please see the 2018 EHRA Practical Guide on the use of NOACs in patients with AF.265 Of note, none of the NOACs is recommended in patients with a creatinine clearance < 15 ml/min according to the EU label.
For patients with impaired swallowing, NOACs can be administered in the following ways:
Predictors Of Poor Outcome And High Mortality Rate
In HF patients, exercise intolerance characterized by the reduction in peak VO2/VO2 max capacity has been considered as the primary predictor of mortality and morbidity . In addition, higher age, increased blood urea nitrogen, creatinine and heart rate, lower systolic pressure and serum sodium, presence of dyspnea at rest, lack of long-term treatment with a -blocker, male gender and lower body mass index and hemoglobin levels have been identified as independent predictors of mortality. The following values have been shown to predict the increased mortality in inpatient settings/hospitals .
Serum urea > 15 mmol/L
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.72 mg/dL
N-terminal pro-brain natriuretic peptide > 986 pg/mL
Left ventricular ejection fraction < 45%
Some of the other predictors of relative poor outcome in chronic heart failure are given below.
High NYHA functional class
Reduced left ventricular ejection fraction
Third heart sound
Increased pulmonary artery capillary wedge pressure
Reduced cardiac index
Raised plasma catecholamine and natriuretic peptide concentrations
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Interactions With Others Healthy Lifestyle And Medical Advice During Covid
- Avoid people who are sick
- Keep a two-metre distance from other individuals whenever possible
- Wash hands thoroughly with soap and warm water for at least 20 seconds
- Cover the mouth or nose when you cough or sneeze with a tissue or use the inside of the elbow
- Avoid touching the eyes, nose and mouth
- To remove the virus, often clean surfaces like doorknobs or handles with a disinfectant
- Self-isolate in case of symptoms of fever, cough or a chest infection
- Stay home as much as possible
- Maintain physical activity to avoid VTE and maintain well-being.
Additionally, individuals should be encouraged to follow the instruction of the Department of Health and local authorities in the resident countries as these may differ.
- Healthy lifestyle:
Maintain a healthy lifestyle .276 Isolation and physical restrictions may lead to inactivity and increased risk of VTE, in combination with co-morbidities. Physical activity should be strongly encouraged either in a home setting or outdoor areas with social space and will also improve well-being. Maintaining social network should be encouraged remotely.
- Medical advice:
- Continue with prescribed medication for CVD
- Seek medical help immediately if experiencing symptoms such as chest pain. Do not neglect symptoms
- Do not interrupt cardiac follow-up and seek advice of a cardiologist promptly in case of deterioration of the CV condition.
Management Of Heart Failure
The major goals of treatment in heart failure are to improve prognosis and reduce mortality and to alleviate symptoms and reduce morbidity by reversing or slowing the cardiac and peripheral dysfunction. For in-hospital patients, in addition to the above goals, other goals of therapy are to reduce the length of stay and subsequent readmission to prevent organ system damage and to appropriately manage the co-morbidities that may contribute to poor prognosis .
The 2013 American College of Cardiology/American Heart Association updated guidelines , 2010 Heart Failure Society of America guidelines and the 2008 European Society of Cardiology guidelines, with varying levels of evidence, recommend the following for different categories of HF patients.
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Symptoms Of Heart Failure
Symptoms of heart failure include:
- new or worsening shortness of breath
- difficulty lying flat at night
- fainting or passing out
- weight gain
- muscular fatigue, tiredness
- swelling of ankles or legs
- swelling of abdomen
- heart palpitations
- chest pain or discomfort in parts of the upper body
- unexplained coughing and wheezing
Heart Failure With Reduced Ejection Fraction
In HFrEF , global LV systolic dysfunction predominates. The LV contracts poorly and empties inadequately, leading to
Increased diastolic volume and pressure
Many defects in energy utilization, energy supply, electrophysiologic functions, and contractile element interaction occur, with abnormalities in intracellular calcium modulation and cAMP production.
Predominant systolic dysfunction is common in heat failure due to myocardial infarction, myocarditis, and dilated cardiomyopathy. Systolic dysfunction may affect primarily the LV or the right ventricle LV failure often leads to RV failure.
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Assessment Of Functional Capacity
Cardiopulmonary stress testing can help in the assessment of a patients chance of survival within the next year, as well as determine the need for referral for either cardiac transplantation or implantation of mechanical circulatory support. A 6-minute walk test evaluates the distance walked, dyspnea index on a Borg scale from 0 to 10, oxygen saturation, and heart rate response to exercise. A normal value is walking more than 1500 feet. Patients who walk less than 600 feet have severe cardiac dysfunction and a worse short- and long-term prognosis.
Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol. 1993 Oct. 22:6A-13A. . .
American Heart Association. Classes of heart failure. Available at . Updated: May 8, 2017 Accessed: June 18, 2017.
Yancy CW, Jessup M, Bozkurt B, et al, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 Oct 15. 128:e240-327. . .
Braunwald E. The pathogenesis of congestive heart failure: then and now. Medicine. 1991 Jan. 70:68-79. .
What Laboratory Studies Should Be Ordered To Help Establish The Diagnosis How Should The Results Be Interpreted
Physical examination in Heart Failure
C. Examination of the precordium in Heart Failure
Palpation of the precordium
Displacement of Apical Impulse: The normal apical impulse, also known as point of maximal impulse , lies just medial to the mid clavicular line. It is the size of a penny and does not extend beyond the first half of systole.
In the absence of mediastinal shift from any source including collection of intrathoracic air or fluid, displacement of the apical impulse to the left indicates cardiomegaly, albeit with low sensitivity. PMI is frequently difficult to palpate because of obesity and obstructive lung disease. In left ventricular hypertrophy, a wide sustained PMI can be palpated.
Other findings during palpation of the precordium: Right ventricular parasternal heave is seen in patients with right ventricular enlargement or hypertrophy and is best felt by placing the heal of the hand on the left sternal border. The pulmonic component of the second heart sound can be palpated in severe pulmonary hypertension.
Third Heart Sound: The third heart sound is a low-pitched sound, which occurs 120 to 160 msec after the second heart sound. The timing corresponds to early rapid filling phase of the ventricle.
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Sleep Disturbance And Sleep
Patients with HF frequently have sleep disturbance the causes are many, including pulmonary congestion and diuretic therapy causing nocturnal diuresis. Anxiety and other psychological problems can also lead to insomnia, and reviewing sleep history is part of the holistic care of patients with HF . Up to one-third of patients with HF have sleep-disordered breathing., Sleep apnoea is of concern in patients with HF because it leads to intermittent hypoxaemia, hypercapnia, and sympathetic excitation. Obstructive sleep apnoea also causes recurrent episodes of negative intrathoracic pressure and increases in LV afterload. It is more common in patients who are obese and whose sleeping partners report that the patient snores or exhibits daytime somnolence . However, not all patients with obstructive sleep apnoea are obese. The prevalence of central sleep apnoea in HF is uncertain and may have declined since the widespread use of beta-blockers and CRT. Screening for and the diagnosis and treatment of sleep apnoea is discussed in detail elsewhere., Diagnosis currently requires overnight polysomnography. Nocturnal oxygen supplementation, continuous positive airway pressure, bi-level positive airway pressure, and adaptive servo-ventilation may be used to treat nocturnal hypoxaemia.
Categorization Of Emergency/urgency Of Invasive Procedures
The rearrangement of the healthcare service required to face the COVID-19 pandemic has posed a series of relevant issues on prioritization of cardiac invasive procedures.136 Different regions in Europe and worldwide differ substantially in terms of local healthcare resources, epidemic density of the COVID-19 outbreak, changes of the epidemic over time and therefore access to healthcare services other than COVID-19 care. These differences have a wide range of implications for national/regional healthcare services, national health care authorities and in-hospital redistribution of resources. Regions may be categorized into three groups according to the degree of involvement in the epidemic, with subsequent different implications for the healthcare system as summarized in Table 7.
The indications provided in this document refer mainly to the scenario of heavy involvement and, in part, to the scenario of moderate involvement. Importantly, healthcare services should continue to be provided according to standard-of-care as described by current clinical practice guidelines, as long as the degree of regional involvement in the epidemic allows it. The rationale to importantly reduce the number of elective hospitalizations is three-fold:
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General Risk Assessment And Protective Measures
Taking into account that there are only a few documents regarding type and level of protection of HCP, the ESC Guidance Document considered the WHO document,73 the American Center for Disease Control and Prevention guidelines on COVID-19,74 the European Centre for Disease Control guidelines on COVID-19 75 but also Chinese data76,77 and experiences from European countries with the largest outbreaks of COVID-19. Importantly, the ESC Guidance document aims to suggest a high level of protection for HCP in the worst transmission scenario of SARS-CoV2 infection. Different settings, such as countries with no cases, countries with sporadic cases, countries experiencing case clusters in time, geographic location and/or common exposure should prepare to respond to different public health scenarios, recognizing that there is no one size fits all approach to managing cases and outbreaks of COVID-19. Each country should dynamically assess its risk and rapidly change the definitions according to their local situation, depending on the phase of the epidemic, demography, healthcare capacity, and governmental/local health authorities decisions.
5.1.1. Risk of SARS-CoV-2 Infection in Health Care Providers
Generally, protection against COVID-19 needs to be differentiated according to the level of risk based on patient presentation, type of procedures and interaction and HCP risk status. Table 3 provides general recommendations.
Acute Cardiac Injury And Myocarditis In Covid
Myocarditis appears in COVID-19 patients several days after initiation of fever. This indicates myocardial damage caused by viral infection. Mechanisms of SARS-CoV-2-induced myocardial injury may be related to upregulation of ACE2 in the heart and coronary vessels.44,61 Respiratory failure and hypoxia in COVID-19 may also cause damage to the myocardium and immune mechanisms of myocardial inflammation may be especially important.27,44,61 For example, cardiac injury leads to activation of the innate immune response with release of proinflammatory cytokines, as well as to the activation of adaptive auto-immune type mechanisms through molecular mimicry.
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Heart Disease And Stroke Statistics For 2016
Heart Disease remains to be the #1 cause of death in the US. Stroke ranks #5.1
Cardiovascular disease, listed as the underlying cause of death, accounts for nearly 801,000 deaths in the US. Thats about 1 of every 3 deaths in the US.1
- Coronary heart disease accounts for 1 in 7 deaths in the US, killing over 360,000 people a year.1
- In Oklahoma, heart disease was the leading cause of death, accounting for 1 in 4 deaths, killing almost 10,000 people a year.2
- Stroke accounts for 1 of every 20 deaths in the US, killing nearly 133,000 people a year.1
- In Oklahoma, stroke is the 5th leading cause of death, accounting for more than 1 in 20 deaths and killing more than 1,800 a year.2
In 2014, heart disease death rates were highest among Oklahoma non-Hispanic Blacks and American Indians. These rates were twice as high as the rate among Hispanics.2
Prognosis For Heart Failure
Generally, patients with heart failure have a poor prognosis unless the cause is correctable. Five-year survival after an initial hospitalization for heart failure is about 35% regardless of the patient’s ejection fraction. In overt chronic HF, mortality depends on severity of symptoms and ventricular dysfunction and can range from 10 to 40%/year.
Specific factors that suggest a poor prognosis include hypotension, low ejection fraction, presence of coronary artery disease, troponin release, elevation of BUN, reduced GFR, hyponatremia, and poor functional capacity .
BNP, NTproBNP, and risk scores such as the MAGGIC Risk Score and the Seattle Heart Failure model, are helpful to predict prognosis in HF patients as an overall group, although there is significant variation in survival among individual patients.
HF usually involves gradual deterioration, interrupted by bouts of severe decompensation, and ultimately death, although the time course is being lengthened with modern therapies. However, death can also be sudden and unexpected, without prior worsening of symptoms.
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