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Chapter 2: Cardiac failure 63

ECG may demonstrate strain patterns or hypertrophy othertreatmentsincludinghigh-dosediuretics,biven-

and underlying pathology such as a previous myocar- tricular pacing, left ventricular assist devices and car-
dial infarct. Cardiac arrhythmias may be present. diac transplantation. Anticoagulation should be con-
Echocardiography is used to assess ventricular func- sidered in atrial fibrillation or with left ventricular

tion. It can demonstrate regional wall motion abnor- thrombus. Automatic implantable cardiac defibrilla-
malities,globaldysfunctionandoverallleftventricular tor (AICD) have been shown to improve survival in
ejectionfraction.Echocardiographycanalsoshowany patients with severe left ventricular dysfunction sec-
underlying valvular lesions as well as demonstrating ondary to ischaemic heart disease. Statin lipid lower-
the presence of cardiomyopathy. ing drugs may be of benefit even in patients without
Other investigations that may be useful include ra- ischaemic heart disease.

dionuclide ventriculography and measurement of B- Patients with right ventricular dysfunction are treated
type natriuretic peptide (BNP). symptomatically with diuretics and may benefit from
ACE inhibitors.
Management
Patients require correction or control of underlying Prognosis
causes or contributing factors where possible, such as Overall mortality is 40% in the first year after diagnosis,
anaemia, pulmonary disease, thyrotoxicosis, hyperten- thereafter it falls to 10% per year.
sion, cardiac arrhythmias and infection. Ischaemic or
valve disease often requires specific treatment.
Patientsshouldbeadvisedtostopsmokingandreduce Acute pulmonary oedema
alcohol and salt intake. Weight loss and regular aerobic
Definition
exercise should be encouraged. Patients with evidence of
Fluidaccumulationwithintheinterstitiallungtissueand
fluid overload should restrict their fluid intake to 1.5–2
alveoli. Pulmonary oedema may be a sign of chronic
L/day.
heart failure (also termed pulmonary venous conges-
Patients with left ventricular systolic dysfunction have
tion) or may occur acutely.
been shown to benefit from
angiotensin-converting enzyme (ACE) inhibitors,

Aetiology/pathophysiology
which should be given to all patients even if asymp-
Acute pulmonary oedema is usually an acute deteriora-
tomatic. These should be used in conjunction with a
tion in patients with cardiac failure who have chronic
diuretic if there is any evidence of peripheral oedema.
pulmonary oedema. There may be a provoking factor
Angiotensin II receptor antagonists may be used in
such as excessive fluid intake/administration, arrhyth-
place of ACE inhibitors in intolerant patients. They
mias, negative inotropic drugs, angina, myocardial in-
can also be used in addition to a combination of ACE
farct or infection. There is an acute accumulation of fluid
inhibitors, β-blockers and diuretics in patients who
in the alveoli. Other causes include inhalation of toxic
remain symptomatic.
gases, drowning and renal failure.
β-blockers(bisoprolol,carvedilolormetoprolol)have

been shown to reduce mortality in all patients with Clinical features
heart failure. They should be started at low dose and Patients develop acute severe dysnoea at rest, hypox-
increased gradually. aemia and distress. There may be wheeze and cough pro-
low-dose spironolactone, which improves progno- ductive of frothy pink sputum. On examination there

sis in patients with moderate to severe heart failure may be poor peripheral perfusion resulting in moist,
(NYHAclassIIIandIV).Patientsrequirecarefulmon- cold cyanosed skin. On auscultation crepitations may be
itoring of renal function and potassium levels. heard throughout the lung fields.
digoxin, which is currently recommended for patients

whoremain symptomatic despite maximal treatment Investigations
with other agents; however, in patients without atrial Chest X-Ray: There may be signs of chronic pul-
fibrillationthereisnoevidenceofimprovedprognosis. monary oedema such as upper lobe vein diversion,