see also:

• cardiology
• cor pulmonale
• acute pulmonary oedema (APO)
• Mx of the wheezy elderly patient - acute pulmonary oedema versus asthma
• AFTB lectures - APO
• heart failure with preserved EF (HFpEF)
• NB. age > 65 with primary Dx of CCF are admitted to cardio-geriatric unit at Western Hospital if present to Western Health

• cardiac failure is the commonest cause for hospital admission in those aged over 65 yrs
• prevalence of CCF increases with increasing age and affects about 10% of the population older than 75 years.
• in spite of significant advances in the treatment of heart failure, mortality rates remain high: 30 to 40 percent of patients with advanced disease and 5 to 10 percent of patients with mild symptoms die within five to 10 years.
• there are two pathophysiologic types of CCF (or congestive heart failure (CHF))
  • systolic failure (impaired ability to contract) characterised by an ejection fraction < 45%
  • diastolic failure (impaired ability to fill in diastole) which is more poorly quantified and agreed criteria has not been reached
• the two types have similar symptoms and signs and usually require echocardiography or angiography to discriminate.
• diastolic heart failure is more common in women and elderly persons and accounts for 25-50% of patients hospitalised with cardiac failure.
• although patients with diastolic heart failure have a lower annual mortality rate than patients with systolic heart failure, they have a higher rate than the general population.

• concurrent presence of either 2 major criteria or 1 major and 2 minor criteria:

• paroxysmal nocturnal dyspnea
• weight loss of 4.5 kg in 5 days in response to treatment
• neck vein distention
• rales
• acute pulmonary edema
• hepatojugular reflux
• S3 gallop
• central venous pressure greater than 16 cm water
• circulation time of 25 seconds
• radiographic cardiomegaly
• pulmonary edema, visceral congestion, or cardiomegaly at autopsy

• nocturnal cough
• dyspnea on ordinary exertion
• a decrease in vital capacity by one third the maximal value recorded
• pleural effusion
• tachycardia (rate of at least 120 bpm)
• bilateral ankle oedema

• SOBOE - most sensitive symptom but not specific
• orthopnoae/PND - more specific but less sensitive (20-30% pts)
• cough with pink, frothy sputum is highly suggestive

• SOA

• peripheral edema, jugular venous distention, and tachycardia are highly predictive of CCF but occur in only 10-20% pts.
• other signs may also occur:
  • hypertension, cold & sweaty skin, pulsus alternans, wheezes, third or fourth heart sounds.
• CXR only 80% sensitive
• a negative BNP has 98% NPV
• a positive BNP is non-specific but more useful if higher values in older people and intermediate pre-test probability - not helpful if low or high pretest probability

• impaired ability of the ventricle to contract resulting in LV ejection fraction < 45%
• update: consider adding an If current blockers if HR > 77 bpm

• The relaxation process has four identifiable phases:
  • isovolumetric relaxation from the time of aortic valve closure to mitral valve opening;
  • early rapid filling after mitral valve opening;
  • diastasis, a period of low flow during mid-diastole; and
  • late filling of the ventricles from atrial contraction
• Diastole is a complex process that is affected by a number of factors, including:
  • ischemia
  • heart rate
    • heart rate determines the time that is available for diastolic filling, coronary perfusion, and ventricular relaxation.
  • velocity of relaxation
  • cardiac compliance (i.e., elastic recoil and stiffness)
  • hypertrophy
    • hypertrophied ventricle has a steeper diastolic pressure-volume relationship; therefore, a small increase in left ventricular end-diastolic volume (which can occur with exercise, for example) causes a marked increase in left ventricular end-diastolic pressure.
  • segmental wall coordination of the heart muscle.

• hypertension
  • hypertension is the most common cause and causes LV hypertrophy and increased connective tissue content, both pf which decrease cardiac compliance.
• ischaemia
  • Hypoxia inhibits the dissociation of myosin-actin crossbridges during muscle relaxation as this requires active transport of calcium ions into the sarcoplasmic reticulum.
• tachycardia:
  • tachycardia adversely affects diastolic function by several mechanisms:
    • decreases left ventricular filling and coronary perfusion times
    • increases myocardial oxygen consumption
    • causes incomplete relaxation because the stiff heart cannot increase its velocity of relaxation as heart rate increases.
• AF:
  • atrial fibrillation worsens failure by two main mechanisms:
    • loss of the atrial “kick” in filling the ventricle
    • adverse effects of tachycardia (as above) if rapid ventricular rate
  • note that diastolic failure increases the risk of AF as the raised atrial pressures and distended atria predispose to AF developing.
• systolic failure
  • residual blood within the ventricles at the end of systole decreases the pressure gradient between the atria and ventricles which thus impairs the rapid phase of early diastolic filling.
• aging
  • increased collagen cross-linking, increased smooth muscle content, and loss of elastic fibers due to aging results in decreased ventricular compliance, increasing susceptibility to diastolic failure.

• generally requires 3 features:
  • symptoms and signs of cardiac failure (although these are rather non-specific features)
  • the presence of normal or mildly abnormal left ventricular systolic function (ejection fraction of greater than 45 percent)
    • HOWEVER, the presence of systolic failure does not exclude possible diastolic failure but does make it harder to definitively diagnose
  • evidence of abnormal left ventricular relaxation, filling, diastolic distensibility, or diastolic stiffness
    • on echocardiography, this may be suggested by either:
      • prolonged tau:
        • the time constant of LV pressure decay during isovolumetric relaxation which is a measure of LV stiffness
      • E-to-A wave ratio:
        • the ratio of peak velocities of blood flow during early diastolic filling (E wave) and atrial contraction (A wave) which is normally ~1.5.
        • the ratio falls to less than 1.0 in early diastolic dysfunction as stiffer heart relaxes more slowly.
        • As diastolic function worsens and left ventricular diastolic pressure rises, left ventricular diastolic filling occurs primarily during early diastole, because the left ventricular pressure at end-diastole is so high that atrial contraction contributes less to left ventricular filling than normal. This results in a rise in the E-to-A wave ratio which may rise higher than 2.0. This “restrictive pattern” confers a poor prognosis.
        • The E- and A-wave velocities are affected by blood volume and mitral valve anatomy and function. Furthermore, these wave velocities are less useful in the setting of atrial fibrillation.
      • E-to-A wave ratio > 2
    • on coronary angiography

• normalise blood pressure (to less than 130/85mmHg) to promote regression of LVH
• avoid tachycardia - eg. low dosage beta blockers
• reduce ischaemia
• Rx symptoms - consider diuretics, ACEIs, digoxin
• consider dihydropyridine calcium channel blockers with care
  • The long-acting dihydropyridine class of calcium channel blockers is safe for use in patients with systolic heart failure, but nondihydropyridine agents should be avoided.

• American Family Physician June 2004
• CVphysiology - pathophysiology of heart failure