Chapter 88

### Introduction

In the year 1775 my opinion was asked concerning a family recipe for the cure of the dropsy. I was told that it had long been kept a secret by an old woman in Shropshire who had sometimes made cures after the more regular practitioners had failed—this medicine was composed of twenty or more different herbs and the active herb could be no other than the Foxglove.

William Withering (1741–99), On the Use of Foxglove (Digitalis) in the Treatment of Heart Disease

Heart failure occurs when the heart is unable to maintain sufficient cardiac output to meet the demands of the body for blood supply during rest and activity.

Chronic heart failure (CHF) remains a very serious problem with a poor prognosis. It has a 50% mortality within 3 years of the first hospital admission.1 Overseas data indicate that 1.5% of the adult population have heart failure. The prevalence of CHF has been shown to increase from approximately 1% in those aged 50–59 years to over 5% in those 65 and older, to over 50% in those 85 years and older.2 Australian research suggests that under-treatment with the all-important ACE inhibitors continues to be a problem. ACE inhibitors (or ARBs) and β-blockers are the gold standard for treating systolic heart failure, with aldosterone antagonists providing added benefit if symptoms persist.3 A major goal of management of CHF is the identification and reversal where possible of underlying causes and/or precipitating factors. CHF is characterised by two pathophysiological factors: fluid retention and reduction in cardiac output.

### Diagnosis

The classic symptom of CHF is dyspnoea on exertion but symptoms may be reported relatively late, mainly due to a sedentary lifestyle. Dyspnoea can progress as follows: exertional dyspnoea → dyspnoea at rest → orthopnoea → paroxysmal nocturnal dyspnoea.

#### Symptoms in summary

• Dyspnoea (as above)

• Irritating cough (especially at night)

• Lethargy/fatigue

• Weight change: gain or loss

• Dizzy spells/syncope

• Abdominal discomfort

• Palpitations

• Ankle oedema

The irritating cough due to left ventricular failure can be mistaken for asthma, bronchitis or ACE-inhibitor-induced cough.

### Examination

The physical examination is very important for the initial diagnosis and evaluation of progress. The signs are as follows.

#### Signs

There may be no abnormal signs initially. It is helpful clinically to differentiate between the signs of right and left heart failure:

Left heart failure

• Tachycardia

• Low volume pulse

• Tachypnoea

• Laterally displaced apex beat

• Bilateral basal crackles

• Gallop rhythm (3rd heart sound)

• Pleural effusion

• Poor peripheral perfusion

Right heart failure

• Elevated jugular venous pressure

• Right ventricular heave

• Peripheral/ankle oedema

• Hepatomegaly

• Ascites

Auscultation is important to identify adventitious sounds, a third ...

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