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ACUTE LEFT VENTRICULAR FAILURE

MA Merchant
Family Physician, Bandra, Mumbai 400 050.

Acute left ventricular failure is a life threatening emergency faced by family-physician in his practice, and he should carry with him sufficient quota of requisite medicine to treat this ailment before shifting him to an ICCU of any hospital.

CAUSES OF LVF


1. Ischaemic Heart Disease - Many a times acute myocardial infarction first presentation is acute LVF

2. Hypertension

3. Rheumatic heart disease

4. Congenital heart disease

5. High altitude

PRECIPITATING FACTORS

1. Tachyarrhythmia - Atrial fibrillation with fast ventricular rate

2. Infective endocarditis

3. Myocarditis

4. Severe physical exertion

5. Fluid overload

Clinical Features

1. Dyspnoea - Pt. is acutely breathless, restless, anxious, profusely sweating, often cyanosed and orthopnoeic. Extremities are cold.

2. Cough - Pt. gets cough with frothy white or pink sputum.

3. Pulse - rapid, pulsus alternance. BP is high in hypertension. BP is low in low output states like mitral stenosis, massive myocardial infarction.

4. Auscultation - Gallop rhythm S3, S4 present. Murmur of underlying heart disease may be present. P2 is accentuated. Respiratory system auscultation reveals crepitation starting from base, from first crackling sound to bubbling crepitations all over. Sometimes rhonchi may be heard.

DIFFERENTIAL DIAGNOSIS

We have to differentiate from many causes. But a family physician should remember the important ones like bronchial asthma, pneumonia, pneumothorax, pulmonary embolism, renal asthma, anxiety neurosis etc.

Br. asthma : Previous H/o allergy and br. asthma present. There are more rhonchi, extremities are warm, no gallop rhythm. X-ray chest may be normal or hyperinflated or BVM + Pneumonia : H/O fever with chest pain, bronchial breathing localised crepitation may be heard. X-ray will show the consolidation.

Pneumo-thorax : H/o trauma or thin individual tall person, previous history of TB pneumothorax site of chest movement is restricted intercostal spaces are full on that side. Breath sounds are absent. On percussion there is hyper resonance. X-ray will reveal the diagnosis.

Pulmonary Embolism : H/O Bed rest, H/O Long air journey, giving rise to DVT, h/o OCP, H/O Valvular heart disease. Chest pain with difficulty in breathing, crepitation may be heard on auscultation. X-ray chest may be normal or shows shadow of consolidation. ECG will show S1, Q3, T with T inversion in V1 to V3 Ventilation - Perfusion lung scan will give the diagnosis.

Renal Asthma : H/O Renal disease, acidotic breathing, rhonchi, no gallop or murmur. BP is usually high. Creatinine high, urine shows casts.

Anxiety Neurosis : Common in females, extremities are cold, anxious dramatising, no gallop or murmur, no crepitation.

INVESTIGATIONS

1. X-Ray chest shows butterfly appearance, heart size may be normal or enlarged.

2. ECG may show the sign of ischaemia like ST-T changes or ST elevation of hyper acute infarction. There may be changes of LVH in hypertensive cases. Arrhythmia may be present.

3. 2-D echo may show reduced ejection fraction. It may also detect chamber enlargement or valvular disease or wall motion abnormality in case of an infarct.

TREATMENT

1 Propped up position.

2. Inj. Frusemide 40-80 mg IV can be repeated depending upon the recovery. Upto 500 to 800 mg can be given depending on the situation.

3. Inj. theophylline or aminophylline 250 mg IV very slowly diluting in patients own blood.

4. Tab. nitroglycerine or isosorbide 1/2 tab (5 mg) sublingually if BP is normal.

5. Inj. pethidine 25-50 mg with promethazine 25 mg IM or Inj. tramodol 50 mg IM.

6. Tab. Captopril 6.25 mg crushed sublingually provided BP is normal or high.

7. Oxygen by nasal catheter or venti mask.

8. IV dopamine or dobutamine in micro drip with 5% glucose if BP is low i.e. 90/60 dose is 5-20 mg/minute.

9. Sublingual nifedipine 5 mg in case of hypertension with LVF can be repeated every 10 minutes. till the BP drops to 150/100 mm Hg.



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