Left Ventricular Failure (LVF)  

Definition:  

Inability of the left ventricle to pump blood effectively leading to pulmonary congestion & decreased cardiac output. 

Aetiology / Causes:  

Systolic Dysfunction (↓EF <40%):  
– Ischaemic heart disease / MI  (can cause acute LVF)
– Dilated cardiomyopathy 
 – Chronic hypertension → pressure overload  
– Myocarditis 

Diastolic Dysfunction (Preserved EF >50%):  
– Hypertensive heart disease  
– Hypertrophic/restrictive cardiomyopathy  
– Ageing (stiff ventricle) 

Other:  
– Arrhythmias (AF)  
– Valvular disease (MR, AS)  
– Toxins (alcohol, drugs) 

Pathophysiology: 
 – ↓ LV contractility or impaired filling → ↑ left atrial pressure → pulmonary venous congestion → pulmonary oedema  
– Neurohormonal activation → fluid retention, ↑ afterload  
– Systolic: impaired ejection; Diastolic: impaired filling 

Clinical Features:  

Symptoms:  
– Dyspnoea (exertional → at rest)  
– Orthopnoea / Paroxysmal nocturnal dyspnea  
– Fatigue, weakness  
– Pulmonary congestion → cough, pink frothy sputum 

Signs:  
– Rales / crackles at lung bases  
– S3 gallop (systolic)  
– Displaced apex beat  
– Tachycardia  
– Cyanosis (can be severe) 

Investigations:  
– Labs: BNP / NT-proBNP ↑, renal function, electrolytes  
– CXR: Cardiomegaly, pulmonary congestion, Kerley B lines  
– Echocardiography: EF, LV size, wall motion, valves  
– ECG: LVH, ischaemia, arrhythmias 

Management:  

Non-pharmacological:  
– Salt & fluid restriction  
– Weight monitoring  
– Lifestyle: exercise, stop smoking 

Pharmacological: 
– ACE inhibitors / ARBs → afterload reduction, remodeling – Beta-blockers → ↓ sympathetic drive, improve survival  
– Diuretics → symptom relief (pulmonary edema)  
– Mineralocorticoid antagonists (spironolactone) → mortality benefit – Digoxin → symptom relief, especially in AF
 
Advanced:  
– ICD / CRT devices  
– Heart transplant (refractory cases) 

Complications:  
– Pulmonary oedema (acute)  
– Arrhythmias (AF, VT/VF)  
– Cardiogenic shock  
– Renal dysfunction  
– Progression to biventricular failure 

Key Points:  
– LVF = dyspnoea + pulmonary congestion  
– Distinguish systolic vs diastolic (EF important)  
– Treat cause + symptoms + mortality reduction  
– Look for underlying disease: ischemia, HTN, valve disease