1. Cardiac SOB

Question 1

What, at its core, causes breathlessness?

Answer 1

Poor carbon dioxide removal

Poor oxygen delivery

Question 2

What is heart failure?

Answer 2

The failure to the heart to maintain cardiac output required for body’s demands.

Question 3

How can we classify HF?

Answer 3

Chronic - long term inadequacy to maintain the body’s circulation
Acute - a medical emergency rapid onset, caused by acute coronary syndrome or decompensation of chronic HF

Also by
low output - heart fails to pump in response to normal exertion
high output - normal CO but higher metabolic needs e.g. anaemia, pregnancy

Question 4

What is congestive heart failure?

Answer 4

Left and right sided heart failure – usually started with congestion in the left that floods into the right

Question 5

Valvular causes of left heart failure?

Answer 5

Aortic stenosis
Aortic regurg
Mitral regurg

Question 6

Muscular causes of lhf

Answer 6

Ischaemia
Cardiomyopathy
Myocarditis
Arryhythmias

Question 7

Systemic lhf causes

Answer 7

Hypertension
Amyloidosis
Drugs e.g. cocaine, chemo

Question 8

Right hf causes?

Answer 8

Lung causes - pulmonary hypertension

• pulmonary embolism
• chronic lung disease

tricuspid regurg
pulm regurg
congestive HF

Question 9

Causes of high output HF?

Answer 9

Nutritional
Anaemia
Pregnancy

Malignancy
Endocrine
Av malformations
Liver cirrhosis
Sepsis

Question 10

Symptoms of HF?

Answer 10

LHF - fluid accumulates in lungs causes resp symptoms e.g. dyspnoea (PND, exertional, orthopnoea - how many pillows), nocturnal cough with pink frothy sputum (pulm oedema, fatigue
RHF - fluid accumulates in peripheries causing swelling signs

Question 11

Signs of LHF?

Answer 11

Heart -

• increase HR and RR
• irregularly irregular heartbeat
• pulsus alternans
• displaced apex beat
• S3 gallop
• S4 in severe
• murmur (AS, AR, MR)

Lungs -
- fine end inspiratory crackles
wheeze

Question 12

Signs of RHF?

Answer 12

Face swelling
Increased JVP
TR murmur, increased HR, RR
Peripheral oedema
Ascites/hepatomegaly

Question 13

HF Investigations

Answer 13

Bedside - ECG
Bloods - FBC, UES, LFT, TFT (high output), BNP
Imaging - CXR (pulm oedema), TTE (transthroracic echo gold standard)

Question 14

What does BNP mean??

Answer 14

BNP is sensitive for cardiac damage, if low it’s not HF, if high need to do TTE

Question 15

What can you calculate with TTE?

Answer 15

Ejection fraction, normal is 50-70%

If low, systolic HF, if high/normal then could be diastolic HF

Question 16

What can you see of HF cxr?

Answer 16

Alv oedema
B-lines
Cardiomegaly
Dilation upper lobe vessels/lobe
Divertion of upper lobe
Effusion

Question 17

What is the framingham criteria?

Answer 17

Major - 2+ of crepitations, weight loss, neck vein distension, hep jug reflex etc.
Minor e.g. hepatomegaly

Question 18

How do we manage chronic HF?

Answer 18

Treat, not cure.

1. Treat underlying
2. Treat exacerbating
3. Lifestyle mod
4. Drugs - ABD, ACE inhibitors (ramipril), beta-blockers (bisoprolol to reduce o2 demands on heart), diuretics (furosemide)

Question 19

How do we manage acute HF?

Answer 19

1. Upright
2. 60-100% oxygen
3. IV Diamorphine
4. GTN infusion
5. IV furosemide (40-80mg)

Question 20

Complications and prognosis of HF?

Answer 20

Comp - respiratory failure, renal failure (hypoperfusion), acute exacerbations, death.
Prog - worse than most malig

Question 21

What are primary and secondary cardiomyopathy?

Answer 21

Prim - confined to myocardium

Sec - part of a systemic disease

Question 22

Presentation of cardiomyopathy?

Answer 22

Symptoms of HF
Sudden death/FHx of

Exam - signs of HF

Investigations - echo!! (bloods etc. too)

Question 23

What happens in dilated cardiomyopathy?

Answer 23

Ventricles enlarge and become dilated, walls thin and weaken - law of laplace

RF - alcohol, post-viral, genetic, haemochromatosis

Question 24

Sign in dilated cardiomyopathy?

Answer 24

Displace apex beat!!!! (signs of HF too)

Globular heart on CXR!!

Question 25

What is/what happens hypertrophic cardiomyopathy?

Answer 25

Muscle thickens comes inwards.
Increased stiffness of muscle affects pumping and disrupts electrical conductions.
HOCM - hypertrophic obstructive cardiomyopathy

half is familial.

Question 26

How does HOCM present?

Answer 26

Sudden cardiac death

Angina, dyspnoea on exertion, palpitations, syncope may be warning but mostly asymptomatic.

Question 27

HOCM signs?

Answer 27

Ejection systolic murmur
Jerky carotid pulse
Double apex beat, not displaced
S4

ECG - q waves, left axis deviation
Echo - shows hypertrophy

Question 28

What is restrictive cardiomyopathy?

Answer 28

Same muscle, but muscle is rigid – reduce preload

Question 29

Causes of restrictive

Answer 29

Sarcoidosis, amyloidosis, haemochromatosis, familial, idiopathic

Question 30

Signs of restrictive

Answer 30

Kussmaul’s sign - paradoxical rise in JVP during inspiration

RHF signs

Question 31

What is constrictive pericarditis?

Answer 31

Chronic inflammation of pericardium with thickening and scarring

Can be idiopathic, infectious, acute pericarditis, cardiac surgery/radiation

Question 32

Signs and symptoms of constrictive pericarditis?

Answer 32

Similar to restrictive cardiomyopathy

Distinguish them using echo for pericardial thickness
CXR - calcification (non-specific)
This can be treated, unlike restrictive

Question 33

What is myocarditis?

Answer 33

Inflammation of myocardium

Caused by infection (coxsakie B virus), drugs, metals, radiation

Question 34

Signs and symptoms of myocarditis?

Answer 34

Flu-like prodrome
Chest pain worse on lying
SOB
Palpitations

ECG - non-specific ST and T wave changes
Cardiac biomarkers- CK and troponins should rule out others
Endomyocardial biopsy - diagnostic but rarely done