17- Pathology Of Heart Failure

Question 1

Suggest 2 definitions for heart failure

Answer 1

Syndrome that arises when the heart is unable to maintain an appropriate blood pressure without support.
A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses.

Question 2

Describe an organ that often also fails with heart failure

Answer 2

Kidneys are a big part of heart failure - often when the heart fails, the kidneys fail because they won’t be perfused enough
• Kidneys receive 35-40% of cardiac output

Question 3

Gives some causes of heart failure

Answer 3

Arrhythmias - mainly tachycardias
• Valve Disease - mitral or aortic regurgitation or valve stenoses
• Pericardial Disease - if the pericardium becomes inflamed and fibrotic then the heart can’t relax and pump as well
• Congenital Heart Disease - if there are holes or misconnections then there is an increased risk of heart failure
• Myocardial Disease - commonest cause of myocardial disease in this country is coronary heart disease

Question 4

What are 4 types of cardiomyopathy and what is cardiomyopathy

Answer 4

Cardiomyopathy is heart disease in the absence of a known cause
• This occurs in about 5% of heart failure in a population
• The different types of cardiomyopathy were mentioned earlier
• Hypertrophic cardiomyopathy is the most common cause of young athletes
dropping dead
Dilated Cardiomyopathy (DCM) - specific or idiopathic
• Hypertrophic Cardiomyopathy (HCM or HOCM or ASH)
• Restrictive Cardiomyopathy
• Arrhythmic Right Ventricular Cardiomyopathy (ARVC)

Question 5

What can cause dilated cardiomyopathy

Answer 5

Infectious causes
o Viruses & HIV o Mycobacteria o Rickettsia
o Fungus
o Bacteria
o Parasites
 Toxins and poisons
o Ethanol
o Metals
o Cocaine
o Carbon dioxide or hypoxia
 Drugs
o Chemotherapeutic agents
o antiviral agents  Metabolic disorders
o Nutritional deficiencies and endocrine diseases
 Collagen disorders, autoimmune cardiomyopathies
 Peri-partum cardiomyopathy, neuromuscular disorders

Question 6

Give some symptoms of heart failure

Answer 6

Symptoms – subjective, expressed by patient

• Ankle swelling
• Exertional breathlessness
• Fatigue
• Orthopnoea
• PND
• Nocturia
• Anorexia + Weight loss

Question 7

Give some signs of heart failure

Answer 7

o Tachycardia
Breathlessness
o Decreased pulse volume
o Pulsus alternans
o Increased Jugular venous pressure o Pitting Oedema
o Rales
o Hepatomegaly
o Ascites

Question 8

What can cause restricted cardiomyopathy

Answer 8

Associations of fibrosis:
Infiltrative disorders: o Amyloidosis
o sarcoid disease
o inborn errors of metabolism o neoplasia
 Storage disorders
o Haemochromatosis and haemosiderosis o Fabry disease
o glycogen storage disease
 Endomyocardial disorders
o Endomyocardial fibrosis o hypereosinophilic syndrome
o carcinoid, metastases, radiation damage

Question 9

What are the hormone medications involved in heart failure

Answer 9

Constrictors
- Noradrenaline
- Renin/angiotensin II
- Endothelin
- Vasopressin
- NPY
 Dilators
- ANP
- Prostaglandin E2 & metabolites
- EDRF
- Dopamine
- CGRP
 Growth factors
- Insulin
- TNF alpha
- Growth hormone
- Angiotensin II
- Catecholamine
- Nitric oxide
- Cytokines
- Oxygen radicals

Question 10

How can an X-ray show heart failure

Answer 10

There is an increase in the cardio-
thoracic ratio
• You measure the widest part of the
heart and the distance between one inside rib and the opposite one at the greatest diameter and compare the two
• In normal people, the width of the heart should NOT be more than 50% the width of the thorax

Question 11

Which drugs are used to treat heart failure

Answer 11

Diuretics
• ACE inhibitors
• Beta Blockers
• Aldosterone Antagonists (Spironolactone)
• Digoxin (for atrial fibrillation)
• Devices (cardiac resynchronisation, implanted cardioverter defibrillator)

Question 12

How can heart failure be evaluated

Answer 12

ECG
• Coronary Angiography - can show where there is a stricture
• M-mode echocardiogram - not used any more
• 2D echocardiogram - you can see how the heart is actually pumping
• MRI scanning - this has revolutionised how we look at the heart and may
replace chest X-rays

Question 13

What are the 4 NYHA CLASSIFICATIONS

Answer 13

irtually no symptoms - the heart is dysfunctioning but most things are fine
• 2 = slight limitation of physical activity
• 3 = marked limitation of physical activity
• 4 = the patient can’t get out of a chair or is in bed