34. Heart Failure

Question 1

what is Heart failure

Answer 1

impaired ventricular filling or ejection fraction. The state in which the heart is unable to pump blood at a rate commensurate with the requirements of the tissues or can do so only at high pressures

Question 2

what happens when there is impairment of left ventricular filling

Answer 2

in diastole, the left ventricular walls relax to allow filling of the LV cavity.
Without proper LV relaxation, the volume of blood filling the cavity is reduced thus reducing stroke volume and the blood ejected with each contraction

Question 3

what happens of there is LV wall damage

Answer 3

due to LV wall damage, the LV may have reduced ability to pump or eject the blood aka impaired ejection of blood

Question 4

what are the steps for the diagnostic evaluation of new onset heart failure

Answer 4

• determine the type of cardiac dysfunction (systolic vs diastolic)
• determine aetiology and treat potentially reversible causes
• define prognosis
  -guide therapy

Question 5

what are some of the aetiology examples of Heart Failure

Answer 5

coronary heart disease (MI)
Hypertension
dilated cardiomyopathy
Valve disease
tachycardic arrhythmias
HFFpEF

Question 6

what are some of the classic symptoms of heart failure

Answer 6

SOB, Orthopnea, Paroxysmal nocturnal dyspnoea, reduced exercise tolerance, fatigue, tiredness, ankle swelling

Question 7

what is the new york heart association functional classification

Answer 7

1-4
1 - no limitation of physical activity
2- slight limitation
3- marked limitation
4- unable (symptoms at rest)

Question 8

what examination techniques would you use for heart failure

Answer 8

• neck exam - looking for elevated JVP
• Auscultation of the lungs - rales or crackles
• Auscultation of the heart - looking for 3rd or 4th heart sounds (S3/S4)(gallop rhythm) or murmurs
• Oedema - in sacrum, feet, ankles or lower legs

Question 9

what diagnostic tests can you do for heart failure

Answer 9

ECG - arrhythmias, past MI, LVH

Chest X ray - size/shape of heart or fluid accumulation in the lungs

Echocardiography - Transthoracic echocardiography TTE

Doppler

MRI

Angiogram

BNP (plus full blood tests)

Question 10

in heart failure what do you see on the x ray

Answer 10

enlarged cardiac silhouette
peripheral congestion
Kerley B lines
fluid in inferior accessory fissure

Question 11

guidelines recommend which diagnostic test as the most useful for HF

Answer 11

Echocardiography

Question 12

what do Echocardiographys show

Answer 12

• chamber size
• right and left ventricular function
• regional wall motion abnormalities
• impaired LV filling (stiffness) a feature of diastolic dysfunction
• valvular heart disease
• diseases of the pericardium
• ejection fraction

Question 13

what is ejection fraction

Answer 13

the percentage of blood that is pumped out of the heart during each beat

Question 14

what is a normal EF

Answer 14

> 50%

Question 15

Heart failure with an EF of 40% is known as what?

Answer 15

HFrEF heart failure reduced ejection fraction

Question 16

what is heart failure reduced ejection fractions percentage EF

Answer 16

<40 %

Question 17

Heart failure when ejection fraction is normal aka >50% is know as what?

Answer 17

HFpEF Heart Failure preserved ejection fraction

Question 18

what is the equation to work out ejection fraction

Answer 18

amount of blood pumped out of the ventricle ////////////over total amount of blood in the ventricle

Question 19

what is HFrEF

Answer 19

LV unable to eject and adequate amount of blood during systole

Question 20

what is HFpEF

Answer 20

less blood ablw to fill the LV in diastole due to myocardial stiffness thus LV has less blood to eject during systole

Question 21

what is BNP

Answer 21

it’s a hormone produced by your heart. When your heart has to work harder than usual, it releases more BNP into your blood. (ventricular hormone)

Question 22

what is ANP

Answer 22

is a hormone produced by the heart, specifically by the atria

Question 23

what scans/imaging techniques can you use

Answer 23

PET
Echo
Cardiac MRI
TI-1201
TC-99 SPECT

Question 24

what does Late Gadolinium Enhanced Cardiac MRI show you?

Answer 24

This is a specific technique used within a CMR scan. After injecting a gadolinium-based contrast agent, LGE highlights areas of the heart muscle that are damaged or scarred. It helps differentiate between healthy and non-viable (damaged) heart tissue. It looks at size of LGE % and Wall thickness too

Question 25

what lifestyle restrictions would you advise for a patient with HF

Answer 25

avoid salt, encourage exercise, keep vaccinations up to date

Question 26

what are the 4 pillars of therapy in Heart failure

Answer 26

ARNI, BB, MRA, SGLT2i

Question 27

what are ARNIs

Answer 27

angiotensin receptor neprilysin inhibitors

Question 28

what are MRAs

Answer 28

mineralocorticoid receptor antagonists

Question 29

what are SGLT2i

Answer 29

sodium-glucose co transporter 2 inhibitors

Question 30

what does the presence of LBBB in HF lead to

Answer 30

abnormal contractile wave-front across the LV causing dyssynchronous contraction and worsening LV systolic function

Question 31

what is it called when the LV doe not contact efficiently

Answer 31

Dyssynchronous Contraction

Question 32

Cardiac resynchronisation therapy (CRT) leads to pacing the LV from where? and what does this do?

Answer 32

From the left lateral wall
- increases synchronous contraction and improved haemodynamics

Question 33

what is involved in cardiac resynchronisation therapy

Answer 33

CRT-D implant

Question 34

what is new in HF treatment (for mild HF)

Answer 34

Eplerenone

Question 35

what is given in addition to BB when they are not enough

Answer 35

ivabradine

Question 36

what is ivabradine

Answer 36

IF channel modulator

Question 37

explain ivabradines function and mode of action

Answer 37

specifically binds to the funny channel
- slows HR

Question 38

what condition does ivabradine not work in

Answer 38

Atrial Fibrillation

Question 39

what does ivabradine not alter

Answer 39

ventricular repolarisation,
myocardial contraction,
Blood pressure

Question 40

what do ARNIs do

Answer 40

Neprilysin inhibitor (NEPi)
- to enhance effects of naturetic peptides
- NEP inhibitor
- Vasodilatior
a. BP
b. Sympathetic tone
c. aldosterone levels
d. natrioresis/ diuresis

Question 41

what do ARBs do

Answer 41

block renin angiotensin aldosterone system (RAAS)
- Valsartan
a. BP
b. Sympathetic tone
c. aldosterone levels
d. cellular growth
e. natriuresis

Question 42

what do SGLT2i do

Answer 42

lower Blood glucose levels and BP through osmotic diuresis
increases urinary caloric loss with reductions in body weight
Reduces albuminuria possibly due to alterations in tubuloglomerular feedback

Question 43

give me a HF drug summary

Answer 43

→ ACE Inhibitors
→ ARBs
→ Beta-blockers
→ Mineralocorticoid antagonists (Spironolactone, eplerenone)
→ Neprilysin inhibitors (salcubitril valsartan)
→ Sglt2 inhibitors (Dapagliflozin / Empagliflozin)
→ Diuretics (Frusemide/Bumetanide)
Digoxin

Question 44

Exercise and SGLT2 inhibitors show MUCH PROMISE for…

Answer 44

HFpEF

Question 45

what drugs helped diuresis in patient with ADHF

Answer 45

Ipragliflozin

Question 46

in refractory end stage HF what must be done

Answer 46

review
control fluid retention - are the diuretics not working or ultrafiltration
IV inotropic/vasodilators during decomposition
consider resynchronization or mechanical assist devices or heart transplant

Question 47

what are some reasons patients might need a heart transplant

Answer 47

• refractory cardiogenic shock
• documented dependence on IV inotropic support
• Peak VO2 <10 ml/kg/min
• severe symptoms of ischameia
• recurrent arrhythmias not responding to treatments

Question 48

what are some contradictions to getting a heart transplant

Answer 48

Age
severe comorbidity
active infection
recent cancer