B.14 Heart Failure. Etiology, DX

Question 1

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

define chronic heart failure

Answer 1

Chronic heart failure (CHF) is a syndrome where the heart is unable to pump blood effectively to meet the body’s needs. It is typically progressive, and classified by:

Systolic (HFrEF): ↓ Ejection fraction (EF <40%)

Diastolic (HFpEF): Preserved EF (≥50%) but impaired filling

Mid-range (HFmrEF): EF 41–49% (newer category)

Question 2

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

most common causes

Answer 2

Ischemic heart disease - Most common cause (MI, chronic CAD)

Hypertension Leads to LV hypertrophy → diastolic failure

Valvular disease Aortic or mitral regurgitation/stenosis

Dilated cardiomyopathy Idiopathic, post-viral, alcohol, drugs (e.g., doxorubicin)

Arrhythmias - Atrial fibrillation, bradycardia, tachycardia-induced

Other Thyroid disorders, anemia, hemochromatosis, amyloidosis

Question 3

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

simple pathophy

Answer 3

↓ Cardiac output → activation of RAAS, SNS, ADH

Leads to vasoconstriction, sodium/water retention, remodeling

Chronic neurohormonal activation worsens myocardial function over time

LVH in HFpEF; dilation in HFrEF

Question 4

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

common clinical features

Answer 4

Left Sided HF
- Dyspnea (exertional/orthopnea/PND)
- fatigue
- Cough, bibasal crackles
- S3 gallop with systolic HF
- Nocturnal cough, wheeze

Right Sided Heart Failure
- Peripheral edema
- Hepatomegaly, ascites
- Jugular venous distension (JVD)
- Abdominal discomfort
- Weight gain

Question 5

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

simple DX

Answer 5

BNP or NT-proBNP – elevated in HF

ECG – LVH, ischemia, arrhythmias

Chest X-ray – pulmonary congestion, cardiomegaly, pleural effusion

Echocardiogram (key test)

Assesses EF, wall motion, valve function, pericardial disease

HFrEF = EF <40%; HFpEF = EF ≥50%

Blood tests – FBC, U&E, LFTs, TSH, iron studies

Question 6

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

definition Heart Failure

Answer 6

a complex clinical syndrome in which there is structural or functional impairment of ventricular filling and/or ejection of blood

Question 7

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Congestive heart failure (CHF)

Answer 7

HF with signs and/or symptoms of fluid overload, e.g., peripheral edema, jugular venous distention

Question 8

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Left heart failure (LHF):

Answer 8

HF caused by structural or functional impairment of the left heart circulatory system that results in tissue hypoperfusion and/or increased pulmonary capillary

Question 9

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Right heart failure (RHF):

Answer 9

HF caused by structural or functional impairment of the right heart circulatory system that results in impaired blood flow to the pulmonary circulation and/or elevated venous pressures

Question 10

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Chronic compensated heart failure:

Answer 10

HF with stable symptoms

Question 11

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Acute decompensated heart failure (ADHF):

Answer 11

AHF due to decompensation of preexisting disease and/or cardiomyopathy (most common)

Question 12

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Systolic dysfunction:

Answer 12

reduced ventricular contractility resulting in ventricular enlargement and reduced ejection fraction

Question 13

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Diastolic dysfunction:

Answer 13

reduced ventricular compliance characterized by elevated filling pressures, abnormal relaxation, and increased ventricular stiffness

Question 14

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Epidemiology

Answer 14

Approx. 1.9% of the US population (6.2 million individuals) has HF

Incidence is higher among African American and Hispanic individuals.

Incidence increases with age: Approx. 20% of individuals aged > 75 years are affected.

An increasing proportion of patients with HF have HFpEF (≥ 50%)

Question 15

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Cardiovascular Etiology

Answer 15

• Ischemic heart disease (50% of HFrEF cases): coronary artery disease (CAD), myocardial infarction
• Hypertension
• Valvular heart disease
• Arrhythmias and heart rhythm-related conditions, e.g., tachycardia, high PVC burden, RV pacing
• Myocarditis, e.g., infectious, toxic, autoimmune
• Constrictive pericarditis
• Cardiomyopathies
  Dilated cardiomyopathy, e.g., hemochromatosis
  Stress-induced cardiomyopathy
  Peripartum cardiomyopathy
  Hypertrophic cardiomyopathy
  Infiltrative restrictive cardiomyopathy, e.g., amyloidosis, sarcoidosis

Question 16

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Endocrine Causes

Answer 16

Diabetes mellitus
Obesity
Thyroid disease
Kidney disease

Question 17

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Pulmonary Causes

Answer 17

COPD
Pulmonary artery hypertension, cor pulmonale

Question 18

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Toxic Causes

Answer 18

Chemotherapy
Alcohol, tobacco
Cocaine, methamphetamines

Question 19

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Other Causes

Answer 19

Familial or genetic

Autoimmune, e.g., SLE, giant cell arteritis

Question 20

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Heart failure with preserved ejection fraction (HFpEF):

Answer 20

HF with reduced stroke volume, normal or reduced EDV, preserved LVEF (≥ 50%), and evidence of increased LV filling pressures, e.g., increased natriuretic peptides, hemodynamic measurements

The ejection fraction is preserved because both the LV end-diastolic volume and stroke volume are reduced.

Question 21

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Ejection Fraction

Answer 21

Ejection fraction (EF): the proportion of EDV ejected from the ventricle

EF = SV / EDV = (EDV - ESV)/EDV
Normally 50–70%
Serves as an index of myocardial contractility: e.g., ↓ myocardial contractility → ↓ EF (seen in systolic heart failure, where EF is < 40%)
Low in systolic heart failure and usually normal in diastolic heart failure

Question 22

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Heart failure with reduced ejection fraction (HFrEF):

Answer 22

HF with reduced stroke volume and reduced LVEF (≤ 40%)

Question 23

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Heart failure with improved ejection fraction (HFimpEF):

Answer 23

previous HFrEF, with a follow-up LVEF measurement > 40

Question 24

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis

Heart failure with mildly reduced ejection fraction (HFmrEF):

Answer 24

HF with an LVEF 41–49% and evidence of increased LV filling pressures, e.g., increased natriuretic peptides, hemodynamic measurement

Question 25

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis American College of Cardiology/American Heart Association (ACC/AHA) stages Stage A

Answer 25

Stage A: at risk for HF Asymptomatic No structural heart disease or abnormal biomarkers Risk factors for HF, e.g., hypertension, ASCVD, diabetes mellitus, family history of cardiomyopathy

Question 26

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis American College of Cardiology/American Heart Association (ACC/AHA) stages Stage B

Answer 26

Stage B: pre-HF Asymptomatic Evidence of ≥ 1 of the following: - Structural heart disease (e.g., reduced ejection fraction, valvular heart disease, ventricular hypertrophy) - Increased filling pressures - Risk factors for HF plus ↑ BNP or ↑ cardiac troponins with no alternative diagnoses

Question 27

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis American College of Cardiology/American Heart Association (ACC/AHA) stages Stage C

Answer 27

Stage C: symptomatic HF Signs and/or symptoms of HF (current or previous) Structural heart disease

Question 28

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis American College of Cardiology/American Heart Association (ACC/AHA) stages Stage D

Answer 28

Stage D: advanced HF Symptoms of HF that disrupt daily life, with frequent hospitalizations despite GDMT optimization

Question 29

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis New York Heart Association NYHA functional classification NYHA class II

Answer 29

Mild symptoms and slight limitations during ordinary physical activity No symptoms at rest

Question 30

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis New York Heart Association NYHA functional classification NYHA class III

Answer 30

Marked limitations in physical activity Less-than-ordinary activity causes symptoms. Comfortable only at rest

Question 31

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis New York Heart Association NYHA functional classification NYHA class IV

Answer 31

Severe limitations Symptoms during any form of physical activity Symptoms at ret

Question 32

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis New York Heart Association NYHA functional classification NYHA class I

Answer 32

No limitations in physical activity No symptoms of HF

Question 33

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis General Clinical Features

Answer 33

Nocturia - In the supine position, cardiac output increases and renal vasoconstriction decreases, leading to an increase in filtered urine and nocturia. Fatigue Tachycardia, various arrhythmias - Due to an increase in sympathetic tone S3/S4 gallop on auscultation - An S3 gallop indicates rapid ventricular filling, while an S4 gallop indicates ventricular hypertrophy (reduced compliance). Other heart sounds may indicate valvular disease as a potential cause of HF. Pulsus alternans - A physical finding characterized by alternating strong and weak pulses (with a regular pulse rhythm) caused by alterations in cardiac output. Associated with left ventricular failure and cardiac tamponade. Cachexia - A state of protein-energy malnutrition secondary to an underlying illness that causes chronic muscle breakdown despite nutritional supplementation.

Question 34

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Clinical Features of Left-Sided Heart Failure

Answer 34

Symptoms of pulmonary congestion: - Dyspnea - Initially exertional dyspnea; as HF progresses, also dyspnea at rest - orthopnea (a sensation of shortness of breath that occurs upon lying down and is relieved by sitting up) - Pulmonary edema - In severe cases or acute decompensated heart failure Paroxysmal nocturnal dyspnea - Nocturnal bouts of coughing and acute shortness of breath - Caused by reabsorption of peripheral edema at night → increased venous return Cardiac asthma - Increased pressure in the bronchial arteries → airway compression and bronchospasm - Symptoms mimic asthma, with shortness of breath, wheezing, and coughing.

Question 35

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Physical Findings of Left Sided Heart Failure

Answer 35

Physical examination findings - Bilateral basilar rales may be audible on auscultation. - Caused by the build-up of fluid in alveoli Laterally displaced apical heart beat (precordial palpation beyond the midclavicular line) - Caused by cardiomegaly - Coolness and pallor of lower extremities - In advanced HF

Question 36

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Clinical features of right-sided heart failure

Answer 36

Symptoms of fluid retention and increased Central Venous Pressure - Predominant signs of right-sided heart failure - Peripheral pitting edema: as a result of fluid transudation due to increased venous pressure - Hepatic venous congestion symptoms - Abdominal pain - Caused by stretching of the liver capsule - Jaundice Other symptoms of organ congestion (e.g., nausea, loss of appetite in congestive gastropathy)

Question 37

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Physical examination findings of right-sided heart failure

Answer 37

- Jugular venous distention: visible swelling of the jugular veins due to an increase in CVP and venous congestion - Kussmaul sign - haracterized by distention of the jugular veins during inspiration (due to elevation of jugular venous pressure) - Hepatosplenomegaly: may result in cardiac cirrhosis and ascites Hepatojugular reflux: jugular venous congestion induced by exerting manual pressure over the patient's liver → ↑ right heart volume overload → inability of the right heart to pump additional blood → visible jugular venous distention that persists for several seconds

Question 38

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Initial Workup

Answer 38

Comprehensive clinical evaluation, focused on acuity and volume status ECG, CXR, and TTE BNP and additional laboratory studies, e.g., CBC, HbA1c HF is confirmed if a patient has clinical features of HF attributable to structural or functional cardiac abnormalities and either: Elevated natriuretic peptides Evidence of cardiogenic pulmonary or systemic congestion

Question 39

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Lab DX BNP

Answer 39

Brain natriuretic peptide (BNP) or N-terminal prohormone of brain natriuretic peptide (NT-proBNP) Indication: all patients with suspected HF Uses: to help confirm the diagnosis and assess disease severity and prognosis Interpretation Elevated levels in patients with classic symptoms of HF support the diagnosis (high predictive index) HF is unlikely if: BNP is < 35 pg/mL or NT-proBNP is < 125 pg/mL in chronic HF [2][12] BNP is < 100 pg/mL or NT-proBNP is < 300 pg/mL in AHF

Question 40

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Additional Labs

Answer 40

Order the following studies to assess for causes of HF, comorbidities, and suitability for pharmacological treatment. CBC: screening for anemia and signs of infection BMP - Creatinine: normal or ↑ - Na+: normal or ↓; hyponatremia may indicate a poor prognosis. HbA1c or fasting glucose: diabetes mellitus screening Liver chemistries: Elevations, particularly of cholestatic enzymes, can indicate hepatic venous congestion. Fasting lipid panel: screening for lipid disorders TSH: to assess thyroid function Iron studies: to assess for iron deficiency in HF Cardiac troponin T/I: may be useful for risk stratification Often elevated in patients with HF - Due to, e.g., subendocardial ischemia, increased wall stress, and endothelial dysfunction.

Question 41

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Transthoracic echocardiogram (TTE) DX

Answer 41

Indications All patients with suspected HF (preferred initial imaging modality) Patients receiving treatment with a change in clinical status Patients undergoing evaluation for device therapy Findings LV systolic dysfunction and/or diastolic dysfunction Quantitative measurement of LVEF Atrial and ventricular size and thickness Evidence of complications, e.g.: Cardiac dyssynchrony, functional mitral regurgitation, left atrial enlargement Pericardial and/or pleural effusion Underlying causes: e.g., LV hypertrophy in hypertension, regional wall motion abnormalities due to CAD

Question 42

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis CXR DX

Answer 42

Indication: all patients with suspected HF; especially useful in AHF Findings Changes to the cardiac silhouette - Cardiomegaly, i.e., cardiothoracic ratio > 0.5 - Boot-shaped heart on PA view: RV enlargement - Signs of pericardial effusion (e.g., water bottle heart) X-ray findings of pulmonary congestion Signs of concomitant heart conditions, including: - Valvular calcifications in valvular disease P- ericardial calcification in constrictive pericarditis

Question 43

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis ECG DX

Answer 43

Indications: all patients with suspected HF Findings - Some patients may have a normal ECG, especially those with HFpEF. - Changes associated with the etiology of HF and other cardiovascular comorbidities, e.g., ECG changes in STEMI, arrhythmias Abnormalities related to HF (common but mainly nonspecific), e.g.: - ECG signs of LV hypertrophy (e.g., positive Sokolow-Lyon index) - Impaired systolic function leads to congestion in the ventricle and compensatory hypertrophy. - ST-segment and T-wave abnormalities (e.g., ST depression) - P wave abnormalities (e.g., P mitrale) - As the ventricle becomes more congested, blood flow backs up, leading to atrial stretch and enlargement and consequent P wave abnormalities. - Prolonged QTc interval

Question 44

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Additional DX Studies

Answer 44

Cardiac MRI: highly accurate assessment of ventricular volume, mass, and ejection fraction Noninvasive stress imaging, i.e., echocardiography, nuclear scintigraphy: to assess for obstructive CAD and myocardial ischemia Right heart catheterization (RHC) - Most sensitive and specific study for HFpEF confirmation, but expensive and invasive - Used to assess right heart function and pulmonary vascular resistance in patients being considered for mechanical circulatory support or heart transplant - May be considered for monitoring and guiding management in certain patients with cardiogenic shock. SvO2 is low in decompensated HF.

Question 45

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis A patient has severe HF but a normal EF. Is this still heart failure?

Answer 45

→ ✅ Yes – HFpEF (diastolic failure)

Question 46

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Patient has fatigue, JVD, ascites, but no pulmonary symptoms. Is this left-sided HF?

Answer 46

→ ❌ No – this is right-sided HF, possibly from cor pulmonale

Question 47

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Can chronic hypertension cause systolic heart failure?

Answer 47

→ ✅ Yes — long-standing pressure overload can lead to LV dilation and eventual systolic dysfunction.

Question 48

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Does a normal BNP exclude heart failure?

Answer 48

→ ❌ No — BNP may be falsely low in obese patients or very early in disease.

Question 49

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis A patient has an EF of 60% but severe dyspnea and elevated BNP. Is this HFrEF?

Answer 49

→ ❌ No — this is likely HFpEF (preserved EF but impaired filling or compliance)

Question 50

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Pathophys of Heart failure with reduced ejection fraction (HFrEF)

Answer 50

Reduced contractility → systolic ventricular dysfunction → decreased left ventricular ejection fraction (LVEF) → decreased cardiac output Causes include: - Damage and loss of myocytes (e.g., following myocardial infarction, CAD, dilated cardiomyopathy) - Cardiac arrhythmias - High-output conditions

Question 51

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Pathophys of Heart failure with preserved ejection fraction (HFpEF)

Answer 51

Decreased ventricular compliance → diastolic ventricular dysfunction → reduced ventricular filling and increased diastolic pressure → decreased cardiac output (while the left ventricular ejection fraction remains normal) Causes include: - Increased stiffness of the ventricle (e.g., long-standing arterial hypertension with ventricular wall hypertrophy, restrictive cardiomyopathy) - Impaired relaxation of the ventricle (e.g., constrictive pericarditis, pericardial tamponade)

Question 52

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Pathophys of Left-sided heart failure (HFrEF and/or HFpEF)

Answer 52

Increased left ventricular afterload: increased mean aortic pressure (e.g., arterial hypertension), outflow obstruction (e.g., aortic stenosis) Increased left ventricular preload: left ventricular volume overload (e.g., backflow into the left ventricle caused by aortic insufficiency)

Question 53

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Pathophys of Right-sided heart failure

Answer 53

Increased right ventricular afterload: increase in pulmonary artery pressure (e.g., pulmonary hypertension) Increased right ventricular preload: right ventricular volume overload (e.g., tricuspid valve regurgitation, left-to-right shunt

Question 54

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Pathophys of Consequences of decompensated heart failure - Forward failure:

Answer 54

Forward failure: reduced cardiac output → poor organ perfusion → organ dysfunction (e.g., hypotension, renal dysfunction)

Question 55

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Pathophys of Consequences of decompensated heart failure - Backward Failure

Answer 55

Left ventricle: increased left-ventricular volumes or pressures → backup of blood into lungs → increased pulmonary capillary pressure → cardiogenic pulmonary edema (presenting with orthopnea) and increased pulmonary artery pressure Right ventricle: increased pulmonary artery pressure → reduced right-sided cardiac output → systemic venous congestion → peripheral edema and progressive congestion of internal organs (e.g., liver, stomach) Nutmeg liver: the macroscopic appearance of the liver which resembles a nutmeg seed due to ischemia and fatty degeneration from hepatic venous congestion

Question 56

B.19 Chronic Heart Failure - Etiology, Symptoms Diagnosis Compensation Mechanism

Answer 56

The compensation mechanisms are meant to maintain the cardiac output when stroke volume is reduced. Increased adrenergic activity: increase in heart rate, blood pressure, and ventricular contractility - Increase of renin-angiotensin-aldosterone system activity (RAAS): activated following decrease in renal perfusion secondary to reduction of stroke volume and cardiac output ↑ Angiotensin II secretion results in: - Peripheral vasoconstriction → ↑ systemic blood pressure → ↑ afterload - Vasoconstriction of the efferent arterioles → ↓ net renal blood flow and ↑ intraglomerular pressure → maintained GFR - ↑ Aldosterone secretion → ↑ renal Na+ and H2O resorption → ↑ preload Secretion of natriuretic peptides: ↑ intracellular smooth muscle cGMP → vasodilation → hypotension and decreased pulmonary capillary wedge pressure → cleavage of the prohormone proBNP into BNP and NT-proBNP - Brain natriuretic peptide (BNP): ventricular myocyte hormone released in response to increased ventricular filling and stretching -NT-proBNP: inert biomarker produced in cardiomyocytes from the cleavage of the prohormone proBNP