Cardiac Failure

Question 1

Define Cardiac Failure

Answer 1

Inability of cardiac output to meet body’s demands despite NORMAL venous pressures

Question 2

How can cardiac failure be classified by output?

Answer 2

Low output: Decreased output

High output: Increased demand

Question 3

Which 5 conditions predispose to left heart failure?

Answer 3

IHD
HTN
Cardiomyopathy 
Aortic valve disease  
Mitral regurgitation

Question 4

Which 7 conditions predispose to right heart failure?

Answer 4

Secondary to left heart failure (congestive cardiac failure)
Infarction
Cardiomyopathy
Pulmonary HTN/ embolus/ valve disease
Chronic lung disease
Tricuspid regurgitation
Constrictive pericarditis/ pericardial tamponade

Question 5

Which 4 conditions predispose to biventricular failure?

Answer 5

Arrhythmia
Cardiomyopathy (dilated or restrictive)
Myocarditis
Drug toxicity e.g. Taxanes

Question 6

Which 6 conditions predispose to high output cardiac failure?

Answer 6

Anaemia  
Beri beri 
Pregnancy  
Paget's disease  
Hyperthyroidism 
Arteriovenous malformation

Question 7

Describe the epidemiology of cardiac failure

Answer 7

10% of >65 yrs

Question 8

List 4 presenting symptoms of left heart failure

Answer 8

Dyspnoea (NYHA)
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue

Question 9

What causes the presenting symptoms in left heart failure?

Answer 9

Pulmonary congestion

Question 10

List 3 additional presenting symptoms in acute left ventricular failure

Answer 10

Wheeze
Cough
Pink frothy sputum

Question 11

List 6 presenting symptoms in right heart failure

Answer 11

Swollen ankles  
Fatigue  
Increased weight (due to oedema)  
Reduced exercise tolerance  
Anorexia 
Nausea

Question 12

What are 6 signs of left heart failure?

Answer 12

Tachycardia 
Tachypnoea 
Displaced apex beat  
Bilateral basal crackles  
S3 gallop (rapid ventricular filling)  
Pansystolic murmur (due to functional MR)

Question 13

What are 5 additional signs in acute left ventricular failure?

Answer 13

Cyanosis  
Peripheral shutdown  
Pulsus alternans  
Wheeze (cardiac asthma)  
Fine crackles throughout lung

Question 14

What are 5 signs in right heart failure?

Answer 14

Raised JVP 
Hepatomegaly  
Ascites  
Ankle/sacral pitting oedema  
Signs of functional tricuspid regurgitation

Question 15

What bloods would be taken in cardiac failure?

Answer 15

FBC 
U+Es 
LFTs 
CRP 
Glucose  
TFTs

Question 16

What bloods must also be taken in acute left ventricular failure?

Answer 16

ABG  
Troponin 
BNP 
Raised plasma BNP suggests cardiac failure  
Low plasma BNP excludes cardiac failure

Question 17

What is seen on a CXR in acute LV failure?

Answer 17

Alveolar oedema (bats wing shadowing)
Kerley B lines 
Cardiomegaly 
Upper lobe Diversion/ Dilated prominent upper lobe veins 
Pleural Effusion

Question 18

What may be seen on an ECG in cardiac failure?

Answer 18

Normal
Ischaemic changes (pathological q waves, t wave inversion)
Arrhythmia or LV hypertrophy

Question 19

What end diastolic pressures would you measure using a Swan-Ganz Catheter in cardiac failure ?

Answer 19

RA
RV
Pulmonary artery
Pulmonary wedge
LV

Question 20

What is the management plan for acute heart failure?

Answer 20

Cardiogenic shock: Inotropes e.g. Dobutamine
Pulmonary oedema: Sit patient up
Morphine, oxygen, IV GTN + aspirin (MONA)
Furosemide if fluid overloaded
Clopidogrel + LMWH (VTE prophylaxis)
Treat cause (MI, arrhythmia)

Question 21

What is the management plan for chronic heart failure?

Answer 21

ACEi’s (ramipril): inhibit RAS + reduce adverse remodeling
B blocker (Bisprolol): Block the effects of chronically activated sympathetic system
Loop diuretics: Furosemide to correct fluid overload
Aldosterone antagonists (Spironolactone)
If the above fail, add ARB (ie. Candesartan) or Digoxin: positive ionotrope
Nitrates (esp. afrocaribbeans)
Cardiac resynchronization if arrhythmic.

Question 22

When treating chronic heart failure what else must you do?

Answer 22

TREAT THE CAUSE (e.g. HTN)

TREAT EXACERBATING FACTORS (e.g. anaemia)

Question 23

What must be avoided when treating patients with heart failure?

Answer 23

Drugs that could adversely affect them due to systolic dysfunction:
NSAIDs
Non-dihydropyridine CCBs e.g. Diltiazem, Verapamil

Question 24

List 3 possible complications of heart failure

Answer 24

Respiratory failure
Cardiogenic shock
Death

Question 25

What is the prognosis for heart failure?

Answer 25

50% with cardiac failure die within 2 years

Question 26

What conservative management advice is used for chronic heart failure?

Answer 26

Stop smoking
Stop drinking alcohol
Decrease salt intake
Optimise weight + nutrition

Question 27

Describe left heart failure

Answer 27

Dysfunction associated with LV

Question 28

Describe right heart failure

Answer 28

Dysfunction associated with the RV

Often a result of left-sided failure.

Question 29

How can heart failure be classified by time course?

Answer 29

Acute: Rapid onset
Chronic: Slow onset

Question 30

What are the 2 types of left heart failure?

Answer 30

Systolic: LV loses its ability to contract normally
Diastolic: LV loses its ability to relax normally

Question 31

Why perform an echocardiogram in cardiac failure?

Answer 31

To assess ventricular contraction.
If LV ejection fraction < 40%: systolic dysfunction.
Diastolic dysfunction: reduced compliance leading to a restrictive filling defect.