Cardiac Failure

Question 1

Pulmonary Oedema

Answer 1

LA, Pulmonary veins and lungs increased volume and pressure causing leaking of fluid from the blood vessels to surrounding tissues which they cannot absorb, leaving excess fluid accumulation.

Question 2

Type of HF

Answer 2

HFrEf - Ejection fraction <50%

HFpEf - someone has clinical features of HF but an ejection fraction >50% - resulting from diastolic dysfunction due to issue LV filling with blood in diastole.

Question 3

Ejection fraction

Answer 3

% of blood in the LV squeezed out with each ventricular contraction. Ideal >50%

Question 4

Paroxysmal nocturnal dyspnoea causes

Answer 4

1. Fluid settles across large surface area as they lay flat to sleep, causing breathlessness compared to fluid being in lung bases when stood up
2. Resp centre in brain is less responsive during sleep - allowing the patient to reach a lower state of hypoxia and pulmonary congestion before they are awoken
3. Less adrenaline causing myocardium relaxation and reduced CO.

Question 5

RF CHF

Answer 5

Ischaemic Heart Disease
Valvular Heart Disease (aortic stenosis)
HTN
Arrhythmias (AF)
Cardiomyopathy
Tamponade
Constrictive pericarditis

Question 6

Presentation CHF

Answer 6

Breathlessness worsened by exertion
Cough - white / frothy pink sputum
Orthopnea
Paroxysmal nocturnal dyspnea
Peripheral oedema
Fatigue

Question 7

Examination findings CHF

Answer 7

Tachycardia and Tachypnoea
HTN
Murmurs or third heart sounds - valvular heart disease
Bilateral basal crackles - pulmonary oedema.
Raised JVP
Peripheral Oedema

Question 8

Ix CHF

Answer 8

N-terminal pro-B-type natriuretic peptide (NT-proBNP)
From 400 - 2000ng/l - echo within 6 weeks
Above 2000ng/l - echo within 2 weeks
ECG
Echo

Question 9

Classification of CHF

Answer 9

NYHC Classification:
1. No limitation on activity
2. Comfortable at rest but symptomatic with ordinary activities
3. Comfortable at rest but symptomatic with any activity
4. Symptomatic at rest

Question 10

Left sided vs Right Sided HF

Answer 10

Left Sided :
Pulmonary oedema, dyspnoea, POD, Bibasal fine crackles
Right Sided:
Peripheral oedema, raised JVP, hepatomegaly, weight gain and anorexia.

Question 11

Treatment progression for CHF - RAMPS

Answer 11

R - Refer to cardiology
A - Advise them about the condition
M - Medical treatment
P - Procedural or surgical interventions
S - Specialist heart failure MDT input

Question 12

Drug treatment CHF

Answer 12

ABAL:
ACE inhibitor / ARB
Beta Blocker
Aldosterone antagonist (given if A+B not working)
Loop Diuretics.

Question 13

How do ACE help HF

Answer 13

reduced water reabsorption and increased excretion. Reduced blood volume and vasodilation causing reduction in BP.

Question 14

How do loop diuretics help

Answer 14

Inhibiting a sodium-potassium-chloride cotransporter (NKCC2) in the thick ascending limb of the loop of Henle in the kidneys - leads to decreased sodium and water reabsorption, resulting in increased urine output and reduced fluid overload.

Question 15

How do SGLT2 inhibitors help HF

Answer 15

Reducing the reabsorption of glucose and sodium in the kidneys, leading to increased excretion of both into the urine, a process called glycosuria and natriuresis.

Question 16

Additional / Secondary prevention CHF

Answer 16

Flu, covid and pneumococcal vaccines
Stop smoking
Treatment of comorbid with written care plan
Cardiac rehab.

Question 17

Surgical interventions CHF

Answer 17

Implantable cardioverter defibrillators
Cardiac resynchronisation therapy
Heart transplant

Question 18

AHF types

Answer 18

De-novo - no PMHx
Decompensated - PMHx

Question 19

De-novo AHF

Answer 19

Without previous medical history.

Increased cardiac filling pressure and myocardial dysfunction leading to ischaemia.

Causes reduced CO and hypoperfusion.

Question 20

BNP function and release

Answer 20

Relax the smooth muscle in blood vessels. This reduces systemic vascular resistance.

BNP also acts on the kidneys as a diuretic to promote water excretion in the urine. This reduces the circulating volume.

Released when cardiac myocytes are overstretched

Question 21

Other causes of raised BNP

Answer 21

Tachycardia
Sepsis
PE
Renal Impairment
COPD

Question 22

Presentation AHF

Answer 22

Fluid congestion
Weight gain
Orthopnoea
Breathlessness

Question 23

Ix AHF

Answer 23

Blood - anaemia, abnormal electrolytes or infection precipitating attack

ABG - Acute LVF causes T1RF - low o2 without increased CO2.

Cxr - pulmonary venous congestion, interstitial oedema and cardiomegaly.

Echo

B-type natriuretic peptide or proBNP - myocardial damage.

Question 24

Triggers of AHF

Answer 24

Iatrogenic (e.g. aggressive IV fluids in frail elderly patient)
MI
Arrhythmias
Sepsis
Hypertensive emergency

Question 25

Treatment AHF

Answer 25

SODIUM:
Sit up
Oxygen or CPAP if they have RF.
Diuretics - IV loop diuretic (furosemide)
IV fluid stopped
Underlying cause identified and treated
Monitor fluid balance.

Question 26

When to stop Beta Blockers in AHF

Answer 26

HR <50bpm
2nd or 3rd degree HB
Shock.