Cardiac Failure

Question 1

What is Congestive Cardiac Failure (CCF)

Answer 1

Failure of both the Left and Right ventricles (L–>R)

Question 2

What are the sx/signs of LHF?

Answer 2

Sx - Fatigue, extertional dyspnoea, PND, orthopnoea

Signs - Cardiomegaly, 3rd heart sound, gallop rhythm, bibasal crackles

Question 3

Define cardiac failure

Answer 3

Failure of the heart as a pump to meet the circulatory needs

Question 4

Distinguish systolic and diastolic failure

Answer 4

Systolic - problem of contraction, decreased CO, EF <40%

Diastolic - problem of relaxation, increased filling pressure, EF >50%

Question 5

What are the typical findings o/e of a patient suffering from CCF?

Answer 5

Symptoms of failure and signs of cardiac dysfunction at rest

• tachycardia
• raised JVP
• hepatomegaly (backup of blood)
• peripheral oedema
• ascites

Question 6

What are the sx/signs of RHF?

Answer 6

Sx - Fatigue, breathlessness, anorexia, peripheral oedema

Signs - Raised JVP, hepatomegaly/ascites, pitting oedema, pleural effusions, cardiomegaly, gallop rhythm

Question 7

What is the long term management of CCF?

Answer 7

Lifestyle advice
ACEi + B-blocker (1st line)
Diuretic if symptomatic
Spironolactone/ATRA/hydralazine (2nd line)
Digoxin (3rd line)

Question 8

How do diuretics treat CCF?

Answer 8

Reduce fluid volume
Symptomatic relief
Decrease pre/after load - decrease cardiac work
Venodilation

Question 9

What are the common side effects of diuretics?

Answer 9

Hypokalemia
Hyponatremia
Hypotension
Arrhythmias
Muscle cramps
Blurred vision
Confusion
Headache
Loss of appetite

Question 10

How do ACEIs work?

Answer 10

Inhibit conversion of AI-AII - decrease level of aldosterone - oppose RAAS
Symptomatic relief
Decrease BP

Question 11

What are the common side effects of ACEIs?

Answer 11

First dose hypotension
Renal damage (w/ NSAIDs)
Dry cough (10%)
Hyperkalemia

Question 12

How do B-blockers work?

Answer 12

Antagonise b-adrenoceptors - decrease SNS

• bradycardic
• decrease renin secretion
• oppose catecholamine activity

Question 13

How does Spironolactone work?

Answer 13

K+ sparing diuretic

Question 14

What are the common side effects of Spironolactone?

Answer 14

Vomiting
Diarrhoea
Stomach pain/cramps
Dry mouth
Dizziness
Gynaecomastia
Erectile dysfunction

Question 15

What are the signs of Digoxin toxicity?

Answer 15

Anorexia
Nausea
Visual disturbances
Diarrhoea

Question 16

How do vasodilators work?

Answer 16

Dilate blood vessels, reduce BP

Question 17

What are the common side effects of vasodilators?

Answer 17

Dizziness
Lightheadedness
Headaches
Flushing
Nausea
Swelling from fluid buildup

Question 18

What investigations should be performed for suspected heart failure?

Answer 18

ECHO - indicate cause, confirm presence LV dysfunction
ECG - look for cause
BNP - defining sign f heart failure <100pg/ml
CXR

Question 19

What signs on a CXR are indicative of cardiac failure?

Answer 19

Alveolar oedema
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
Pleural effusion

Question 20

What are the common causes of heart failure?

Answer 20

Ischaemic Heart Disease (35-40%)
Dilated Cardiomyopathy (30%)
HTN (20%)

Question 21

What are the maladaptive processes of neurohormonal adaptation in cardiac failure?

Answer 21

Reduced cardiac output leads to activation of SNS/RAAS
RAAS leads to vasoconstriction & Na retention
SNS activation at first increases contractility, if prolonged causes myocyte apoptosis/necrosis

Question 22

What are the adaptive processes of neurohormonal adapation in cardiac failure?

Answer 22

ANP released in response to atrial stretch, counteracts RAAS

Question 23

How does Digoxin work?

Answer 23

Positive ionotrope (increase muscle contraction) & negative chronotrope (heart rate decreases)
Inhibits Na/K pump
Impairs AVN conduction/increases vagal activity

Question 24

What are the key lifestyle interventions in heart failure?

Answer 24

Patient education, obesity control, smoking cessation
Low level endurance activity
Vaccination (against pneumoccocal disease/influenza)
Sex (avoid viagra/sildenafil)