Cardiac failure

Question 1

presentation of acute heart failure?

Answer 1

SOB/breathlessness, ankle swelling,

reduced exercise tolerance, fatigue, tiredness,

increased time to recover after exercise, and nocturnal cough.

PND - waking up at night SOB as have been lying flat

Question 2

Define heart failure ?

Answer 2

A clinical syndrome resulting from an abnormality of cardiac structure and/or function

important because can results from
Myocardial dysfunction eg Acute MI
Valvular dysfunction eg Aortic stenosis

Question 3

signs of poor perfusion in heart failure?

Answer 3

Cold extremities
Narrow pulse pressure
Oliguria

Dizziness
Central cyanosis
Delayed capillary refill time

Question 4

Signs of HF?

Answer 4

-> Obvi depends on if L/R HF

Left:
pulmonary congestion - crackles, wheeze
cough, bloody sputum
pnd
cyanosis

Right;
ascites,
hepatomegaly
leg oedema
anorexia 
raised jvp

Question 5

IVX for HF?

Answer 5

Bloods:
BNP - should be raised ! (NT-proBNP)
Troponins - high
CRP - high
do the full work up

ECG:
usually abnormal
eg LVH + sinus tachycardia
some arrhythmia

Cxr:
Pulmonary congestion
Pleural effusion
Interstitial or alveolar oedema
Cardiomegaly.

Echo:
Systolic/diastolic dysfunction/valve disease etc
Ejection fraction

Question 6

Mx of heart failure patients?

Answer 6

Acutely;

1. IV furosemide
2. Fluid restriction
   - daily weights
   - Consider respiratory support if serious
   - Mechanical pump support; intra-aortic balloon pump
   - Inotrope support

Continuing care - important (give all meds):

1. ACEi or ARB
2. BBlocker
3. SGLT2i; empagliflozin
4. Implantable defibrillator (ICD) if EF< 35%

+ spirinolactone
ARB - Valsartan (improves LV function; start when EF<40 - given if not responding to cocktail of others)

Mnemonic: BASE

Question 7

prognosis of HF ?

Answer 7

50% mortality in first 5 years even with optimal medical therapy

Question 8

How does HF lead to death?

Answer 8

Arrythmias; VT/VF or PEA

Pump failure -> multi-organ failure due to low perfusion

Question 9

how is HF classified

Answer 9

New York Heart Association (NYHA - neehaa) classification:

Class I: asymptomatic
Ordinary physical activity does not result in undue breathlessness, fatigue, or palpitations

Class II: mild symptoms with moderate exertion
Comfortable at rest

Class III: symptoms with minimal activity
Less than ordinary physical activity causes undue breathlessness, fatigue, or palpitations

Class IV: symptoms at rest
Unable to carry on any physical activity without discomfort

Question 10

key history points to ask in HF?

Answer 10

Can they tolerarte stairs without SOB? how much of it?

helps with NYHA class

Question 11

What is the use of ICDs / pacemakers?

Answer 11

treat many dysrhythmias, and it is specifically designed to address ventricular tachyarrhythmias. ICDs have revolutionized the treatment of patients at risk for sudden cardiac death due to ventricular tachyarrhythmias.

Question 12

In patients with heart failure who have left ventricular dysfunction with an LVEF of 35% what are their non-medical treatment options

Answer 12

Implantable cardioverter defibrillators,

Cardiac resynchronisation therapy (CRT) with defibrillator (CRT-D)

or CRT with pacing (CRT- P) are recommended

Question 13

in severely impaired LVEF, which pacing would you not give?

Answer 13

Permanent tpace maker - only paces right ventricle, can make situaiotn worse

can do CRT and icd