CARDIAC FAILURE

Question 1

Define cardiac failure

Answer 1

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

Question 2

LIST the aetiology and risk factors of cardiac failure

Answer 2

LOW output HF:
Left heart failure
Right heart failure
Biventricular heart failure
HIGH output cardiac failure.

Question 3

Explain the aetiology and risk factors of cardiac failure (4)

Answer 3

LOW output:
o  Left Heart Failure 
•  Ischaemic heart disease   
•  Hypertension 
•  Cardiomyopathy 
•  Aortic valve disease  
•  Mitral regurgitation 

o Right Heart Failure
• Secondary to left heart failure (in which case it is called congestive cardiac
failure)
• Infarction
• Cardiomyopathy
• Pulmonary hypertension/embolus/valve disease
• Chronic lung disease
• Tricuspid regurgitation
• Constrictive pericarditis/pericardial tamponade

o  Biventricular Failure:
•  Arrhythmia 
•  Cardiomyopathy (dilated or restrictive)  
•  Myocarditis  
•  Drug toxicity  

HIGH OUTPUT cardiac failure: 
o  Anaemia  
o  Beri beri 
o  Pregnancy  
o  Paget's disease  
o  Hyperthyroidism 
o  Arteriovenous malformation

Question 4

Summarise the epidemiology of cardiac failure

Answer 4

• 10% > 65 yrs old

Question 5

Recognise the presenting symptoms of LEFT heart failure

Answer 5

Left Heart Failure -symptoms caused by pulmonary congestion

o Dyspnoea - divided based on the New York Heart Association classification:
• 1 - no dyspnoea
• 2 - dyspnoea on ordinary activities
• 3 - dyspnoea on less than ordinary activities
• 4 M dyspnoea at rest

o Orthopnoea
o Paroxysmal nocturnal dyspnoea
o Fatigue

Question 6

Recognise the presenting symptoms of ACUTE LEFT VENTRICULAR heart failure

Answer 6

o Dyspnoea
o Wheeze
o Cough
o Pink frothy sputum

Question 7

Recognise the presenting symptoms of RIGHT heart failure

Answer 7

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

Question 8

Recognise the signs of LEFT heart failure on physical examination

Answer 8

o Tachycardia
o Tachypnoea
o Displaced apex beat
o Bilateral basal crackles
o S3 gallop (caused by rapid ventricular filling)
o Pansystolic murmur (due to functional mitral regurgitation)

Question 9

Recognise the signs of ACUTE LEFT VENTRICULAR heart failure on physical examination

Answer 9

o  Tachypnoea 
o  Cyanosis  
o  Tachycardia  
o  Peripheral shutdown   
o  Pulsus alternans
o  Gallop rhythm 
o  Wheeze (cardiac asthma)  
o  Fine crackles throughout lung

Question 10

Recognise the signs of RIGHT heart failure on physical examination

Answer 10

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

(think more systemic)

Question 11

Explain the pathophysiology of pulsus alternans

Answer 11

• Arterial pulse waveforms showing alternating strong and weak beats
• Sign of left ventricular systolic impairment
• Explanation:
! In left ventricular dysfunction, ejection fraction significantly decreases leading to a reduction in stroke volume
! This causes an increase in endMdiastolic volume
! This means that the left ventricle is stretched more for the next
contraction
! Due to Starling’s Law, the increased stretch of the left ventricle
caused by the increased endMdiastolic volume following the previous beat leads to an increase in the strength of the myocardial contraction
! This results in a stronger systolic pulse

Question 12

Identify appropriate investigations for cardiac failure

Answer 12

•  Bloods 
o  FBC 
o  U&E 
o  LFTs 
o  CRP 
o  Glucose   
o  Lipids   
o  TFTs

•  CXR  "ABCDE" 
o  Alveolar shadowing   
o  Kerley B lines  
o  Cardiomegaly 
o  Upper Lobe Diversion  
o  Pleural Effusion 

• ECG
o May be normal
o May show ischaemic changes (pathological q waves, t wave inversion)
o May show arrhythmia or left ventricular hypertrophy

• Echocardiogram
o Assess ventricular contraction
o Systolic dysfunction = LV ejection fraction < 40%
o Diastolic dysfunction = decreased compliance of the myocardium leads to
restrictive filling defect

• SwanJGanz Catheter
o Allows measurement of right atrial, right ventricular, pulmonary artery, pulmonary wedge and l

Question 13

Identify appropriate investigations for ACUTE LEFT VENTRICULAR heart failure

Answer 13

o ABG
o Troponin
o BNP
- Raised plasma BNP suggests diagnosis of cardiac failure
- Low plasma BNP rules out cardiac failure (90% sensitivity)

Question 14

Generate a management plan for ACUTE left ventricular failure

Answer 14

o Treating Cardiogenic Shock:
• This is severe cardiac failure with low blood pressure
• Requires the use of inotropes (e.g. dobutamine)
• Managed in ITU

o Treating Pulmonary Oedema:
• Sit the patient up
• 60-100% Oxygen (and consider CPAP)
• Diamorphine (venodilator + anxiolytic)
• GTN infusion (venodilator MM> reduced preload)
• IV furosemide (venodilator and later diuretic effect)
• Monitor:
! BP
! Respiratory rate
! Oxygen saturation
! Urine output
! ECG
• TREAT THE CAUSE! (e.g. MI, arrhythmia)

Question 15

Generate a management plan for CHRONIC left ventricular failure

Answer 15

o TREAT THE CAUSE (e.g. hypertension)
o TREAT EXACERBATING FACTORS (e.g. anaemia)

ACE Inhibitors
• Inhibits reninMangiotensin system and inhibits adverse cardiac remodelling
• They slow down the progression of heart failure and improve survival

Beta Blockers
• Blocks the effects of a chronically activated sympathetic system
• Slows progression of heart failure and improves survival
• The benefits of ACE inhibitors and beta blockers are additive

Loop Diuretics
• Alongside dietary salt restriction, can correct fluid overload

Aldosterone Antagonists
• Improves survival in patients with NYHA class III/IV symptoms on standard
therapy
• Monitor K+ (as these drugs may cause hyperkalaemia)

Angiotensin Receptor Blockers
• May be added in patients with persistent symptoms despite the use of ACE
inhibitors and betaMblockers
• Monitor K+ (as these drugs may cause hyperkalaemia)

Hydralazine and a Nitrate
• May be added in patients (particularly AfroMCaribbeans) with persistent
symptoms despite the use of ACE inhibitors and betaMblockers

Digoxin
• Positive inotrope
• Reduces hospitalisation but does NOT improve survival

N-3 Polyunsaturated Fatty Acids
• Provide a small beneficial advantage in terms of survival

Cardiac Resynchronisation Therapy
• Biventricular pacing improves symptoms and survival in patients with a left ventricular ejection fraction < 35%, cardiac dyssynchrony (QRS > 120 msec) and moderateMsevere symptoms
• These patients are also candidates for implantable cardioverter defibrillator (ICD)
• They may receive a combined device

CAUTION: avoid drugs that could adversely affect a patient with heart failure due to systolic dysfunction (e.g. NSAIDs, nonMdihydropyridine CCBs)

Question 16

Identify the possible complications of cardiac failure

Answer 16

• Respiratory failure
• Cardiogenic shock
• Death

Question 17

Summarise the prognosis for a patient with cardiac failure

Answer 17

50% with cardiac failure die within 2 years

Question 18

What are the finding of cardiac failure on a CXR?

Answer 18

CXR  "ABCDE" 
o  Alveolar shadowing   
o  Kerley B lines  
o  Cardiomegaly 
o  Upper Lobe Diversion  
o  Pleural Effusion