Cardiac Failure - Chronic Heart Failure Flashcards
What is the incidence of chronic heart failure?
1 - 20 cases per 100,000
2 - 200 cases per 100,000
3 - 2000 cases per 100,000
4 - 20,000 cases per 100,000
2 - 200 cases per 100,000
Equally as common in men and women
What age does the incidence of chronic heart failure peak?
1 - >80
2 - >70
3 - >60
4 - >50
2 - >70
Chronic heart failure refers to the clinical features of impaired heart function, including filling of blood and ejecting that blood around the body. All of the following can lead to CHF, but which is by the far the most common cause?
1 - hypertension
2 - CKD
3 - IHD / CAD
4 - cardiomyopathy
5 - valvular heart diseases
6 - arrhythmias (AF)
3 - IHD / CAD
Valvular heart diseases: Conditions such as rheumatic heart disease, mitral regurgitation, aortic stenosis and regurgitation can lead to CHF by causing chronic volume or pressure overload.
IHD/CAD is the leading cause of chronic heart failure CHF), however, all of the following non-cardiac causes can also lead to CHF, although which one is least likely?
1 - Diabetes mellitus:
2 - Renal dysfunction
3 - Obesity (diet, sedentary lifestyle)
4 - Aging
5 - Liver disease
6 - Toxins (alcohol/tobacco)
5 - Liver disease
CHF can lead to hepatomegaly, but not typically the other way around
Which 2 of the following lead to chronic heart failure (CHF)?
1 - impaired left ventricle contraction
2 - impaired right ventricle contraction
3 - impaired left ventricle relaxation
4 - impaired right ventricle relaxation
1 - impaired left ventricle contraction
Systolic HF
3 - impaired left ventricle relaxation
Diastolic HF
Stroke volume (SV) is the volume of blood ejected from the heart per beat. How do we calculate SV?
1 - SVR / EDV
2 - SVR / ESV
3 - EDV - ESV
4 - EDV - EF
SVR = systemic vascular resistance
ESR = end systolic volume
EDV = end diastolic volume
EF = ejection fraction
3 - EDV - ESV
EDV = fully relaxed left ventricle filled with blood
occurring at the end of diastolic filling and heard at S1 closure of mitral and tricuspid valves
ESV = blood remaining in left ventricle after contraction, occurring at the end systole and heard at S2 closure of aortic and pulmonary valves
Ejection fraction (EF) is a measure of left ventricular function. How can we calculate EF?
1 - EF = HR x SV
2 - EF = (HR / SVR) x 100
3 - EF = (SV / EDV) x 100
4 - EF = (SV / ESV) x 100
SV = stroke volume
HR = heart rate
EDV = end diastolic volume
ESV = end systolic volume
3 - EF = (SV / EDV) x 100
Normal EF = >55%
- 40-50% is borderline heart failure
- <40% is systolic heart failure
The frank starling mechanism is useful to understand the relationship between systolic and diastolic function. What does the frank starling mechanism show?
1 - increased atrium filling means more ventricular contraction
2 - increased ventricular stretching results in greater stroke volume (SV)
3 - increased ventricular stretching results in reduced preload
4 - reduced ventricular filling increased afterload
2 - increased ventricular stretching results in greater stroke volume
- like a rubber band, the more the stretch the ventricle in diastole = a greater contract force and a larger SV in systole
- reduced stretching due to a dilated or weak left ventricle will cause a reduction in the SV
All of the following can occur In systolic heart failure, but which is typically the first sign?
1 - increased LV diastolic pressure
2 - increased end diastolic volume
3 - reduced ejection fraction
4 - reduced SV
4 - reduced SV
- weak heart so decreased left ventricle contractility
In systolic heart failure (HF), stroke volume is decreased due to a weakened left ventricle (LV), causing more blood to remain in is left in the LV at the end of systole. Which of the following can this then cause?
1 - increased left atrium (LA) pressure
2 - increased pulmonary venous pressure
3 - pulmonary oedema
4 - all of the above
4 - all of the above
- More blood in LV means increased pressure in the LA to force blood into LV
- increased pressure in pulmonary veins needed to overcome pressure in LA
- fluid backs up into the lungs causing pulmonary oedema
In systolic heart failure, stroke volume (SV) is decreased due to pressure building up in left atrium, pulmonary veins and fluid overload in the lungs. Which of the following can this then lead to?
1 - increased pulmonary artery pressure
2 - increased right atrium pressure
3 - increased right ventricle pressure
4 - peripheral oedema
5 - all of the above
5 - all of the above
- pressure essentially works backwards from the lung to the heart, and eventually increases pressure for blood to return to the heart
If the pressure in the left atrium increases as a response to having to work harder to pump blood into the left ventricle (if not emptying properly), this can affect the left atrium (LA). How is the LA affected?
1 - tricuspid regurgitation
2 - left atrium hypertrophy
3 - left atrium dilation
4 - atrial flutter
3 - left atrium dilation
Reduction in ejection fraction leads to reduced organ perfusion, especially the kidneys where the renin-angiotensin aldosterone system (RAAS) is activated. Which of the following occurs in the RAAS system?
1 - renin released by juxtaglomerular cells in response to poor renal perfusion and low BP
2 - renin is cleaved by angiotensinogen (released by the liver) creating angiotensin I
3 - angiotensin I is cleaved into angiotensin II by angiotensin converting enzyme (ACE) (mainly in the lungs)
4 - angiotensin II vasoconstricts smooth muscle around blood vessels, specifically efferent arterioles to increase renal perfusion
5 - angiotensin II binds with proximal convoluted tubules increasing Na+ and H2O retention
6 - angiotensin II binds thirst centre in hypothalamus and increases ADH secretion
7 - angiotensin II binds adrenal gland causing aldosterone secretion which binds distal tubules and collecting ducts, increasing Na+ and H2O retention
8 - all of the above
8 - all of the above
Angio = blood vessels
Tensin = tense or contraction
All of these factors cause an increase in circulating blood and systemic vascular resistance to accommodate the reduced cardiac output
The following are key symptoms of chronic heart failure (CHF), EXCEPT which one?
1 - Breathlessness, worse by exertion
2 - RUQ pain and mass
3 - Dry cough (may be frothy white/pink)
4 - Orthopnoea
5 - Paroxysmal nocturnal dyspnoea
6 - Peripheral oedema
7 - Fatigue
2 - RUQ pain and mass
Hepatomegaly is NOT a common symptom
Orthopnoea = breathlessness when lying flat, patients often sleep with lots of pillows
Paroxysmal nocturnal dyspnoea = being woken by the feeling of drowning/severe SOB when asleep
All of the following may be observed during the examination of a patient with chronic heart failure, EXCEPT which one?
1 - Bradycardia
2 - Tachypnoea
3 - Hypertension (RAAS activation)
4 - Valvular heart disease with murmur
5 - 3rd heart sound on auscultation
6 - Bilateral basal crackles (pulmonary oedema)
7 - Raised JVP (increased RA pressure)
8 - Peripheral oedema
1 - Bradycardia
Tachycardia is more common
Normal levels of N-terminal pro b-type natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) are:
- NT-proBNP = <400 pg/ml (47 pmol/litre)
- BNP = <100 pg/ml (29 pmol/litre)
High levels = specialist assessment including transthoracic echocardiography <2 weeks
Raised levels = specialist assessment including transthoracic echocardiography <6 weeks
Referral is based on NT-proBNP = <400 pg/ml and BNP levels
Very high NT-proBNP and BNP = poor prognosis
Transthoracic echocardiogram (TEE) is the 1st line diagnosis for chronic heart failure, but what can we typically see on a chest X-ray?
1 - cardiomegaly
2 - pulmonary congestion
3 - kerley B lines
4 - bat wings sign (oedema)
5 - all of the above
5 - all of the above
