Cardiac Failure: Heart failure

Question 1

What is acute heart failure (AHF)?

Answer 1

AHF is a life-threatening emergency characterized by the sudden onset or worsening of heart failure symptoms.

Question 2

What is de-novo AHF?

Answer 2

De-novo AHF refers to acute heart failure without a past history of heart failure.

Question 3

What is decompensated AHF?

Answer 3

Decompensated AHF is the more common form of AHF, presenting with a background history of heart failure.

Question 4

What age group is most commonly affected by AHF?

Answer 4

AHF usually presents after the age of 65 years.

Question 5

What are common causes of de-novo heart failure?

Answer 5

De-novo heart failure is typically caused by increased cardiac filling pressures and myocardial dysfunction, often due to ischaemia.

Other causes include viral myopathy, toxins, and valve dysfunction.

Question 6

What are the most common precipitating causes of acute AHF?

Answer 6

The most common causes include acute coronary syndrome, hypertensive crisis, acute arrhythmia, and valvular disease.

Question 7

How are patients with heart failure classified?

Answer 7

Patients are classified into 1 of 4 groups based on the presence of hypoperfusion and fluid congestion.

Question 8

What are common symptoms of AHF?

Answer 8

Common symptoms include breathlessness, reduced exercise tolerance, oedema, and fatigue.

Other symptoms may include chest signs and S3-heart sound.

Question 9

What are common signs of AHF?

Answer 9

Common signs include cyanosis, tachycardia, elevated jugular venous pressure, and displaced apex beat.

Question 10

What is the blood pressure status in patients with AHF?

Answer 10

Over 90% of patients with AHF have a normal or increased blood pressure.

Question 11

What does the diagnostic workup for AHF include?

Answer 11

The diagnostic workup includes blood tests, chest X-ray, echocardiogram, and B-type natriuretic peptide levels.

Raised levels of B-type natriuretic peptide (>100mg/litre) indicate myocardial damage.

Question 12

What is dyspnoea?

Answer 12

Dyspnoea is a feature associated with respiratory distress.

Question 13

What is a characteristic of cough in this context?

Answer 13

Cough may be worse at night and associated with pink/frothy sputum.

Question 14

What is orthopnoea?

Answer 14

Orthopnoea is difficulty breathing when lying flat.

Question 15

What is paroxysmal nocturnal dyspnoea?

Answer 15

Paroxysmal nocturnal dyspnoea is sudden shortness of breath that occurs at night.

Question 16

What is ‘cardiac wheeze’?

Answer 16

‘Cardiac wheeze’ refers to wheezing associated with heart conditions.

Question 17

What is ‘cardiac cachexia’?

Answer 17

‘Cardiac cachexia’ is weight loss that occurs in up to 15% of patients, which may be hidden by weight gained due to oedema.

Question 18

What are bibasal crackles?

Answer 18

Bibasal crackles are abnormal lung sounds heard on examination.

Question 19

What are signs of right-sided heart failure?

Answer 19

Signs include raised JVP, ankle oedema, and hepatomegaly.

Question 20

What is a recommended treatment for all patients with acute heart failure?

Answer 20

IV loop diuretics, e.g. furosemide or bumetanide.

Question 21

What additional treatment should be given to maintain oxygen levels?

Answer 21

Oxygen should be given in line with British Thoracic Society guidelines, keeping oxygen saturations at 94-98%.

Question 22

When should vasodilators be considered in acute heart failure?

Answer 22

Nitrates may have a role if there is concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease.

The major side-effect/contraindication is hypotension.

Question 23

What is the treatment for patients with respiratory failure?

Answer 23

CPAP.

Question 24

What should be considered for patients with hypotension or cardiogenic shock?

Answer 24

Inotropic agents, e.g. dobutamine, should be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock.

Question 25

When are vasopressor agents used in acute heart failure?

Answer 25

Vasopressor agents, e.g. norepinephrine, are normally only used if there is insufficient response to inotropes and evidence of end-organ hypoperfusion.

Question 26

What mechanical assistance options are available for acute heart failure?

Answer 26

Mechanical circulatory assistance options include intra-aortic balloon counterpulsation or ventricular assist devices.

Question 27

What does NICE state about the use of opiates in acute heart failure?

Answer 27

NICE states ‘do not routinely offer opiates to people with acute heart failure.’

Opiates were previously used to reduce dyspnoea/distress but studies suggest increased morbidity.

Question 28

What general medication guidelines should be followed for heart failure?

Answer 28

Regular medication such as beta-blockers and ACE-inhibitors should be continued unless specific conditions are met.

Question 29

When should beta-blockers be stopped in heart failure patients?

Answer 29

Beta-blockers should only be stopped if the patient has a heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock.

Question 30

What is heart failure?

Answer 30

Heart failure is a clinical syndrome where the heart is unable to pump enough blood to meet the metabolic needs of the body.

Question 31

What are the two main classifications of heart failure by ejection fraction?

Answer 31

Heart failure can be classified as heart failure with reduced ejection fraction (HF-rEF) and heart failure with preserved ejection fraction (HF-pEF).

Question 32

What is the typical definition of reduced left ventricular ejection fraction (LVEF)?

Answer 32

A reduced LVEF is typically defined as < 35 to 40%.

Question 33

What percentage of heart failure patients are affected by HF-rEF?

Answer 33

Roughly 50% of people diagnosed with heart failure are affected by HF-rEF.

Question 34

What conditions are typically associated with systolic dysfunction?

Answer 34

Conditions associated with systolic dysfunction include ischaemic heart disease, dilated cardiomyopathy, myocarditis, and arrhythmias.

Question 35

What conditions are typically associated with diastolic dysfunction?

Answer 35

Conditions associated with diastolic dysfunction include hypertrophic obstructive cardiomyopathy, restrictive cardiomyopathy, cardiac tamponade, and constrictive pericarditis.

Question 36

How is heart failure classified by time?

Answer 36

Heart failure is classified as acute or chronic, with acute heart failure typically referring to an acute exacerbation of chronic heart failure.

Question 37

What are common symptoms of left-sided heart failure?

Answer 37

Common symptoms include pulmonary oedema, dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, and bibasal fine crackles.

Question 38

What are common symptoms of right-sided heart failure?

Answer 38

Common symptoms include peripheral oedema, raised jugular venous pressure, hepatomegaly, and weight gain due to fluid retention.

Question 39

What is high-output heart failure?

Answer 39

High-output heart failure refers to a situation where a ‘normal’ heart is unable to pump enough blood to meet the metabolic needs of the body.

Question 40

What are some causes of high-output heart failure?

Answer 40

Causes include anaemia, arteriovenous malformation, Paget’s disease, pregnancy, thyrotoxicosis, and thiamine deficiency (wet Beri-Beri).