CCF

Question 1

CCF causes

Answer 1

1. HTN
2. CAD
3. Prior MI
   …
   ↓blood flow to kidneys
   …
   Fluid retention
   …
   vicious cycle

HF can be systolic/diastolic

Question 2

LHF/CCF pathology

Answer 2

LV unable to push blood out
LV hypertrophy … weakness
blood filled in LV
LA accumulates blood … pulm vein
Lungs accumulate blood

*Pulm edema - SOB, Bibasilar crepts, Gallop rhythm(S3)

Pulm artery HTN

RV failure
RA accumulates blood
SVC - raised JVP
IVC - Peripheral edema, Hepatomegaly (tender), ascitis

= CCF

Question 3

Ejection fraction low in systolic/diastolic HF?

Answer 3

Systolic HF

45-65% normal

Question 4

HF symptoms

Answer 4

1. SOB, dyspnoea, orthopnoea, dry cough
2. Ankle edema
3. Abdominal discomfort - hepatomegaly, ascites
4. weak/lethargy
5. Syncope
6. Displaced apical beat - lateral to mid-clavicular line, 6th intercostal space

Question 5

LHF vs RHF

Answer 5

LHF: pulm symptoms
Pulm edema
Pulm rales
Gallop rhythm (S3)

RHF: fluid accumulation symptoms
Raised JVP
HSM, Ascites

Question 6

Systolic vs diastolic HF

Answer 6

Systolic HF:
Inadequate pumping action
Ejection fraction LV - <40%
Ex - Ischemic/dilated cardiomyopathy (mc - MI)

Diastolic HF:
Impaired adequate filling of LV
Ejection fraction preserved
Ex:
1. In elderly with HTN, normal heart size and ejection fraction
2. Infiltrative cardiomyopathy - amyloidosis

Question 7

HF investigations

Answer 7

●Initial, first line - ECG

●Best/m appropriate: ECHO when HF suspected
1. Ejection fraction
2. Valves
3. Cardiac anomalies - dilated/thickened ventricles

●CXR can be done - cardiomegaly/pulm edema etc
Kerly B lines - ↑pressure in pulm veins

●Prognosis of HF/Rx working: BNP
1. Brain natriuretic peptide - cardiac myocytes on stretching
2. R/O CHF as cause of dyspnoea if BNP normal

BNP can be done when ECHO not possible

Question 8

Systolic HF Mx

Answer 8

ACEI/ARB

If edema+:
Furesemide
Add Spironolactone (aldosterone antagonist) if still +
Add B Blockers - compensated/euvolaemic pts
Add Digoxin (lot of S/E)
…
Still not controlled/Severe HF with <25% HF
ARNI - angiotensin receptor naprolysin inhibitor
1. Valsartan
2. Sacubitril

Can try - empaglifloxin (only diabetic drug which protects heart)

Can try evabradin

Question 9

Beta blockers in HF

Answer 9

Slows HR, Cardiac output
Hence cannot use in decompensated HF (congestion, systolic dysfunction etc)

After diuretics work, pt euvolaemic
can start B blockers

Question 10

Diastolic HF Rx

Answer 10

Rx the cause - HTN, DM, ischemia
Durgs: Ionotropic agents
1. CCB (rate limiting) - verapamil, diltiazm
2. B blockers (cardio protective)

Avoid diuretics - less blood volume makes diastole worse

Question 11

Which drugs improve survival in CHF

Answer 11

1. ACEI
2. Spironolactone
3. B blockers

Question 12

Digoxin is indicated in?

Answer 12

Na/K pump inhibition
↑Na … ↑Ca … ↑Contractility
↑Heart contractility and Cardiac output
AF + HF

Question 13

S/E of Digitalis

Answer 13

1. Nausea/vomitings
2. Eye - blurry vision, yellow halos
3. Gynecomastia
4. Arrhythmia esp PAT, PVC (paroxysmal atrial tachy, premature ventricular contraction

Stop Digoxin
Add Digibind - antidote

Question 14

AICD

Answer 14

Automatic implantable cardioverter/defibrilator
In Dilated cardiomyopathy with ejection fraction <35%

Question 15

Biventricular pacemaker used in

Answer 15

Dilated cardiomyopathy with QRS wider than 120msec
Re-synchronise the two ventricles