CHF

Question 1

What is the definition of congestive heart failure?

Answer 1

The inability of the heart to meet metabolic demand and reduced CO

Question 2

What symptoms characterise CHF?

Answer 2

Poor exercise tolerance, reduced CO, peripheral oedema, breathlessness

Question 3

Why is the terminal decline after a period of stabilisation in CHF?

Answer 3

MI causes decline and LV remodelling and dysfunction, however increased peripheral vascular resistance stabilizes this - caused by neurohormonal stimulation

Question 4

How does neurohormonal stimulation cause reduced heart function?

Answer 4

1. It causes increased peripheral resistance which increases cardiac workload
2. It directly causes myocyte cell death - adrenaline and neuradrenaline

Question 5

Which neurohormonal concentrations are increased in CHF?

Answer 5

Neuradrenaline, vasopressin, renin, ANP, endothelin-1

Question 6

What are the 4 chronic effects of increased neurohormonal stimulation?

Answer 6

1. Increased afterload
2. Reduced SV
3. Myocyte apoptosis / necrosis
4. Sodium retention

Question 7

What are some of the aetiologies of CHF?

Answer 7

1. MI
2. Hypertension
3. Idiopathic dilated cardiomyopathy
4. Valvular disease
5. Myocarditis
6. Secondary cardiomyopathy (alcohol etc.)

Question 8

What is myocarditis?

Answer 8

Inflammation of the heart muscle

Question 9

What are the signs and symptoms of left sided HF?

Answer 9

1. Dyspnoea
2. Orthopnoea
3. Paroxysmal nocturnal dyspnoea
4. Cough
5. Chest crackles
6. S3 and S4 sounds

Question 10

What are the signs and symptoms of right sided HF?

Answer 10

1. Oedema
2. Elevated JVP
3. Hepatomegaly
4. Abdominal distension and loss of appetite

Question 11

What are the 4 initial managements of acute heart failure?

Answer 11

1. Sit patient up
2. Give oxygen
3. Check ECG rhythm
4. IV loop diuretic

Question 12

What are the 3 main neurohormonal pathways that impact heart function in CHF?

Answer 12

1. Beta receptors
2. Angiotensin II receptors
3. Aldosterone receptors

Question 13

What are ACE inhibitors?

Answer 13

They block the conversion of angiotensin 1 to angiotensin 2
- are used to treat hypertension and CHF

Question 14

What are beta blockers?

Answer 14

Beta-adrenergic receptor blockers
- produce negative chronotropic and negative ionotropic effects

Question 15

What are the 2 types of CHF?

Answer 15

1. CHF with reduced EF
2. Diastolic HF with preserved EF
   - NOTE: there is no clear treatment for diastolic HF - just need to control fluid intake etc.

Question 16

What percent of CHF patients die of sudden cardiac death?

Answer 16

30%

Question 17

Why should chest X-rays be performed upright?

Answer 17

Supine increases venous return to the heart - increases heart size
Basilar infiltrates also exaggerated

Question 18

How does AP orientation impact chest X-rays?

Answer 18

It enlarges the heart as the heart is more anterior

Question 19

How many ribs does an inspiratory CXR usually show?

Answer 19

9 or 10 ribs

Question 20

What is the usual cause of an enlarged heart on CXR?

Answer 20

Cardiomegaly (but sometimes pleural effusion or fat deposits)

Question 21

What are the 3 stages of congestive heart failure seen on CXR?

Answer 21

1. Redistribution - increased pulmonary markings, cardiomegaly, broad vascular pedicle
2. Interstitial oedema - Kerley lines, hazy contour of vessels, thickened interlobular fissure
3. Alveolar oedema - consolidation, air bronchogram, cotton wool appearance, pleural effusion