Chronic Heart Failure

Question 1

What are the 2 types of Chronic Heart Failure?

Answer 1

1. Systolic - Impaired Left Ventricular Contraction (HF-rEF).
2. Diastolic - Impaired Left Ventricular Relaxation (HF-pEF).

Question 2

What is the consequence of both types of Chronic Heart Failure?

Answer 2

Impaired left ventricular function results in a chronic back-pressure of blood trying to flow into and through the left side of the heart.

Question 3

Give 5 causes of Systolic Dysfunction.

Answer 3

1. Ischaemic Heart Disease.
2. Dilated Cardiomyopathy.
3. Myocarditis.
4. Arrhythmias.
5. Infiltration e.g. Haemochromatosis, Sarcoidosis.

Question 4

Give 4 causes of Diastolic Dysfunction.

Answer 4

1. Hypertrophic Obstructive Cardiomyopathy.
2. Restrictive Cardiomyopathy.
3. Cardiac Tamponade.
4. Constrictive Pericarditis.

Question 5

What is Left Heart Failure due to?

Answer 5

Increased left ventricular after load e.g. Systemic HTN, Aortic Stenosis or increased left ventricular preload e.g. Aortic Regurgitation.

Question 6

What is Right Heart Failure due to?

Answer 6

Increased right ventricular after load e.g. Pulmonary HTN or increased right ventricular preload e.g. Tricuspid Regurgitation.

Question 7

What is High-Output Heart Failure?

Answer 7

A ‘normal’ heart is unable to pump enough blood to meet the metabolic needs of the body. CO is normal but increased peripheral metabolic demands.

Question 8

Give 6 causes of High-Output Heart Failure.

Answer 8

2A2P2T :

1. Anaemia.
2. AV Malformation.
3. Paget’s disease.
4. Pregnancy.
5. Thyrotoxicosis.
6. Thiamine Deficiency (Wet Beri-Beri).

Question 9

Clinical Presentation of Chronic Heart Failure.

Answer 9

1. Breathlessness worsened by exertion.
2. Cough with frothy white/pink sputum.
3. Orthopnoea.
4. Paroxysmal Nocturnal Dyspnoea.
5. Peripheral Oedema.
6. Cardiac Wheeze.
7. Cardiac Cachexia - Weight Loss | Weight Gain - Oedema.

Question 10

What is Orthopnoea?

Answer 10

SOB when lying flat, relieved by sitting upright or standing.

Question 11

What is Paroxysmal Nocturnal Dyspnoea?

Answer 11

Sudden waking at night with a severe attack of shortness of breath and cough.

Question 12

Mechanisms of Paroxysmal Nocturnal Dyspnoea.

Answer 12

1. Fluid settles across a large surface area of their lungs when lying flat.
2. The respiratory centre becomes less responsive so RR and effort do not increase in response to reduced saturation.
3. Less adrenaline circulates so myocardium is more relaxed, worsening the cardiac output.

Question 13

Examination Findings in Chronic Heart Failure (2).

Answer 13

1. Bibasal Crackles.

2. RHF Signs : Raised JVP, Ankle Oedema, Hepatomegaly.

Question 14

Aetiology of Chronic Heart Failure (4).

Answer 14

1. Ischaemic Heart Disease.
2. Valvular Heart Disease - Aortic Stenosis.
3. Hypertension.
4. Arrhythmias - Atrial Fibrillation.

Question 15

Diagnosis of Chronic Heart Failure.

Answer 15

1. Clinical Presentation.
2. NT-proBNP Blood Test. (N-Terminal pro-B-type Natriuretic Peptide).
3. Echocardiography.
4. ECG.

Question 16

Classification of Chronic Heart Failure (4).

Answer 16

NYHA :

1. Class I - No Symptoms & No Limitation.
2. Class II - Mild Symptoms and Slight Limitation.
3. Class III - Moderate Symptoms and Marked Limitation.
4. Class IV - Severe Symptoms and Severe Limitation.

Question 17

CXR Findings in Chronic Heart Failure.

Answer 17

ABCDEF :

1. A - Alveolar Oedema (Batwing Perihilar Shadowing).
2. B - Kerley B Lines (Interstitial Oedema).
3. C - Cardiomegaly.
4. D - Upper Lobe Diversion.
5. E - Bilateral Transudative Pleural Effusion.
6. F - Fluid in Horizontal Fissure.

Question 18

Management of Chronic Heart Failure (5).

Answer 18

1. Refer to Specialist for Transthoracic Echo (Urgent (2- not 6 weeks) if NT-proBNP > 2000ng/Litre).
2. Reassurance and Education.
3. Medical Management.
4. Surgical management - Valvular Disease.
5. HF Specialist Nurse Input.

Question 19

Lifestyle Advice in Chronic Heart Failure (4).

Answer 19

1. Annual Flu and One-Off Pneumococcal Vaccine.
2. Smoking Cessation.
3. Optimising Treatment of Co-Morbidities.
4. Exercise.

Question 20

Medical Management of Chronic Heart Failure (4).

Answer 20

ABAL :

1. A - ACE Inhibitor/ARB.
2. AND B - B Blocker.
3. A - Aldosterone Antagonist (if symptoms are not controlled on A or B).
4. L - Loop Diuretic to improve symptoms (no long-term reduction in mortality).

Question 21

When should ACE Inhibitors be avoided in Chronic Heart Failure?

Answer 21

Valvular Heart Disease.

Question 22

Specialist Options for Management in Chronic Heart Failure.

Answer 22

1. Ivabradine (if Sinus Rhythm > 75/min and Left Ventricular Fraction < 35%).
2. Sacubitril-Valsartion (Left Ventricular Fraction < 35%).
3. Digoxin (Symptomatic - inotropic, especially if AF).
4. Hydralazine + Nitrate (if Afro-Carribean).
5. Cardiac Resynchronisation Therapy (Widened QRS e.g. LBB)