Chronic Heart Failure

Question 1

Define heart failure

Answer 1

A clinical syndrome comprising of dyspnoea, fatigueor fluid retention due to cardiac dysfunction, either atrest or on exertion, with accompanyingneurohormonal activationnot a final diagnosis - underlying condition that is causing it

Question 2

prevalence of HF in UK?

Answer 2

1-2 %

Question 3

why is the prevalence of HF in the UK increasing?

Answer 3

due to:-treatment of AMI (heart attack)aging populationincidence/prevalence of things like hypertension, CHD, obesity, diabetes

Question 4

what is the one-year survival rate for heart failure worse than?

Answer 4

breast canceruterusprostate bladder

Question 5

What can be said about re-admission rates for HF?

Answer 5

High! and readmission is most likely to happen early.Length of hospital admission is longer than any other condition.

Question 6

What are the symptoms of heart failure?

Answer 6

breathlessnessFatigueOdemaReduced exercise capacity

Question 7

What are the signs of heart failure?

Answer 7

OedemaTachycardiaRaised JVPChest crepitations or effusions3rd Heart soundDisplaced or abnormal apex beat

Question 8

Is heart failure easy to diagnose based on clinical signs alone?

Answer 8

no, it is very difficult!diagnosis incorrect in approximately 40-50% of cases

Question 9

3 things you need to consider to diagnose heart failure?

Answer 9

Symptoms or signs of HF (rest or exercise)Objective evidence of cardiac dysfunction (in doubtful cases)Response to therapy (diuretics)

Question 10

what tests can give objective evidence of a diagnosis of HF?

Answer 10

ECHO - key, may show cause ie MI, valvular heart diseaseRadionucleotide ScanLeft VentriculogramCardiac MRI

Question 11

potential screening tests for heart failure

Answer 11

12 Lead ECGBNP (brain (B-type) natriuretic peptide

Question 12

what is a 12 Lead ECG and how does it give evidence of heart failure?

Answer 12

test that uses 10 electrodes to generate 12 different views of the heart’s electrical activity.LV Systolic Dysfuntion very unlikely if ECG normal (90-95% sensitive)• Problems with confidence of interpretation in primary care, must be entirely normal or else loses reliability

Question 13

what is BNP and how does it give evidence of heart failure?

Answer 13

BNP is a hormone secreted by cardiomyocytes in the heart ventricles in response to stretching caused by increased ventricular blood volume.BNP levels go up in heart failure

Question 14

why is BNP a good test?

Answer 14

Highly sensitive test for HF, stable for up to 72 hours, ‘bedside’ testing available if desired, relatively inexpensiveLow BNP effectively rules out heart failure or LVSD, elevated BNP indicates need for an echo/cardiac assessment

Question 15

what other reasons are there for an elevated BNP?

Answer 15

AFElderlyValve Disease

Question 16

What investigations/tests are carried out to look for CHF/HF? (7)

Answer 16

FBC - BNP levels - raised in HFECHO fasting blood glucoseserum ureaelectrolytesurinalysis - myoglobinthyroid functionCXR

Question 17

what things are you looking for in the clinical examination for HF diagnosis? (5)

Answer 17

rales - abnormal lung sounds - discontinuous clicking/rattlingbilateral ankle oedemaheart murmurjugular venous dilatationlaterally displaced/ broadened apical beat

Question 18

Give examples of structural heart diseases that, if severe enough, can cause heart failure?

Answer 18

LV systolic dysfunction – many causesValvular heart diseasePericardial constriction or effusionLV diastolic dysfunction/heart failure with preserved systolic function/heart failure with normal ejection fractionCardiac arrhythmias: tachy or bradyMyocardial ischaemia/infarction (usually via LVSD)Restrictive cardiomyopathy eg amyloid, HCMRight ventricular failure: primary or secondary to pulhypertension

Question 19

Causes of LV systolic dysfunction

Answer 19

ischaemic heart diseasesevere Aortic Valve disease or MR Dilated cardiomyopathy (DCM): Means LVSD not due to IHD or secondary to other lesion ie valves/VSDInherited• Toxins: eg alcohol, catecholamines(phaeochromocytoma or stresscardiomyopathy (takosubo’scardiomyopathy)• Viral: acute myocarditis or chronicDCM• Other infective: HIV, chaga’sdisease, Lyme’s disease…….• End stage hypertrophiccardiomyopathy• End stage arrhythmogenic RVcardiomyopathy• Systemic disease: sarcoidosis,haemachromatosis, SLE,mitochondrial dis.• Muscular dystrophies• Peri-partum cardiomyopathy• Hypertension• Isolated non compaction• Tachycardia relatedcardiomyopathy• RV pacing inducedcardiomyopathy

Question 20

How do you figure out which type of heart failure is present? Ischaemic heart disease (IHD), valvular disease or dilated cardiomyopathy

Answer 20

take a detailed history ECG, CXR, always do an echoMost patients should be assessed by a cardiologist

Question 21

why is echocardiography such an essential investigation?

Answer 21

gives images of the heartit enables you to identify and severity of heart problem:-• LV systolic dysfunction• Valvular dysfunction• Pericardial effusion / tamponade• Diastolic dysfunction• LVH• Atrial/ventricular shunts / complex congenital heartdefects• Pulmonary hypertension / Right heart dysfunctionMay not identify constriction / may miss shunts(but you will see atrial dilatation)

Question 22

what is the LV ejection fraction

Answer 22

the amount of blood that actually gets pumped out by the LV during systole as a % of the total blood in the LV

Question 23

what can change the LVEF?

Answer 23

Disease / physiological changes can both decrease and increase the LVEF - it is however a continuous biological variable like haemoglobin / anaemia

Question 24

why can it be very difficult to quantify the LVEF accuratelyand reproducibly by echo?

Answer 24

Quality of imagesExperience of operatorCalculation method of LVEF – M-mode, Simpson’s biplaneUse of contrast agentsTime-consuming to perform accuratelyNormal range is centre specific, but LVEF not routinelymeasured and NR not routinely established

Question 25

Normal value for ejection fraction?

Answer 25

50-80%

Question 26

value for mild ejection fraction

Answer 26

40-50%

Question 27

moderate ejection fraction value

Answer 27

30-40%

Question 28

severe ejection fraction value?

Answer 28

<30%

Question 29

what is a MUGA scan?

Answer 29

scan using ionising radiation to help measure LVEFPros:- It is much easier to obtain an accurate LVEF greater reproducibility cons:- ionising radiationno additional info about structure of the heart

Question 30

what is the gold standard investigation for LVEF

Answer 30

MRI scan

Question 31

pros and cons for MRI scan to investigate LVEF?

Answer 31

Pros:- Greater reproducibilitynormal rangeAdded information aboutCan see cause of LV problem such as• Fibrosis• Infiltration• OedemaCan see heart valvesCons:- Time consuming – Approx 1hourPatient complianceLong breath holdsClaustrophobicAbility to lie flatSpecialist centresLong waiting lists

Question 32

class 1 and 4 of NYHA classification of heart failure?

Answer 32

class 1 - no limitation on exercise tolerance, symptoms- no symptoms during usual activity class 4 - severe limitation, symptoms - any physical activity brings on discomfort and symptoms occur at rest

Question 33

treatment/therapy for heart failure due to LV systolic dysfunction

Answer 33

diureticsACE inhibitors/ ARBs (Angiotensin II receptor blockers) Beta blockers - carvedilol/bisoprololAldosterone receptor blockersARNI’s (angiotensin receptor-neprilysin inhibitor)

Question 34

Give 1 example of ARNI’s medication?

Answer 34

Entresto

Question 35

Give 4 examples of ACE inhibitors/ ARBs (Angiotensin II receptor blockers)

Answer 35

Ramiprilenalaprilcandesartanvalsartan

Question 36

give 2 examples/types of diuretic medication used for heart failure?

Answer 36

furosemidebumetanide

Question 37

Why does cardiac output not mean heart failure?

Answer 37

because someone can have a higher cardiac output than a normal person due to for example LV dilatation and yet this person could have severe heart failure