Chronic Heart Failure Flashcards
What is heart failure?
Impaired ability of the heart to function as a pump and maintain sufficient cardiac output to meet the demands of the body
What is the incidence of heart failure in the over 65s?
Estimated annual incidence of 10%
What is the 5-year prognosis of heart failure?
50% mortality within 5 years (NYHA class III/IV) - poor long-term outcome
What are the 3 main causes of heart failure? Can you name any other causes?
Main causes:
- Ischaemic heart disease - developed world
- Dilated cardiomyopahty
- Hypertension - Africa
Other causes:
- Cardiomyopathy (hypertrophic, restrictive)
- Valvular heart disease (mitral, aortic, tricuspid)
- Congenital heart disease (atrial septal defect, ventricular septal defect)
- Alcohol and chemotherapy, e.g. imatanib, doxorubicin
- Hyperdynamic circulation (anaemia, pregnancy, thyrotoxicosis, Paget’s disease)
- Right heart failure (RV infarct, pulmonary hypertension, pulmonary embolism, cor pulmonale, COPD)
- Arrhythmias (severe bradycardia or tachycardia)
- Pericardial disease (constrictive pericarditis, pericardial effusion)
- Infections (Chagas’ disease)
Describe the 5 main pathophysiological mechanisms leading to heart failure
When the heart fails, compensatory mechanisms attempt to maintain CO and peripheral perfusion. However, mechanisms are eventually overwhelmed and become pathophysiological.
- Sympathetic NS
- arteriolar constriction increases afterload - Renin-angiotensin system
- salt and H2O retention leads to oedema and dyspnoea
- angiotensin II increases afterload via arteriolar constriction - Natriuretic peptides
- ANP, BNP, C-type peptide
- diuretic, natriuretic and hypotensivee (reduce preload and afterload) - Ventricular dilatation
- compensatory effects of dilatation become limited by flattened contour of Starling’s curve
- Increased venous pressure contributes to pulmonary and peripheral oedema
- as ventricular diameter increases, myocardial O2 requirements increase - Ventricular remodelling
- hypertrophy, loss of myocytes and interstitial fibrosis lead to irreversible contractile failure
Name 5 risk factors that may aggravate or initiate heart failure by increasing myocardial work
- Arrhythmias
- Anaemia
- Hyperthyroidism
- Pregnancy
- Obesity
Differentiate between the 3 clinical syndromes of heart failure
- LVSD
- ishaemic HD, valvular HD, HTN - RVSD
- secondary to LVSD
- pulmonary HTN, RV infarction, adult congenital HD - Diastolic heart failure
- normal LVEF (above 45-50%)
- echo: abnormal LV relaxation and filling +/- LVH
- decreased CO due to impaired filling
What is the commonest cause of left ventricular systolic dysfunction?
Ischaemic heart disease
Define diastolic heart failure
A clinical syndrome in which patients have:
1. Symptoms and signs of HF
2. Normal or near normal LV systolic function
3. Normal LV chamber size
4. Evidence of LV diastolic dysfunction (eg, abnormal LV filling and/or elevated filling pressures)
DHF is a major cause of HF with preserved ejection fraction.
List 4 key symptoms associated with heart failure
- Exertional dyspnoea
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Fatigue
List 10 signs you might expect to find on examination of a patient with heart failure
- Displaced apex beat (cardiomegaly)
- S3 and S4
- Elevated JVP
- Tachycardia
- Hypotension
- Bi-basal lung crackles
- Pleural effusion
- Ankle oedema (+/- sacral)
- Ascites
- Tender hepatomegaly
Name and outline the classification system for assessing severity of heart failure. What else does it predict?
New York Heart Association (NYHA) classification
Class I
- No limitation
Class II
- Mild limitation. Normal physical activity produces fatigue, dyspnoea or palpitations
Class III
- Marked limitation. Marked symptoms with gentle physical activity
Class IV
- Symptoms occur at rest and exacerbated by any physical activity
Also predicts response to therapy.
List 4 key initial investigations indicated in a patient with symptoms and signs of heart failure?
1st line Ix:
- Chest X-ray
- Cardiac enlargement
- Features of LV failure: hilar haziness and Kerley B lines (pulmonary oedema), upper lobe venous diversion, fluid in right horizontal fissure
- Can be normal - ECG
- Evidence of underlying causes: arrhythmias, ischaemia, LVH in HTN - Blood tests
- FBC: anaemia
- LFT: hepatic congestion
- Glucose: diabetes
- U&E: baseline for diuretics and ACE-I
- Thyroid function: elderly, AF
- BNP: normal (: - Cardiac catheterisation
- Thallium perfusion imaging
- PET scanning
- Cardiac MRI
- Dobutamine stress echo
In these patients revascularisation will improve LV function and long-term prognosis.
What is ‘hibernating myocardium’ and how can it be identified?
Hibernating myocardium = a region of impaired myocardial contractility due to persistently impaired coronary blood flow.
Echocardiography: A wall motion abnormality at rest which improves during a low-dose dobutamine stress test is classified as “hibernating myocardium”. Low dose dobutamine stimulates contractile function and thus helps to predict functional recovery after revascularisation.
List 5 radiological features you might see in a patient with signs and symptoms of heart failure
- Cardiac enlargement
- Hilar haziness
- Kerley B lines
- Upper lobe venous diversion
- Fluid in right horizontal fissure
- Can be normal
List 6 blood tests you might order for a patient with signs and symptoms of heart failure
- FBC: anaemia
- LFT: hepatic congestion
- Glucose: diabetes
- U&E: baseline for diuretics & ACE-I
- Thyroid function: elderly, AF
- BNP or NTproBNP: normal (BNP <100mg/ml) excludes heart failure