Chronic Heart Failure: epidemiology, investigation and diagnosis Flashcards
<p>What is the definition of heart failure?</p>
<p>A clinical syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction, either at rest or on exertion, with accompanying neurohormonal activation</p>
<p>What is the prevalence of heart failure and of asymptomatic LVSD?</p>
<p>Heart failure: 0.4 - 2%</p>
<p>Asymptomatic LVSD: 0.4 - 2%</p>
<p>Prevalence and incidence increase with age (mean age 74years)</p>
<p>Estimated 40-60 000 patients with HF/LVSD(left ventricular systolic dysfunction) in Scotland</p>
<p>What is the largest costattached to heart failure</p>
<p>Hospital inpatient care</p>
<p>What can be said about re-admission rates for HF?</p>
<p>High! and readmission is most likely to happen early.</p>
<p>Length of hospital admission is longer than any other condition.</p>
<p>What are the signs of heart failure?</p>
<p>Breathlessness</p>
<p>Fatigue</p>
<p>Oedema</p>
<p>Reduced exercise capacity</p>
<p>What are the signs of heart failure?</p>
<p>Oedema</p>
<p>Tachycardia</p>
<p>Raised JVP</p>
<p>Chest crepitations or effusions</p>
<p>3rd Heart sound</p>
<p>Displaced or abnormal apex beat</p>
<p>Is heart failure easy to diagnose based on clinical signs alone?</p>
<p>Yes very difficult - diagnosis incorrect in approximately 40-50% of cases</p>
<p>What are the 3 key features that indicate heart failure?</p>
<p>Symptoms and signs of HF (rest or at exercise)</p>
<p>Objective evidence of cardiac dysfunction and in (doubtful cases)</p>
<p>Resonse to therapy</p>
<p></p>
<p>(They look like they have it, tests think they have it, and they respond to treatment)</p>
<p>What is objective evidence of cardiac dysfunction?</p>
<p>•Echocardiography, Radionuclide ventriculography (RNVG/MUGA), MRI, left ventriculography</p>
<p>What are the screening tests available?</p>
<p>12 lead ECG - left ventricular systolic dysfunction is very unlikely if there is a normal ECG but it is still possible (90-95% sensitive)</p>
<p>(Problems with confidence of interpretation in primary care, must be entirely normal or else loses reliability)</p>
<p>BNP(brain (B-type) natriuretic peptide)</p>
<p>Amino acid peptide can be measured easily in bood</p>
<p>–Elevated in heart failure, therefore low BNP effectively excludes heart failure</p>
<p>Potential as diagnostic/ screening test for long time</p>
<p>What does a high / low BNP indicate?</p>
<p>•Low BNP effectively rules out heart failure or LVSD, elevated BNP indicates need for an echo/cardiac assessment</p>
<p>What is the common rule as to what will cause heart failure?</p>
<p>If sufficiently severe almost any structural cardiac abnormality will cause heart failure</p>
<p>e.g</p>
<p>•LV systolic dysfunction – many causes</p>
<p>•Valvular heart disease</p>
<p>•Pericardial constriction or effusion</p>
<p>•LV diastolic dysfunction/heart failure with preserved systolic function/heart failure with normal ejection fraction</p>
<p>•Cardiac arrhythmias: tachy or brady</p>
<p>•Myocardial ischaemia/infarction (usually via LVSD)</p>
<p>•Restrictive cardiomyopathy eg amyloid, HCM</p>
<p>•Right ventricular failure: primary or secondary to pul hypertension</p>
<p>What are common causes of LV systolic dysfunction?</p>
<p><strong>Ischaemic heart disease (usually MI)</strong></p>
<p>•<strong>Dilated cardiomyopathy(DCM): Means LVSD not due to IHD or secondary to other lesion ie valves/VSD</strong></p>
<p>e.g</p>
<p>–Inherited</p>
<p>–Toxins: eg alcohol, catecholamines (phaeochromocytoma or stress cardiomyopathy (takosubo’s cardiomyopathy)</p>
<p>–Viral: acute myocarditis or chronic DCM</p>
<p>–Other infective: HIV, chaga’s disease, Lyme’s disease.......</p>
<p>–Systemic disease: sarcoidosis, haemachromatosis, SLE, mitochondrial dis.</p>
<p>–Muscular dystrophies</p>
<p>–Peri-partum cardiomyopathy (post pregnancy)</p>
<p>–Hypertension</p>
<p>–Isolated non compaction</p>
<p>–Tachycardia related cardiomyopathy</p>
<p>–RV pacing induced cardiomyopathy</p>
<p>–End stage hypertrophic cardiomyopathy</p>
<p>–End stage arrhythmogenic RV cardiomyopathy</p>
<p><strong>Severe aortic valve disease or mitral regurgitation</strong></p>
<p>How do you figure out which type of heart failure is present? IHD, valvular disease or dilated cardiomyopathy</p>
<p>Take a detailed history - may provide answer</p>
<p>Esculde renal failure, anaemia, thyroid function tests</p>
<p>Serology to check for viruses and autoantibodies</p>
<p>Consider to exclude phaechromocytoma (cancer in the adrenal gland)</p>
<p>Consider other causes such as thyroid, muscular dystrophy</p>
<p><strong>ECG, ECHO and sometimes a CXR</strong></p>
<p><b>Consider coronary angiography in patients with chest pain who are over 70.</b></p>
<p><b>Cardiac MRI</b>looking for infarction, inflammation and fibrosis</p>
<p></p>
<p>Why is echocardiography always an essential investigation?</p>
<p>Assesses:</p>
<p>–LV systolic dysfunction</p>
<p>–Valvular dysfunction</p>
<p>–Pericardial effusion / tamponade</p>
<p>–Diastolic dysfunction</p>
<p>–LVH</p>
<p>–Atrial/ventricular shunts / complex congenital heart defects (ventral septal defects)</p>
<p>–Pulmonary hypertension / Right heart dysfunction</p>
<p>•May not identify constriction / may miss shunts (but you will see atrial dilatation)</p>
<p></p>
Classification of Heart Failures
<p>What are the resultant symptoms of neurohormonal ativation?</p>
<p>Dyspnoea</p>
<p>Fatigue</p>
<p>Oedema</p>
<p></p>
<p>HEART FAILURE</p>
