Heart Failure 1 & 2

Question 1

In Asia, majority of people with heart failure are those considered:

A) older and senile
B) young and dependent
C) young and productive
D) young and sickly

Answer 1

C is correct. Due to prevalence of risk factors such as hypertension (51.9%), coronary artery disease (50.2%), and diabetes mellitus (40.4%)

Note: prevalence of HF in the Philippines is 1.6%

Question 2

Which one is not a major HF etiology in the Philippines:
A) anemia
B) HTN
C) rheumatic heart disease
D) CAD
E) cardiomyopathy
F) congenital heart disease

Answer 2

Answer: A

Question 3

Which is more common in the Philippines: Chagas disease or rheumatic fever (both infections)?

Answer 3

Rheumatic fever! Both can cause HF. Other factors/conditions that can cause HF are high BP, heart problems, lung problems, other medical conditions, and lifestyle.

Question 4

Most common etiology (60-70%) that leads to depressed ejection fraction?

Answer 4

coronary artery disease (can lead to myocardial infarction & ischemia)

Question 5

Framingham Criteria for HF (2 major, or 1 major + 2 minor). Identify which is a major criteria and which is a minor criteria. (Bonus: identify if found in Hx or PE)

1) dyspnea on exertion
2) pleural effusion
3) rales
4) hepatomegaly
5) neck-vein distention
6) orthopnea
7) S3 gallop

Answer 5

1) minor, Hx
2) minor, PE
3) major, PE
4) . minor, PE
5) major, PE
6) major, Hx
7) major, PE

Note: considered “minor” since it can be common in other conditions as well

Question 6

What are the cardinal symptoms of HF?

Answer 6

breathlessness & fatigue (seen in Hx along with fluid retention

Note: found in PE - congested lungs, gallop rhythm, distended neck veins, fluid retention or edema

Question 7

Important mechanism of cardiac dyspnea (arrange in order)
I. accumulation of interstitial or intra-alveolar fluid
II. stimulates rapid, shallow breathing
III. activated juxtacapillary J receptors
IV. pulmonary congestion

Answer 7

IV, I, III, II

Question 8

Classification of HF based on EF: Identify under which classification the criteria belongs

1) LVEF >50%
2) No elevated natriuretic peptides
3) Better prognosis than HFrEF
4) LVEF 40-49% with diastolic dysfunction

Answer 8

1) HFpEF
2) HFrEF
3) HFpEF
4) HFmrEF

Question 9

Stages & Classification

1) The stage where you can no longer go back to the previous one: ___
2) Recent dyspnea at rest in this sub-class: ___

Answer 9

1) Stage C

2) Class IIIb - sign of decompensation

Question 10

Identify if systolic or diastolic HF

1) S4 gallop
2) HFrEF
3) large, dilated heart
4) tx not well-established
5) broad age group and more common in men
6) Reduced EF (=<40%)

Answer 10

1) D (S: S3)
2) S (D: HFpEF)
3) S (D: small LV cavity, concentric LVH
4) D (S: well-established Tx)
5) S
6) S (D: EF >40%)

Note: systolic HF can’t PUMP hard enough
diastolic HF can’t FILL enough

Question 11

Presentations of acute HF: cardiogenic shock, acute decompensation of chronic HF, and ____

Answer 11

acute cardiogenic pulmonary edema

Note some diagnostic modalities: electrocardiogram, chest radiograph, 2D echocardiogram, nuclear imaging, hemodynamic studies, contrast left ventriculography, biomarkers

Question 12

ECG: what does deep S in V1 and tall R in V5/V6 indicate?

Answer 12

Left ventricular hypertrophy

Question 13

Biomarkers very specific for heart failure:
A) ST2 & BNP
B) BNP & NT-proBNP
C) MR-proANP & NT-proBNP
D) Galectin-3 & high sensitivity troponins

Answer 13

Answer: B - markers of cardiac myocyte strain (along with MR-proANP

ST2, Galectin-3: markers of cardiac myocyte remodeling
high sensitivity troponins: markers of cardiac myocyte injury

Question 14

Pathophysio of HF

Decreasing ejection fraction is a sign of ____.

Answer 14

remodelling (we don’t want this in the heart!)

Question 15

Pathophysio: Identify if neurohormonal activation, secondary damage, or endothelial changes

1) Fibrosis
2) ↑ ANP/BNP
3) ↑ RAS activity
4) ↑ Hypertrophy
5) Vasoconstriction
6) ↑ Apoptosis
7) ↑ Cytokines

Answer 15

1) SD
2) NA
3) NA
4) SD
5) EC
6) SD
7) NA

SD: LV remodelling, ↓ contractility, NOS/ROS, changes in electrophysiology
NA: ↑ SNS activity, ↑ endothelin
EC: NOS/ROS, structural changes, cytokines

Question 16

LV remodelling: Identify which leads to/is a characteristic of concentric or eccentric hypertrophy

1) parallel sarcomeres
2) ↑ diastolic wall stress
3) pressure overload
4) volume overload
5) ↑ systolic wall stress

Answer 16

1) CH
2) EH
3) CH
4) EH
5) CH

Question 17

Left-sided vs right-sided: Which is which?

1) paroxysmal nocturnal dyspnea, elevated pulmonary capillary wedge pressure, blood-tinged sputum, cough, orthopnea, exertional dyspnea, cyanosis: ___
2) fatigue, ↑ peripheral venous pressure, distended jugular veins, ascites, anorexia & complaints of GI distress, cyanosis, dependent edema: ___

Answer 17

1) left-sided failure (hint: emphasis on lung involvement)
2) right-sided failure (hint: emphasis on venous involvement)

Note:
Left-sided: usually systolic, d/t ischemic heart disease, long-standing HTN, dilated cardiomyopathy
Right-sided: often caused by left-sided HF, d/t R-to-L shunt, cor pulmonale

Question 18

Identify the stage of the indicated treatments

1) Heart transplantation, advanced care measures, left ventricular assist device
2) Diuretics, RAS blockers, Beta blockers, aldosterone antagonists, SGLT2 inhibitors, hydralazine/isosorbide dinitrate (for select pts)
3) RAS blockers for HTN, statins for Hypercholesterolemia
4) ACEi, RAS blockers, Beta blockers, perform ICD or revascularization in select pts

Answer 18

1) Stage D
2) Stage C - HFrEF (HFpEF has no approved therapies)
3) Stage A - treat risk factors
4) Stage B - prevent progression to heart failure

Stage B - ACEi -> BACE
Stage C - HFrEF -> H for hydralazine, r for RAS blockers

Question 19

HF Tx: 3 treatments using devices & surgery

Answer 19

revascularization (pacemakers, implantable cardioverter defibrillators, catheter interventions, surgery), ultrafiltration, hemodialysis

Question 20

Identify which device is being described (LVAD - left ventricular assist device, ICD - implantable cardioverter defibrillator, or CRT - cardiac resynchronization therapy?)

1) For pt with asynchronous contractions (wide QRS)
2) Improves ejection fraction by synchronizing LV & RV
3) assists LV in pumping blood into the systemic circulation
4) similar to a pacemaker
5) very expensive
6) can detect ventricular tachycardia and fibrillation then automatically fires and returns patient to sinus rhythm

Answer 20

1) CRT
2) CRT
3) LVAD
4) ICD
5) LVAD
6) ICD

Question 21

Normal ejection fraction is ___

Answer 21

50-70% (accdg. to Osmosis vid)

Note: 40-50% is borderline
<40% - systolic HF

Ejection fraction: stroke volume/total volume

Question 22

Heart failure cells: ___

Answer 22

hemosiderin-laden macrophages