Heart Failure

Question 1

What is heart failure?

Answer 1

Cardiac output is inadequate for the body’s requirement.

Question 2

What is this describing?

Inability of the ventricle to contract normally, leading to decreased cardiac output. Ejection fraction <40%.

Answer 2

Systolic heart failure

Question 3

What are the causes of systolic heart failure?

Answer 3

IHD, MI, cardiomyopathy, HTN

Question 4

What is this describing?
Inability of the ventricle to relax and fill normally, causing increased filling pressures. Ejection fraction >50%, reduced preload, SV reduced.

Answer 4

Diastolic heart failure

Question 5

What are the causes of diastolic heart failure?

Answer 5

Ventricular hypertrophy, constrictive pericarditis, tamponade, obesity, HTN, hypertrophic cardiomyopathy.

Question 6

What is this a presentation of and what causes it?
Dyspnoea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough and pink frothy sputum, wheeze, cold peripheries, displaced apex beat, pulmonary oedema.

Answer 6

1. Left ventricular failure

2. IHD, HTN

Question 7

What are the causes of right ventricular failure?

Answer 7

LVHF, pulmonary stenosis, cor pulmonale, left to right shunt.

Question 8

What are the two types of right heart failure and what causes them?

Answer 8

1. Acute - massive PE most common cause, heart does not have time to compensate (circulatory collapse, shock and death)
2. Chronic - right ventricle damages slowly, caused by COPD, pulmonary fibrosis, recurrent small PEs.

Question 9

What is this a presentation of?

Peripheral pitting oedema (up to thighs, sacrum), ascites, nausea, hepatomegaly, raised JVP, RV heave (pulmonary HTN).

Answer 9

Right ventricular failure

Question 10

What is this describing?
New onset or decompensation of chronic heart failure characterised by pulmonary oedema. Almost always caused by a complication of an MI.

Answer 10

Acute heart failure

Question 11

What is this describing?

Progresses slowly, most common form of heart failure, almost always due to chronic left ventricular failure.

Answer 11

Chronic heart failure

Question 12

Why does heart failure cause SOB?

Answer 12

Blood backs up to the lungs causing pulmonary oedema.

Question 13

What is the pathophysiology in congestive cardiac failure?

Answer 13

1. LVF and RVF occurring together.
2. Reduced cardiac output caused neurohormonal activation.
3. Sympathetic activation - increases vascular resistance, RAS activation - increases volume and Na+ retention.
4. These both increase vascular resistance which increases cardiac workload, ventricular stress and dilation.
5. Loops back to LV systolic dysfunction
6. Release of catecholamines and aldosterone increases myocyte damage.

Question 14

What is the diagnostic criteria of congestive cardiac failure?

Answer 14

Framingham criteria:
Need 2 major or 1 major and 2 minor:
1. Major - acute pulmonary oedema, cardiomegaly, hepatojugular reflex, neck vein distension, paroxysmal nocturnal dyspnoea/orthopnoea, pulmonary crackles.
2. Minor - ankle oedema, dyspnoea on exertion, hepatomegaly, nocturnal cough, pleural effusion, HR >120.

Question 15

What are the risk factors for congestive cardiac failure?

Answer 15

MI, DM, dyslipidaemia, old age, male, HTN, LVH, renal insufficiency, valvular disease, sleep apnoea, high CRP, AF, thyroid disorders, high BNP.

Question 16

How should you investigate suspected heart failure?

Answer 16

1. FBC, U&Es
2. ECG - evidence of MI, ischaemia, LVH
3. BNP - if normal, heart failure unlikely
4. CXR - cardiomegaly, alveolar oedema, Kerly B lines, pleural effusion, congested hilar region
5. Echo - determine pathology and ejection fraction

Question 17

What is BNP?

Answer 17

Brain natriuretic peptide, hormone secreted by ventricular myocytes in response to volume and pressure overload of LV. Normally promotes salt and water diuresis.

Question 18

What is the management of heart failure before medications?

Answer 18

1. Stop smoking, reduce alcohol, eat less salt, optimise weight and nutrition.
2. Treat cause
3. Treat exacerbating factors (anaemia, thyroid disease, infection, HTN)
4. Avoid exacerbating factors (NSAIDs = fluid retention) and verapamil (-ve inotrope)
5. Annual flu vaccine, one-off pneumococcal vaccine

Question 19

What are the three steps in medical management of heart failure?

Answer 19

1. Offer ACEi and beta blocker 1st line
2. If symptoms persist - aldosterone antagonist, vasodilators, loop diuretics
3. Then - digoxin/cardiac resynchronisation therapy.

Question 20

What are the typical medications used in heart failure and how do they help?

Answer 20

1. Catopril (ACEi) - decreases mortality
2. Carvedilol (BB) - decreases mortality
3. Spironolactone (Aldosterone antagonist) - decreases mortality
4. Hydralazine and isosorbide dinitrate (vasodilators) - reduces mortality in black patients/intolerant to ACEi/ARB
5. Furosemide (loop diuretic) - symptomatic relief
6. Digoxin - symptomatic relief

Question 21

What are the stages of the New York classification of heart failure?

Answer 21

I - no dyspnoea from ordinary activity
II - normal at rest, dyspnoea during ordinary activity
III - less than ordinary activity causes dyspnoea
IV - dyspnoea at rest