Heart Failure

Question 1

What is heart failure?

Answer 1

Heart failure is a complex clinical syndrome in which the heart fails to meet the metabolic demands of the body. It can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood

Question 2

How is heart failure diagnosed?

Answer 2

A diagnosis of heart failure is based on the presence of a triad of typical symptoms (shortness of breath on exertion and at rest, fatigue), signs (tachycardia, tachypnoea, raised jugular venous pressure, peripheral oedema, and pulmonary congestion), and objective evidence of a structural or functional cardiac abnormality (cardiomegaly, abnormal echocardiogram, raised natriuretic peptide concentration).

NT-proBNP > 400-2000 –> heart failure

Question 3

What are the end-stage results of heart failure?

Answer 3

Progressive pump failure

Sudden cardiac death

Question 4

What pathologies can lead to heart failure?

Answer 4

Ischaemic heart disease
Idiopathic dilated cardiomyopathy
Valve disease
Hypertension

Question 5

What are the physiological causes of heart failure?

Answer 5

1. Volume overload
2. Pressure overload
3. Contractile dysfunctioni

Question 6

What remodeling changes occur in heart failure?

Answer 6

1. Myocardial damage leads to increased myocardial wall stress
2. Wall thickness increases to reduce wall stress –> increase of myocardiocytes isn’t functional and decrease in CO (diastolic failure)
3. Hyperdilation of ventricles and severely decreased CO

Question 7

What are the signs of heart failure?

Answer 7

1. Tachycardia
2. Hypotension
3. Raised JVP
4. Displaced apex beat
5. 3rd heart sound
6. Cachexia
7. Cardiomegaly
8. Pleural effusion
9. Ascites
10. Peripheral ankle oedema
11. Tender hepatomegaly
12. Bi-basal crackles

Question 8

What are the 4 steps in the NYHA classification of heart failure?

Answer 8

1. No limitation pf physical activity
2. Slight limitation of physical activity (walking up stairs)
3. Marked limitation of physical activity (getting dressed)
4. Symptoms at rest

Question 9

What are the specific symptoms of left-sided heart failure?

Answer 9

Nocturnal dyspnoea
Orthopnea
Tachycardia 
Pulmonary congestion -> cough, crackles, wheezes
Fatigue
Cyanosis 
Exertional Dyspnoea

Question 10

What are the specific symptoms of right-sided heart failure?

Answer 10

fatigue
Increased peripheral venous pressure
Ascites
Enlarged liver and spleen
Weight gain

Question 11

What does an ECG in heart failure show?

Answer 11

No definitive markers for heart failure, but only 2% of patients with heart failure have a normal ECG

• Often observed:
  
  • Sinus tachycardia
  • Arrhythmias
  • LVH
  • Evidence of ischaemia or infarction
  • Conduction system defects

Question 12

What does a CXR in heart failure show?

Answer 12

Pulmonary congestion

Cardiomegaly

Question 13

What does an echocardiography in heart failure show?

Answer 13

Key in confirming diagnosis

Question 14

What do natriuretic peptide levels in heart failure patients show?

Answer 14

A normal plasma concentration in an untreated patient has a high negative predictive value, making HF an unlikely cause of symptoms.

Question 15

How would you pharmacologically manage heart failure?

Answer 15

First line: offer diuretics for congestive symptoms and fluid retention, then offer ACE-I and beta-blocker

Question 16

What dose would you give furosemide?

Answer 16

40 mg daily in the morning

Question 17

What do thiazides do?

Answer 17

Thiazides and related compounds are moderately potent diuretics; they inhibit sodium reabsorption at the beginning of the distal convoluted tubule

Question 18

What are examples of thiazides?

Answer 18

Bendroflumethiazide
Chlortalidone
Xipamide
Metolazone

Question 19

What do loop diuretics do?

Answer 19

The mechanism of action for loop diuretics like furosemide is by inhibiting the apical sodium/potassium/chloride transporter in the thick ascending limb of the loop of Henle

Question 20

What are examples of loop diuretics?

Answer 20

Furosemide
Bumetanide
Torasemide

Question 21

Name an example of an aldosterone antagonist

Answer 21

Spironolactone

Improves survival in heart failure patient

Question 22

What dose would you give for spironolactone?

Answer 22

25-400 mg daily depending on the condition

Question 23

How would you non-pharmacologically manage heart failure?

Answer 23

1. Revascularisation
2. Biventricular pacemaker
3. Cardiac transplantation