Heart failure

Question 1

Define heart failure

Answer 1

CO is inadequate for the body’s oxygenation requirements despite adequate filling pressures

Question 2

List two changes that occur during compensated heart failure in response to reduced CO

Answer 2

 Starling effect dilates heart to enhance contractility
 Remodelling → hypertrophy
 RAS and ANP/BNP release
 Sympathetic activation

Question 3

Describe two phenomena that arise when there is decompensated heart failure

Answer 3

 Progressive dilatation → impaired contractility +
functional valve regurgitation
 Hypertrophy → relative myocardial ischaemia
 RAS activation → Na
+ and fluid retention → ↑ venous
pressure → oedema
 Sympathetic excess → ↑ afterload → ↓ CO

Question 4

Describe three causes of low output heart failure

Answer 4

Decreased CO which fails to improve with increasing exertion

1. Pump failure- MI/ischaemia, HTN, myocarditis, arrhythmias
2. Excessive preload- AR, MR, fluid overload
3. Excessive afterload: AS, HTN

Question 5

Name two causes of high output heart failure

Answer 5

Increased oxygen demand

Anaemia
Thyrotoxicosis
Pregnancy

Question 6

Two causes of RVF?

Answer 6

LVF
Cor pulmonale
Tricuspid and pulmonary valve disease

Question 7

Three signs of RVF

Answer 7

 ↑JVP + jugular venous distension
 Tender smooth hepatomegaly (may be pulsatile)
 Pitting oedema
 Ascites

Question 8

Three causes of LVF?

Answer 8

1 st : IHD 
2 nd : idiopathic dilated cardiomyopathy 
3 rd : Systemic HTN 
4 th : Mitral and aortic valve disease 
Specific cardiomyopathies

Question 9

Symptoms of RVF?

Answer 9

Anorexia and nausea

Question 10

Symptoms of LVF?

Answer 10

  Fatigue 
  Exertional dyspnoea 
  Orthopnoea  
  Nocturnal cough (± pink, frothy sputum) 
  Wt. loss and muscle wasting

Question 11

Three signs of LVF?

Answer 11

  Cold peripheries ± cyanosis 
  Often in AF 
  Cardiomegaly c¯  displaced apex 
  S3 + tachycardia = gallop rhythm 
  Wheeze (cardiac asthma) 
  Bibasal creps

Question 12

Signs of chronic heart failure on CXR?

Answer 12

CXR: ABCDE 
  Alveolar shadowing 
  Kerley B lines 
  Cardiomegaly (cardiothoracic ratio >50%) 
  Upper lobe Diversion 
  Effusions 
  Fluid in the fissures

Question 13

Which biomarker is the most helpful in diagnosing HF?

Answer 13

BNP

Question 14

When is BNP secreted and what are its functions?

Answer 14

increase in pressure/stretch

Increases GFR, decreases renal NA absorption, decereases preload by relaxing smooth muscle

Question 15

Which classification system is used for heart failure?

Answer 15

New york hear association classification

Question 16

What is the specific medical treatment of heart failure?

Answer 16

(always treat underlying cause if ID)

ACEi/ARB- lisinopril/candesartan
Beta blocker- bisoprosol
Loop diuretic- furosemide, bumetanide

Question 17

List a surgical management for heart failure

Answer 17

LVAD

Transplant

Question 18

What are kerley B lines a sign of?

Answer 18

interstitial leaking= sign of pulmonary oedema

Question 19

What are the two characteristic changes that arise in HF?

Answer 19

systemic vasconstriction and neurohumoral activation

Question 20

Why does systemic vasoconstriction arise?

Answer 20

the body recognises impaired pump function as a failure circulatory volume (similar to shock). Because the body sees a reduction in blood volume, salt and water restrictive processes are activated, increasing sympathetic drive, resulting in vasoconstriction

Question 21

What are examples of neurohumoral activation?

Answer 21

SNS (symp NS), RAAS, ET, ADH, natriuretic peptides

Question 22

Which natriuretic peptides are released in response to changes in pressure within the heart as seen in HF?

Answer 22

BNP, NT-proBNP

Question 23

What is the effect of blocking neprilysin?

Answer 23

endogenous enzyme that degrade natiruretic peptides

increases the bioavailability of natriuretic peptides, therefore promotion vasodilation, diuresis

Question 24

Which diabetic drug can be given to patients with HF?

Answer 24

SGLT2 inhibitors

dapagliflozin

Question 25

What is the management of acute HF?

Answer 25

1. Dobutamine, dopamine, milrinone- increased inotropy 2. Furosemide 3. Nitrates- vasodilation 3. Nitrates, nitroprusside- arterial vasodilation 4. Ultrafiltration 5. Continuous positive airway pressure- preload reduction

Question 26

What is an acronym for ID of cause of acute HF?

Answer 26

CHAMP- acute Coronary syndrome, Hypertension emergency, Arrhythmia, Mechanical acute cause, Pulmonary embolism

Question 27

What determines whether acute HF pt is wet or dry?

Answer 27

wet- presence of congestion, dry-no congestion

Question 28

What are the signs of of right heart failure?

Answer 28

raised JVP, ascites, right ventricular heave

Question 29

What are the signs of left heart failure?

Answer 29

tachycardia, pink-frothy sputum, gallop rhyhm, displaced apex beat, increased RR, reduced Oxygen saturations

Question 30

What are the symptoms of right heart failure?

Answer 30

tiredness, anorexia, nausea, bloated feeling

Question 31

What are the symptoms of left heart failure?

Answer 31

dyspnoea, orthopnoea, fatigure, wheeze, poor exercise tolerance, nocturnal cough

Question 32

What is the Frank-Starling law?

Answer 32

the greater the end diastolic volume, the greater the stroke volume

Question 33

Name three factors that could result in a fall in stroke volume and therefore cardiac output

Answer 33

reduced preload, increased afterload, reduced contractility