Heart Failure

Question 1

What is the aetiology of heart failure?

Answer 1

Usually due to an underlying cause

Question 2

What is the epidemiology of heart failure? (risk factors and prevalence)

Answer 2

Prevalence and incidence highest in the elderly (mean age around 74)
Prevelance = 0.4-2%, asymptomatic LVSD (left ventricular systolic dysfunction) = 0.4-2%

Hypertension, Diabetes, CHD, Obesity, Hyperlipidemia

Question 3

What is the prognosis of heart failure?

Answer 3

Poor, simelar to that of a lot of cancers, approx 60% 1year survival rate.

Question 4

What investigations are used in Heart Failure?

Answer 4

BNP current first line medical treatment, helps determine prognosis and although it isn’t specific, a low BNP level would effectively rule out chronic heart failure or LVSD, and a positive test means high likelihood of CHF.

If +ive BNP, then an echo is used

ECGs can also be used but aren’t first choice - minor irregularities indicate it could be Chronic heart failure, if ECG entirely normal then LVSD very unlikely

Question 5

What are the treatment options for heart failure?

Answer 5

ACE inhibitors
Aldosterone receptor blockers
Beta Blockers
Diuretics

Now also ARNI (Angiotensin Receptor and Neprolysin Inhibitor)

Question 6

What is heart failure? Should it be qualified on diagnosis?

Answer 6

It is basically when the heart isn’t keeping up with how it should be working, leading to dyspnoea, fatigue, fluid retention.

Yes, should be qualified as it is usually due to an underlying condition, eg heart failure due to severe aortic stenosis

Question 7

Av length of stay in hosp and presenting symptoms reasons for hosp stay?

Answer 7

Av length of stay is looonnnggg, about 2 weeks, second to stroke (over 3 weeks!)

Presenting symptoms include:

• acute breathlessness
• Deteriation of heart failure
• Stable heart failure
• MI
• AF

Question 8

Is there a high re admission rate? When is ti highest?

Answer 8

Yes, and readmission highest in the first week.

Question 9

SYmptoms of HF?

Answer 9

Dyspnea (SOB)
Fatigue
Oedema
Reduced exercise capacity

Question 10

SIgns of HF?

Answer 10

Increased JVP
Oedema
3rd heart sound
Chest crepitations/effusion
shifted apex beat
Tachycardia

Question 11

Why is objective evidence of cardiac dysfunction mandatory for a formal diagnosis?

Answer 11

Because the symptoms and signs could also be for a lot of other causes, many patients present with symptoms only. There has been a large proportion of misdiagnosis - 40-50%

Question 12

What is required to diagnose Heart Failure?

Answer 12

The signs/symptoms of HF AND objective evidence of cardiac dysfunction

If not obvious, also require response to treatment

Question 13

Whta is objective evidence of cardiac dysfunction?

Answer 13

Somthing that shows that the heart isn’t working optimally.

EG ECHO, Radionuclide ventriculography (RNVG/MUGA), MRI, left ventriculography

Question 14

What “screening” tests can be done? WHy not always Echo?

Answer 14

BNP (used as first line test in patients with suspected HF)

Potentially ECG as entirely normal ECG rules out the diagnosis of CHF (90-95% sensitive)

ECHO not always used as large amounts of patients needing diagnostic/screenining test and wait list is too long.

Question 15

BNP test?

Answer 15

Brain (type B) natriuretic peptide), measured in blood. If low can effectively exclude CHF as levels are elevated in patients with CHF, but can be other reasons for t to be high so if high needs a follow up ECHO/cardiac assesment.

Relatively cheap, bedside testing.

Question 16

What can be the underlying causes of heart failure?

Answer 16

Pretty much any cardiac conditions if they are severe enough.

Valvular diseases
Scarring (prev MI etc)/ischemia
Arrythmias (tachy/brady)
Stenosis
Pericardial constriction/effusion
LV dysfunction (systolic/diastlic)
Restrictive cardio myopathy
Right ventricular failure

Question 17

Causes of LVSD?

Answer 17

Ischaemic heart disease (MI)
Dilated Cardiomyopathy (DCM) - basically issue with heart MUSCLE, can be inherited, toxins, viral/infective, hypertension, systemic diseases (eg sarcoidosis, haemachromatosis, SLE), cardioyopathy
Severe valve disease/mitral regurgitation

Question 18

What is peri-partum cardiomyopathy?

Answer 18

A weakness in the heart muscle developing in final month of pregnancy to 5 months after producing mild-sesvere symptoms.

Question 19

How can you come to a diagnosis?

Answer 19

History!!! Then basically try and find the cause!!::

Echo, possibly ECG sometimes CXR
possibly Autoantibodies/viral serology, bloods
Exclude Phaechromocytoma, renal failiure, anaemia, Thyroid function test
Other causes (sarcoid/muscular dystrphy)
Coronary Angiography? - CHEST PAIN!
Cardiac MRI - check fro infarction/inflammation/fibrosis
Most then assesed by cardiologist

Question 20

Can lymes disease cause LVSD?

Answer 20

Suprisingly it can, and is something you’ll want to check for in walkers, it can cause dilated cardiomyopathy.

Question 21

What is phaechromocytoma?

Answer 21

Tumour in the adrenal gland, in cells that produce hormones.

Question 22

When would you consider a coronary angiogram?

Answer 22

Chest pain, esp if elderly (over 70) but also younger patients, who you would want t catch so that you are able to then give them effective treatment

Question 23

What alternative tests can be done?

Answer 23

ECG, CXR, Bloods, Viral serology, autoantibodies, coronary angiography, CT angiogram, cardiac MRI

Question 24

Whys an echo essential? Give an eg of

Answer 24

To easily see the function of the heart, non invasive, can do at bedside, relativly cheap and no radiation.

Can identify and quantify:
LV systolic dysfunction
Valvular dysfunction
Pericardial effusion / tamponade
Diastolic dysfunction
LVH
Atrial/ventricular shunts / complex congenital heart defects
Pulmonary hypertension / Right heart dysfunction

Question 25

What can’t am echo show?

Answer 25

Pericardial thickness/constriction, may miss shunts. But should be able to see atrial distress.

Question 26

What is a LV ejection fraction? What is used to to calculate LVEF in ECHO?

Answer 26

Its the proportion of blood entering the left side of the heart that is then pumped out

EF = SV/EDV x 100

Variable between people and with certain conditions, may be lower than previous but not pathologically low.

Question 27

Normal/Mild/Moderate/Severe LVEF for LV function

Answer 27

Normal = 55-70%
Mild = 40-55%
Moderate = 30-40%
Severe = Under 30%

Question 28

What does radiologist do to help calc LVEF? How to improve this reading?

Answer 28

Measures around the perimeter of the heart. The computer and algorithms do the rest.

Can be improved with contrast agents, qulaity images and experienced oparator. Simpson’s biplane (echo gold standard) calculation method should be usde.

Question 29

What other tests can be used to give a LVEF? With pros and cons when would be used?

Answer 29

Radionuclide angiography (MUGA)
Pros: Much more accurate figure for LVEF ( so used when an acurate figure is needed)
-ive : Ionisation, no additional structural information

Cardiac MRI
Pros: Much clearer image and more acurate than echo, especially if looking for fibrosis, masses, inflammation etc also still no ionisation
Cons: Expensive, requires breath holding, can’t be done at bedside, claustrophobia issues

Question 30

How is Heart failure graded usually? Why?

Answer 30

Based on symptoms using the NYHA scoring system, because based on LVEF outcome isn’t that differential.

Class 1: No symptoms or exercise limitation
II: Comfortable at rest or mild excertion
III:Comfortable only at rest
IV: Symptoms at rest and any activity brings discomfort and symptoms

Question 31

WHy is CO at rest irrelevant with Heart Failure?

Answer 31

Because CO can be the same or higher (within healthy ranges) in patients with HF

eg lower ejection fraction but higher EDV (think football compared to satsuma), same cardiac output, and with higher heart rate gives a higher cardiac output

Question 32

What is the Neurohormonal hypothesis? Which mal adaptive systems are involved?

Answer 32

It basically says that Heart failure isn’t just a heart pumping problem, but a whole body problem , inc. renal dysfunction, muscle dysfunction, inflamm, neurohormonal activaition

• Renin-Angiotensin-aldosterone system, causing salt and water retention, hypokalaemia, hypomagnesaemia, LV remodelling and fibrosis
• Sympathetic nervous system, arrhythmogenic, adverse haemodynamics, increases in renin etc

Question 33

What is the pharmacological therapy used?

Answer 33

diuretics
ACE inhbiters
Beta blockers
Aldosterone Receptor blockers

ALSO Now ARNI - (Angiotensin receptor and Neprolysin Inhibitor)