Heart Failure

Question 1

What is Congestive Heart Failure?

Answer 1

The heart is unable to maintain a high enough CO to meet the needs of the body due to some failing in the heart.
Most common is LVSD but can affect both sides and can be systolic (reduced ejection fraction )or diastolic (preserved ejection fraction: unable to relax and fill properly so EDV goes way down).

Question 2

What is Heart Failure caused by?

Answer 2

Valvular Disease
Pericarditis
Tamponade
MI
Arrythmias
Cardiomyopathy
Hypertension (systemic -> LVF & Pulmonary -> RVF)
Alcohol & drugs
Congenital Heart Defects (e.g. Persistant Truncus Arteriosus)

Question 3

What are the risk factors for Heart failure developing?

Answer 3

Old Age
Smoking
Diabetes
Hypertension
Coronary Artery Disease
Valvular Disease
Alcoholism/Drug Abuse
Congenital Heart Defects
Obesity
OSA
Viral Infection

Question 4

How does Heart Failure present?

Answer 4

IT varies depending on which side is affected.

Left Heart specific:
Pulm Oedema (Crackles) - Palpitations - Orthopnea - PND - Cough - Shifted Apex Beat ~haemoptysis ~pleural effusion

Right Heart Specific:
Raised JVP - Ascites - Peripheral Oedema - Hepatomegaly

Both:
Dyspnoea - Tachycardia - Tachypnoea - Confusion - Fatigue/weakness - Syncope - Cyanosis -

May also notice murmurs of valvular disease

Question 5

What can you detect on a HF exam?

Answer 5

Murmurs of Valvular Disease
Audible S3/4

Left:
Displaced Apex Beat - Crackles - Pleural Effusion

Right:
Peripheral Oedema - Ascites - Hepatomegaly - Raised JVP

Question 6

What tests do we do for HF?

Answer 6

ECG
MRI/CT/CXR
ECHO
MUGA - Radionuclide Angiography
FBC - Renal Function - LFTs - TFTs
Biopsy
Stress Test
BNP level (should increase)
Calculate EJection fraction with images from echo or muga to determine systolic vs diastolic

Question 7

What potential screening methods are there for HF?

Answer 7

Bedside ECGs and BNP levels.

Question 8

What areas of treatment are there for HF?

Answer 8

Underlying Causes
Acute Precipitating Cause
- Pulmonary Congestion (LMNOP)
- Prevent Thrombus
- Reduce preload/afterload
- Increase contractility
- Reduce Heart Rate
- Prevent fibrosis of Myocytes
- Surgery

Question 9

How do we treat pulmonary congestion?

Answer 9

LMNOP
Lasix - Brand of IV furosemide, a loop diuretic (which also lowers preload)
Morphine
Nitrate - Isosorbide
Oxygen
Position - upright to pool blood in legs rather than lungs

Question 10

How do we reduce preload/Afterload?

Answer 10

With vasodilators!
ACEI/ARB - CCB - Hydralazine - Nitrates - ANP/BNP agent sacubitril

Question 11

How does sacubitril work?

Answer 11

It inhibits the action of neprilysin which is the enzyme that breaks down natriuretic peptides

Question 12

How do we increase contractility/

Answer 12

Digoxin & Dopamine

Question 13

How do we reduce Heart Rate?

Answer 13

B blockers (digoxin helps too)

Question 14

How do we prevent fibrosis of myocytes?

Answer 14

Its caused by aldosterone so SPIRONOLACTONE

Question 15

What surgery do we do for HF?

Answer 15

We can hook up a hear bypass machine (e.g. VAD, Ventricle Assist Device)
And a heart transplant

Question 16

Why doesnt HF have ot have a lower CO?

Answer 16

The heart is failing, Ejection fraction begins to fall. In response the heart dilates (chronic) or activates symp system and increases HR+Cotnractility (Acute). Thus CO is maintained temporarily.
Evetually the HF will progress to be un-compensatable and CO will drop off.

Question 17

How is HF a systemic disorder?

Answer 17

When CO does begin to fall it lowers GFR which is registered by the kidney as a fall in MAP and so RAAS is activated.
This leads to increased fluid retention and vasoconstriction which only exacerbates the hypertension and congestion in HF through raising afterload/preload.

Question 18

What test confirms HF after history and exam?

Answer 18

Doppler Echocardiogram