Heart Failure

Question 1

What is hf?

Answer 1

Any structural or functional
impairment of ventricular filling or ejection of blood Also, when the heart fails to
pump blood at a rate equal to the requirements of
the metabolizing tissues or is able to do so only with
an elevated diastolic filling pressure

Question 2

What is ejection fraction

Answer 2

is a measurement, expressed as a percentage,
of how much blood the left ventricle pumps out with
each contraction.
Ejection fraction = Stroke Volume / End-Diastolic
Volume

Question 3

What is the normal EF?

Answer 3

Normal ejection fraction is ≥ 50%

Question 4

Types of low output hf?

Answer 4

1. Left-sided heart failure.
2. Right-sided heart failure.
3. Biventricular heart failure

Question 5

What is the difference between preload and afterload?

Answer 5

Cardiac output is determined by preload (the volume and pressure of blood in the
ventricles at the end of diastole), afterload (the volume and pressure of blood in the
ventricles during systole) and myocardial contractility

Question 6

What is myocardial remodelling?

Answer 6

Myocardial insult causes pump dysfunction/impaired filling leading to myocardial
remodeling:
1. Pressure overload (e.g., aortic stenosis or HTN) leads to compensatory hypertrophy
(concentric remodeling) and eventually interstitial fibrosis
2. Volume overload (e.g., aortic regurgitation) leads to dilatation (eccentric remodeling)

Question 7

What are the most common causes of hf?

Answer 7

1-ischemic heart disease,
2-hypertension,
3-Diabetes mellitus and
4-valvular heart disease
5. Arrhythmia
6. Infection and inflammation (myocarditis)
7. Drugs
8. Dilated cardiomyopathy
9. Restrictive cardiomyopathy (amyloidosis, sarcoidosis)
10. Hypertrophic cardiomyopathy
11. Constrictive pericarditis

Question 8

What happen to na+ during hf?

Answer 8

Na+ and water retention

Question 9

Describe the Classification of HF by Left Ventricular Ejection Fraction (LVEF)?

Answer 9

1. HF with reduced ejection fraction (HFrEF): EF ≤ 40 % (Systolic heart failure)
2. HF with mildly reduced ejection fraction (HFmrEF): LVEF 41-49%
3. HF with preserved ejection fraction (HFpEF): EF ≥ 50% (Diastolic heart failure)

Question 10

What are the most cause RVHF?

Answer 10

Lvhf

Question 11

What are the causes of rvhf?

Answer 11

Caused by:
LV failure
Coronary artery disease (ischemia)
Pulmonary hypertension
Pulmonary valve stenosis
Pulmonary embolism
Chronic pulmonary disease

Question 12

Why does biventricular heart failure occurs?

Answer 12

occur because the disease process, such as
dilated cardiomyopathy or ischemic heart disease, affects
both ventricles or because disease of the left heart leads
to chronic elevation of the left atrial pressure, pulmonary hypertension and right heart failure.

Question 13

What causes high output hf?

Answer 13

demand for increased cardiac output.

Question 14

What causes high output hf?

Answer 14

Anemia
2. Systemic arteriovenous fistulas
3. Hyperthyroidism
4. Pregnancy
5. Beriberi heart disease (thiamine deficiency)
6. Paget disease of bone

Question 15

What are Heart failure exacerbation?

Answer 15

1-New cardiac insult/disease: MI, arrhythmia, valvular
disease.
2-New demand on CV system: HTN, anemia,
thyrotoxicosis, infection, etc.
3-Medication non-compliance.
4-Increase salt intake .
5-bstructive sleep apnea.

Question 16

What are symptoms and sings of lvhf and rvhf?

Answer 16

Low CO( forward)
1- Left Failure :
Syncope, Fatigue , Systemic hypotension ,Cool extremities,
Slow capillary refill, Peripheral cyanosis , Pulsus alternans MR , S3

2- right heart failure:

Left failure symptoms if decreased RV output leads to LV underflling, TR, S3(right-sided).

Venous Congestion (Backward)

1- left heart failure:
Dyspnea, orthopnea, PND, cough and Crackles.

2- right heart failure:

Peripheral edema, Elevated JVP with abdominojugular refux,
± Kussmaul’s sign, Hepatomegaly, Pulsatile liver

Question 17

When a patient has raised jvp in right v hf, what do we say?

Answer 17

jugular venous pressure (JVP): > 4 cm
above sternal angle

Question 18

What are ddx of hf or symptoms that similar to hf?

Answer 18

1-Acute Respiratory Distress Syndrome (ARDS) .
2-Pneumonia
3-Chronic Obstructive Pulmonary Disease (COPD)
4-Pneumothorax
5- Pulmonary Embolism (PE)
6-Pulmonary Fibrosis
7-Myocardial Infarction
8-Cardiogenic Pulmonary Edema
9-Cirrhosis
10-Nephrotic Syndrome
11-Venous Insufficiency

Question 19

How to approach to a patient with hf?

Answer 19

1- stabilise the patient and start with ABCs.
2- take proper history.
3- examine the patient.
4- do chest X-ray and
5- ECG
And then u can ask for
6- eco
7- BNP

Identifying the specific cause of HF is important because conditions that cause HF may require
disease specific therapies

Question 20

What are the investigation in hf?

Answer 20

1. complete blood cell (CBC) count: severe anemia, which may cause or aggravate
   heart failure. Leukocytosis may signal underlying infection.
   2.SerumElectrolytes: Hyponatremia
2. Renal function tests: Patients with severe heart failure may have elevated BUN and creatinine levels
   indicative of renal insufficiency owing to chronic reductions of renal blood flow from
   reduced cardiac output.
3. Liver function tests: low albumin and abnormal levels of AST and ALT.
   5- BNP

Question 21

What is the purpose of taking BNP for patents who have dyspnea?

Answer 21

BNP secreted from the ventricles when they are under increased pressure and stress(expansion).

Levels can aid clinicians in differentiating between cardiac and noncardiac
causes of dyspnea.

Normal BNP level < 100  pg/mL.  Normal NT-proBNP < 125 pg/mL.

Question 22

Why do ask for chest x-ray in hr?

Answer 22

1- To assess heart size and pulmonary congestion.
2-In heart failure: cardiomegaly (HFrEF), pulmonary edema and
pleural effusion can be seen in chest x-ray.

Question 23

What can we look for in ECG

Answer 23

Look arrhythmia and ischemia/infarction

Question 24

How can we asses or measure EJECTION FRACTION?

Answer 24

by using ECO (echocardiography )

Question 25

How to evaluate for ischemic heart disease in HF patients?

Answer 25

As we know HF is often caused by coronary atherosclerosis and evaluation for IHD can determine the presense of CAD by using:

1- Noninvasive testing:
• stress echocardiography, Single-photon emission computed tomography (SPECT),
cardiac magnetic resonance (CMR), or positron emission tomography (PET) can be
helpful in identifying patients likely to have obstructive CAD.
2- Invasive tests: cardiac catheterization

Question 26

If a patient comes to ER and we did investigations and we find out that he has HF, which treatment should we use?

Answer 26

Acute treatment LMNOPP
which
L- Lasix.
M- morphine
N- nitroglycerin
O- oxygen in hypoxemic patients.
P- positive airway pressure (CPAP/ BiPAP)
P- position: standing because they suffer from orthopnea.

Question 27

What are the long-term treatment for HFrEF patients?

Answer 27

Start with quadruple therapy by using:

1-ARNI (Valsartan or Sacubitril) or ACEi (Captopril, analapril) or ARB (Valsartan,losartan ),
2-BB ( bisoprolol, metoprolol)
3- MRA (Spironolactone)
4- SGLT2 inhibitors ( empagliflozin and dapagliflozin) recommended for
treatment of HFrEF (strong recommendation) and HFpEF (moderate
recommendation),
And it should be avoided with pateitns who has DM type 1.
5- + ADDLasix as needed.

• Reassess symptoms: Doing well: Continue
  Not doing well:
  HR more than 70 bpm. Add Ivabradine.

Question 28

What are the long treatment for HFmrEF and HFpEF?

Answer 28

Diuretics( Lasix) as needed and SGLT2i as it has mortality benefits.

Question 29

Why NSAIDS should be avoided in HF patients?

Answer 29

Cause sodium and water retention, worsen renal
function, interact with HF medications (ACEi/ARB),
increase cardiovascular events and worsen HF.

Question 30

What are the complications of HF?

Answer 30

1- Renal failure :is caused by poor renal perfusion due to low cardiac output and may
be exacerbated by diuretic therapy, ACE inhibitors and ARBs
2- Hypokalaemia may be the result of treatment with potassium-losing diuretics or
hyperaldosteronism caused by activation of the renin–angiotensin system.
3- Hyperkalaemia may be due to the effects of drugs that promote renal resorption of
potassium, in particular the combination of ACE inhibitors, ARBs and
mineralocorticoid receptor antagonists.
4- Hyponatraemia is a feature of severe heart failure and is a poor prognostic
sign. It may be caused by diuretic therapy or inappropriate water retention due to
high vasopressin secretion.

5- Impaired liver function is caused by hepatic venous congestion and poor
arterial perfusion.
6- Atrial and ventricular arrhythmias are very common and may be related to
electrolyte changes
7-Sudden death and is most probably due to ventricular fibrillation