Heart Failure

Question 1

Definition of heart failure

Answer 1

The inability of the heart to deliver blood + O2 at a rate that is commensurate with the metabolic requirements of the body
* a syndrome not a diagnosis *

Question 2

Epidemiology

Answer 2

MALES
African descent
65+

Question 3

Risk factors

Answer 3

Smoking
Obesity
Previous Mi

Question 4

Difference in systolic vs diastolic HF

Answer 4

Systolic = inability of the heart to contract properly = reserved ejection fraction < 40%
Diastolic = inability of the heart to relax and fill properly = preserved ejection fraction > 40%

Question 5

Systolic HF Pathophysiology

Answer 5

Inadequate O2 output = compensatory physiological changed:
- Sympathetic stimulation
- RAAS
- Cardiac changes
- Myocyte hypertrophy (ventricular remodelling) -> eventually becomes pathological -> myocardium fails =
1. Increase in preload + ventricular load =
2. hypertrophy of myocardium
3. increase in myocardial demand for O2
4. myocardium becomes ischaemic
5. Patchy fibrosis = Stiffness and reduced contractility
6. Increase in work load + amount of blood remaining = more force needed = cells become tired = pathological

Question 6

Diastolic HF pathophysiology

Answer 6

Concentric hypertrophy = less filling room = DHF

Question 7

Aetiology

Answer 7

Any factor that increases myocardial work = Anaemia, arrhythmias, hyperthyroidism, pregnancy, obesity
Systolic =
- IHD (MC)
- Long standing HTN
- Previous MI
- Cardiomyopathy
Diastolic =
- Aortic stenosis
- Chronic hypertension

Question 8

Signs

Answer 8

Murmurs + Displaced apex beat
3rd heart sounds
Cyanosis
Cardiomegaly
Tachycardia
Hypotensive
Bi-basal crackles (rales) heard on auscultation
Effusion = stony dullness on percussion

Question 9

Symptoms

Answer 9

3 CARDINAL NON-SPECIFIC SIGNS:
- SOB
- ANKLE SWELLING (Pulmonary oedema)
- FATIGUE
Dyspnoea/ Orthopnoea (worse when laying flat)
Fatigue and weakness
Cough with pink, frothy sputum
Cardiogenic wheeze

Question 10

NY heart association: Class 1-4 of HF severity

Answer 10

NY heart association: Class 1-4 of HF severity
1. no limit on physical activity
2. slight limit on moderate activity
3. marked limit on moderate activity + gentle activity
4. Symptoms even at rest!!!

Question 11

Diagnosis

Answer 11

FIRST LINE = Brain Natriuretic Peptide (released when myocardial walls are under stress) > 400 ug/mL
Inactive BNP = NT ProBNP = 5 times higher than BNP = 2000ug/mL
ECG: Abnormal e.g. evidence of LVH = broad QRS complex
CXR = ABCDE
Alveolar oedema
Kerly B lines
Cardiomegaly
Dilated upper lobe vessels in lungs
Effusions (pleural)
GOLD STANDARD = Echo = assess heart chamber dimensions

Question 12

Treatment ABAL

Answer 12

Conservative = lifestyle changes = reduce BMI, stop smoking + alcohol
Pharmacological = ABAL
FIRST LINE = ACE-i (Ramipril)+ bb (bisoprolol)
SECOND LINE = Aldosterone antagonist (spironolactone) + loop diuretic (furosemide)
THIRD LINE = consider cardiac resynchronisation or Digoxin
Surgery = last resort

Question 13

How does ASD/VSD lead to isolated RSHF

Answer 13

Cardiac shunt -> Allows blood to flow from higher pressure left side to lower pressure right side
Increases fluid volume on right side -> concentric hypertrophy of right ventricle
More prone to ischaemia -> systolic dysfunction + smaller volume = diastolic dysfunction

Question 14

Cor Pulmonale Pathophysiology

Answer 14

Chronic lung disease = hard to exchange O2
-> Hypoxia
-> Pulmonary arteriole constriction
-> Increase in: Pulmonary blood pressure
-> Harder for right side of heart to pump against
-> Right sided hypertrophy + heart failure

Question 15

Right sided heart failure signs and symptoms

Answer 15

Symptoms:
- swelling in legs
- distended abdomen
- fatigue and weakness
Signs
- raised JVP
- peripheral pitting oedema
- hepatosplenomegaly
- ascites