Heart failure

Question 1

Which beta blockers are recommended for chronic heart failure?

Answer 1

Carvedilol and bisoprolol.

Question 2

What is cardiac output?

Answer 2

The volume of blood ejected by the heart per minute.
HR x SV

Question 3

What is stroke volume?

Answer 3

The volume of blood ejected during each beat/contraction.

Question 4

An 85 year old patient with chronic kidney disease and aortic stenosis is prescribed 2 litres of fluid over 4 hours and then starts to drop her oxygen saturation. What is the likely diagnosis and how would you manage her?

Answer 4

Acute LVF and IV furosemide.

Question 5

Define ejection fraction

Answer 5

The percentage of blood in the left ventricle that is squeezed out with each ventricular contraction.

Question 6

Define preload

Answer 6

Stretching of cardiomyocytes at the end of diastole. Ventricular filling pressure.

Question 7

Define afterload

Answer 7

Pressure or load against which the ventricles must contract. How hard heart pumps against resistance.

Question 8

Define inotropy

Answer 8

Myocardial contractility.

Question 9

What is the Frank-Starling law?

Answer 9

The relationship between ventricular stretching and contractility. Stretching of cardiac muscle (within physiological limits) will increase the force of contraction.

Question 10

Define end diastolic volume (EDV)

Answer 10

Amount of blood in ventricles before contraction.

Question 11

If EDV increases what happens to SV?

Answer 11

SV increases due to increase in preload therefore increasing contractility.

Question 12

Define end systolic volume (ESV)

Answer 12

Amount of blood remaining in the ventricle after contraction.

Question 13

If ESV increases what happens to SV?

Answer 13

SV decreases because there is more blood left in ventricles.

Question 14

If afterload increases what happens to SV?

Answer 14

SV decreases and ESV increases.

Question 15

How do you calculate SV?

Answer 15

EDV-ESV

Question 16

What factor influences EDV?

Answer 16

Preload

Question 17

Which factors influence ESV?

Answer 17

Contractility and afterload

Question 18

Why should you monitor U&Es closely in patients taking diuretics, ACEi and aldosterone antagonists?

Answer 18

Diuretics can cause hypokalaemia.
ACEi and aldosterone antagonists can cause hyperkalaemia.

Question 19

MOA of digoxin?

Answer 19

Inhibits Na+/K+ pump increasing intracellular Ca2+ which has a positive inotropic effect. It also increases vagal activity having a negative chronotropic effect.

Question 20

Should calcium channel blockers be used in HF?

Answer 20

No

Question 21

What causes pulmonary oedema in HF?

Answer 21

Backlog of blood in LA, pulmonary veins and lungs increases the volume and pressure, causing interstitial fluid leak into lungs and alveoli. Resulting in SOB and reduced O2%.

Question 22

Name some potential triggers for acute LV failure

Answer 22

Iatrogenic (e.g. aggressive fluids in elderly patient with impaired LV function), MI, arrhythmias, sepsis and hypertensive emergency.

Question 23

Describe the symptoms of acute LVF

Answer 23

Acute SOB, fatigue, orthopnoea, cough with white/pink sputum.

Question 24

Describe the signs of acute LVF

Answer 24

Tachypnoea, type 1 respiratory failure, tachycardia, bilateral basal coarse crackles.

Question 25

What are the signs of right sided heart failure?

Answer 25

Raised JVP, peripheral oedema, ascites, hepatomegaly.

Question 26

What blood test is used for HF?

Answer 26

Pro-BNP

Question 27

When is BNP normally released?

Answer 27

Hormone released from ventricles when myocardium is stretched and heart is overloaded.

Question 28

What is a normal EF?

Answer 28

>55%

Question 29

Describe the management plan for acute LVF

Answer 29

Sit patient up. Oxygen if sats are low. Diuretics - IV furosemide. IV fluids stopped. Underlying causes identified and treated. Monitor fluid balance.

Question 30

In severe cases what drugs would you use to manage acute LVF?

Answer 30

Dobutamine (inotrope), noradrenaline (vasopressor).

Question 31

What is chronic HF?

Answer 31

The clinical features of impaired cardiac function, specifically LV dysfunction.

Question 32

What is HF with reduced EF?

Answer 32

EF < 50%

Question 33

What is HF with preserved EF?

Answer 33

Clinical features of HF but an EF > 50%

Question 34

What are the most common causes of chronic HF?

Answer 34

IHD and hypertension.

Question 35

Describe the compensatory mechanism for a reduced CO in HF

Answer 35

Increasing preload, increasing HR, activation of RAAS system, activation of sympathetic NS.

Question 36

Describe the symptoms of chronic HF

Answer 36

SOB, cough with pink/white frothy sputum, orthopnoea, PND, peripheral oedema, fatigue.

Question 37

Describe the signs of chronic HF

Answer 37

Tachycardia, tachypnoea, hypertension, S3/4 heart sounds, bilateral basal coarse crackles, raised JVP, peripheral oedema, displaced apex beat, hepatomegaly and ascites.

Question 38

Describe the CXR findings for chronic HF

Answer 38

Alveolar opacification/oedema. Kerley B lines. Cardiomegaly. Dilated upper lobe vessels. Pleural effusions.

Question 39

How would you confirm HF?

Answer 39

Echocardiogram

Question 40

Describe the NYHA classification of HF

Answer 40

Class 1: no limitation on activity. Class 2: comfortable at rest but symptomatic with ordinary activities. Class 3: comfortable at rest but symptomatic at any activity. Class 4: symptomatic at rest.

Question 41

Which vaccines would you offer to a patient with chronic HF?

Answer 41

Annual flu, pneumococcal and COVID vaccines

Question 42

What are the first line medications for chronic HF?

Answer 42

ACEi and beta blocker.

Question 43

What medication would you add on if reduced EF HF wasn’t controlled by ACEi or beta blocker?

Answer 43

Aldosterone antagonist e.g. spironolactone or eplerenone.

Question 44

What medication would you use for preserved EF HF or fluid overload?

Answer 44

Loop diuretic e.g. furosemide.

Question 45

What type of pacemaker is used for HF and at what EF?

Answer 45

EF < 35% and cardiac resynchronisation therapy (CRT) - biventricular pacing.

Question 46

Where is the site of action of furosemide?

Answer 46

Inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle.

Question 47

Which drug should be considered for Afro-Caribbean patients with HF who are not responding to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy?

Answer 47

Hydrazine and nitrate

Question 48

Which drugs are contraindicated in moderate-severe aortic stenosis?

Answer 48

ACEi, GTN, ARBs, dihydropyridine CCB, hydralazine - due to the vasodilatory effect.

Question 49

How can NSAIDs worsen HF?

Answer 49

They reduce renal sodium excretion and can cause fluid retention.

Question 50

How can Verapamil worsen HF?

Answer 50

Negative inotropic effect

Question 51

ECG sign of digoxin toxicity

Answer 51

Reverse tick sign

Question 52

Name 2 factors which may precipitate digoxin toxicity

Answer 52

- Hypokalaemia - Renal failure

Question 53

Management of digoxin toxicity

Answer 53

Digibind