heart failure

Question 1

what is heart failure?

Answer 1

the heart is unable to pump blood around the body properly.

It usually occurs because the heart has become too weak or stiff. Therefore the cardiac output is inadequate for the body’s requirements

Question 2

what is systolic heart failure?

Answer 2

The inability of the ventricle to contract normally

-> Cardiac Output decreases
-> Ejection Fraction (EF) is <40%.

caused by MI, IHD, Cardiomyopathy

Question 3

what is diastolic heart failure?

Answer 3

Inability of the ventricle to relax, and fill normally

-> EF >50%

caused by:
Constrictive Pericarditis
Tamponade
Restrictive Cardiomyopathy
Hypertension

Question 4

what are the symptoms of left ventricular failure?

Answer 4

Breathlessness (Orthopnoea) and Fatigue mainly
Nocturnal Cough
Poor Exercise Tolerance
Wheeze
Weight Loss
Nocturia
Muscle Wasting
Cold Peripheries

Question 5

what are the symptoms of right ventricular failure?

Answer 5

Peripheral Oedema (up to thighs, sacrum, abdominal wall) mainly
Ascites
Anorexia
Nausea
Neck and Face Pulsation
Epistaxis
Facial Engorgement

Question 6

what are the signs of heart failure?

Answer 6

Reduced ability to do exercise
Reduced Blood Pressure
Right Ventricular Heave
Raised JVP
Exhaustion
Crepitations
Cool Peripheries
Cyanosis
Heart Murmurs
Tachycardia
Displaced Apex
Pulsus Alternans (physical finding with arterial pulse waveform showing alternating strong and weak beats)
Pulmonary Oedema
Narrow Pulse Pressure
3rd Heart Sound
Wheeze

Question 7

what investigations are used to diagnose heart failure?

Answer 7

ECHO (look for Valvular heart disease) (This is the key investigation)

BNP (elevated in Heart Failure) (This is the first line investigation)

Bloods - FBC, U&E’s, Glucose

Endomyocardial Biopsy

ECG (look for Ventricular hypertrophy, MI, Evidence of Ischaemia)

CXR (look for ABCDE - Alveolar Oedema, Kerley B Lines, Cardiomegaly, Dilated Prominent Upper Lobe Veins, Pleural Effusion)

MRIRNVG/MUGA

Question 8

what is the diagnosis based on?

Answer 8

the Framingham Criteria requires at least one/two major criteria in conjunction with two minor criteria.

Major criteria = Nocturnal Dyspnoea, Pulmonary Oedema, Crepitations, S3 Gallop, Cardiomegaly, Increased CVP, Weight Loss, Neck Vein Distension, Hepatojugular Reflux

Minor criteria = Nocturnal Cough, Bilateral ankle oedema, Breathlessness, Tachycardia, Decreased in vital capacity by a third of the maximum recorded, Pleural effusion, Hepatomegaly

Question 9

what are the first and second-line treatments?

Answer 9

First-line treatment: ACEI and a B-blocker

Second-line treatment: Aldosterone Antagonist OR ARBs, OR Hydralazine with a nitrate (if symptoms persist, consider CRD or Digoxin)