Heart failure

Question 1

What are the pathophysiological changes in heart failure?

Answer 1

• Ventricular dilatation
• Myocyte hypertrophy
• Increased collagen synthesis
• Altered myosin gene expression
• Altered sarcoplasmic Ca2+-ATPase density
• Increased ANP secretion
• Salt and water retention
• Sympathetic stimulation
• Peripheral vasoconstriction

Question 2

What are the 3 main causes of heart failure?

Answer 2

Ischaemic heart disease (35-40%)
Cardiomyopathy (30-34%)
Hypertension (15-20%)

Question 3

What are some common conditions that precipitate decompensation in heart failure?

Answer 3

• Adherence and process of care issues
• cardiac
• non-cardiac

Question 4

What are some adherence and process of care issues in decompensated cardiac failure?

Answer 4

• non-adherence to meds
• iatrogenic volume overload
• drugs interactions/side effects

Question 5

What are some cardiac issues in decompensated cardiac failure?

Answer 5

• MI or ischaemia
• valvular disease
• AF and other arrhythmias
• stress induced
• cardiotoxic agents
• right ventricular pacing

Question 6

What are some cardiotoxic agents?

Answer 6

• alcohol
• cocaine
• chemotherapeutics

Question 7

What are some non-cardiac issues in decompensated cardiac failure?

Answer 7

• fluid overload
• severe htn
• renal failure
• PE
• other: anaemia, hypo or hyperthyroidism, fever, infection, uncontrolled diabetes

Question 8

What are some symptoms of heart failure?

Answer 8

• Exertional dyspnoea
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
• Fatigue

Question 9

What are some signs of heart failure?

Answer 9

• Cardiomegaly
• 3rd and 4th heart sounds
• elevated JVP
• tachycardia
• hypotension
• Bi-basal crackles
• Pleural effusion
• Peripheral ankle oedema
• Ascites
• Tender hepatomegaly

Question 10

What are the criteria for the 4 classes of heart failure?

Answer 10

Class I: No limitation. Normal physical exercise does not cause fatigue, dyspnoea or palpitations

Class II: Mild limitation. Comfortable at rest but normal physical activity produces fatigue, dyspnoea or palpitations

Class III: Marked limitation. Comfortable at rest but gentle physical activity produces marked symptoms of heart failure

Class IV: Symptoms of heart failure occur at rest and are exacerbated by any physical activity

Question 11

What are the diagnostic criteria of heart failure?

Answer 11

Essential features:

1. Symptoms and signs of heart failure
2. Objective evidence of cardiac dysfunction (e.g. echo)

Non-essential features:
3. Response to treatment directed towards heart failure

Question 12

What are some investigations used in suspected heart failure?

Answer 12

• CXR
• ECG
• blood tests: FBE, LFTs, U&Es, cardiac enzymes, BNP, ANP, thyroid fx
• Echo
• others

Question 13

What are the general principles of management of heart failure?

Answer 13

• reduce venous pressure
• block the RAAS
• block the SNS
• treat underlying and precipitating causes

Question 14

What drugs are used to treat heart failure?

Answer 14

• diuretics
• aldosterone antagonists
• ACE inhibitors
• ARBs
• beta blockers