Heart failure

Question 1

What are the causes of heart failure?

Answer 1

Ischaemic heart disease
Non-Ischaemic dilated cardiomyopathy
Hypertension
Valvular disease
CHD
Arrhythmias
Pericardial disease
Alcohol/drugs
Hyperdynamic circulation (Anaemia, Thyrotoxicosis, Padgets)

Question 2

What murmur can occur in LHF?

Answer 2

Mitral regurgitation - Displaced apex beat

Question 3

What murmur can occur in RHF?

Answer 3

Tricuspid regurgitation - Pansystolic, V waves, Pulsatile

Question 4

What are some of the physiological changes in HF?

Answer 4

Ventricular dilatation
Myocyte hypertrophy
Neurohumeral - Increased ANP
Salt/Water retention
Sympathetic stimulation
Peripheral vasoconstriction

Question 5

How do you calculate CO?

Answer 5

CO = SV x HR

Question 6

How is CO maintained in patients with heart failure?

Answer 6

Increase in venous pressure
Tachycardia
Decreased CO causes Adrenergic activation and RAAS activation

Question 7

What is an objective measure of heart failure?

Answer 7

Ejection fraction seen on echo
Normal = >55%
Mild = 45-54%
Moderate = 35-44%
Severe =

Question 8

What are the symptoms of LHF?

Answer 8

Fatigue
Orthopnoea/PND
Exertional dyspnoea

Question 9

What are the signs of LHF?

Answer 9

Displaced apex beat due to cardiomegaly
Gallop rhythm heard on auscultation - 3rd heard sound, kentucky
Features of mitral regurgitation
Crackles at the lung bases due to pulmonary oedema
Pitting oedema dependent on the activation of RAAS

Question 10

What valvular diseases cause LHF?

Answer 10

Mitral/Aortic

Mitral stenosis causes LA HTN and signs of LV failure, but does itself not cause the LV to fail

Question 11

What are the causes of LHF?

Answer 11

Ischaemic heart disease
Non ischaemic dilated cardiomyopathy
HTN
Mitral/Aortic valve disease

Question 12

What are the causes of RHF?

Answer 12

Chronic lung disease (Cor Pulmonale)
PE
Pulmonary HTN
Tricuspid/Pulmonary valve disease
Left to right shunts (ASD/VSD)
Isolated RV cardiomyopathy

Question 13

What are the symptoms of RHF?

Answer 13

Fatigue
Dyspnoea
Anorexia/Nausea

Question 14

What are the signs of RHF?

Answer 14

Increased jugular venous pressure
V waves of Tricuspid regurgitation (Seen in julgular vein, measn RV enlargement)
Cardiomegaly
Hepatic enlargement - tender and smooth
Ascites
Peripheral pitting oedema

Question 15

What investigations would you perform in a patient with suspected heart failure?

Answer 15

Bloods - FBC, ANP/BNP, LFT, U&Es
CXR
Echocardiogram

Question 16

What is the NYHA HR classification - Class I?

Answer 16

No limitation of physical activity

Question 17

What is the NYHA HR classification - Class II?

Answer 17

Slight limitation of physical activity - Symptomatically mild heart failure

Question 18

What is the NYHA HR classification - Class III?

Answer 18

Marked limitation of physical activity - Symptomatically moderate heart failure

Question 19

What is the NYHA HR classification - Class IV?

Answer 19

Symptoms at rest - Symptomatically severe heart faulure

Question 20

What is the general lifestyle management for patients with HF?

Answer 20

Low intensity exercise
Low salt diet
Smoking cessation
Education 
Vaccination

Question 21

What is the pharmacological management of patients with HF?

Answer 21

Diuretics
ACEi
B-Blockers
Spironolactone
Inotropic agents
Nitrates
Anticoagulation

Question 22

What is the routine for Diuretics when treating heart failure?

Answer 22

1) Furosemide (40mg-80mg)
2) Change to Bumetanide if Furosemide doesn’t work
3) Add a Thiazide for complete diuresis (watch U&Es)
* Acute fluid offloading*

Question 23

Why do patients on ACEi develop a dry cough?

Answer 23

Prevents the breakdown of Bradykinin which builds up and causes bronchospasm –> cough

Question 24

Which drugs improve prognosis in HF patients?

Answer 24

ACEi

Spironolactone

Question 25

Give an example of a drug that can be used as an alternative to ACEi in patients with HF

Answer 25

Losartan, Candesartan - Angiotensin II receptor antagonist

Question 26

When are B blockers used for HF?

Answer 26

In stable and chronic patients

Initiated in patients with LV dysfunction after diuretics and ACEi used

Question 27

What is a complication of Ramipril?

Answer 27

Dry cough

AKI

Question 28

What is a complication of B blockers?

Answer 28

Claudication in patients with PAD

Question 29

What are some of the side effects of Spironolactone?

Answer 29

Hyperkalaemia

Gynacomastia

Question 30

Which group of patients would benefit from Digoxin treatment?

Answer 30

Those with HF and AF

Patients with severe HF and no other conventional treatments have been effective

Question 31

What are some of the side effects of Digoxin?

Answer 31

Xanthopsia (Yellow vision, esp in patients with renal failure)
Reverse tick in ST segment on ECG

Question 32

When are Inotropic agents (eg Dobuatmine) used?

Answer 32

Support myocardial function in patients with acute LVF with hypotension

Question 33

What is important about the administration of Nitrates?

Answer 33

Tolerance develops with chronic use so administered BD

Question 34

Why is anticoagulation considered in HF patients?

Answer 34

4x increase risk of stroke

Underlying arrhythmia causing HF may also increase risk of stroke

Question 35

What is the non pharmacological management of HF?

Answer 35

Revascularisation
Biventricular pacemaker
Implantable cardioverter defibrillator (ICD)
Cardiac transplant
Left ventricular assist device (LVAD)
May depend on the underlying cause of the HF

Question 36

Superior Vena Cava Obstruction has a raised JVP, what is difference between this and a raised JVP in RHF?

Answer 36

The JVP is fixed in SVCO and is not in RHF

Question 37

What is a complication of Aspirin that may cause HF?

Answer 37

Microcytic anaemia

Question 38

What drug can cause Lupus?

Answer 38

Hydralazine