heart failure

Question 1

Causes of Right sided Heart failure

Answer 1

Cardiac causes
left-sided heart 
pulmonic valve stenosis
right ventricular infarct
Atrial septal defect, 
Primary tricuspid regurgitation
pulmonary parenchymal causes
COPD
Interstitial lung disease (sarcoidosis)
adult respiratory distress syndrome
chronic lung infection or bronchiectasis
pulmonary vascular causes
pulmonary embolism
primary pulmonary hypertension

Question 2

Causes of Left sided heart failure

Answer 2

Valvular disease
impaired contractility
coronary artery disease, MI, transient myocardial ischemia
chronic volume overload  eg. mitral regurgitation, aortic regurgitation, patent ductus arteriosus
dilated cardiomyopathies
increased after load
aortic stenosis
uncontrolled severe hypertension
impaired diastolic filling
left ventricular filling
restrictive cardiomyopathy
myocardial fibrosis
transient myocardial ischemia
pericardial constriction or temponade

Question 3

Other conditions that may cause Heart failure

Answer 3

CAD
Hypertension
Diabetes mellitus
Valvular heart disease (regurgitant or stenotic)
Disorders of rate or rhythm (eg, tachycardia-induced cardiomyopathy)
Myocarditis (viral or inflammatory)
Congenital heart disease
Drug induced (alcohol, anthracyclines)
Idiopathic dilated cardiomyopathy (familial)
Peripartum cardiomyopathy
Systemic conditions (hypo- or hyperthyroidism, amyloidosis, sarcoidosis, haemochromatosis, scleroderma, cryoglobulinaemia, etc.)

Question 4

Epidemiology of Heart failure World wide

Answer 4

Morbidity - 20 000/100 000 hospital admissions
overall 20/1000
>65yrs 130/1000
70-80yrs 100/1000

Question 5

Epidemiology of Heart failure in Australia

Answer 5

1.5-2% overall
50-59yr 1%
>65 yr 10%
>85 yrs over 50%

Question 6

Pathogenesis of Heart failure

Answer 6

Cardiac injury ->Increase load ->frank starling mechanism and Neurohumeral activation. Norepinephrine = vaso constriction = decrease peripheral perfusion
Renin-Angiotensin (decreased renal BF) = ^ Aldosterone, ^ Na reabsorption = fluid retention and leads to growth and remodelling (Hypertrophy) and ischema and energy depletion -> apoptosis and Necrosis and Cell death which starts the cycle again.
Progression is venous congestion, fluid retention, HTN.

Question 7

Classic symptoms of Heart failure

Answer 7

Exertion dyspnoea or fatigue. Late stage - Orthopnoea, PND, ankle oedema.

Question 8

Symptoms indicative of right sided HF

Answer 8

Peripheral edema - improves over night , symmetrical and worse in the evenings
anorexia, nausea
right upper quadrant discomfort (due to hepatic enlargement),
weight gain
compliant of GI distress

Question 9

Symptoms indicative of left sided HF

Answer 9

exertional dyspnea (SOB), orthopnea, paroxysmal nocturnal dyspnea,
fatigue and weakness
restless ness
confusion
Cough - dry and irritating cough particularly at night
Nocturia
Dizzy spells or palpitations

Question 10

Symptoms related to fluid retention in HF

Answer 10

Epigastric pain
Abdominal distention
Ascites
Sacral and peripheral oedema

Question 11

Classification of congestive HF

Answer 11

New York heart association functional classification of CHF
Class 1- asymptomatic evening during exercise, left ventricular dysfunction
Class 2 - Reduced physical capacity during medium exercise.
Class 3 - Severely reduced physical capacity during slight exercise but asymptomatic at rest
Class 4 - symptoms at rest

Question 12

Thing to ask on Hx for someone with symptoms of HF

Answer 12

Risk factors for CV disease
Recent viral infection
PmHx - MI, HTN, RHD, Mururs
FmHx - CHF, Cardiomyopathy
SoHx - alcohol intake

Question 13

Signs to look for on examination of left sided HF

Answer 13

often no signs in early stages
Inspection - cyanosis (central due to pulmonary oedema) peripheral due to low CO, diaphoresis, Cachexia, Cheyne-stokes breathing in elderly, Mitral facies (low output), Down’s or Marfan’s.
Vitals - pulse alternates with volume, ↓BP, ↑HR, ↑RR, BMI, BSL, Temp
Hands - Palmer erythema, xanthomata, hepatic flap, ↓perfusion.
Face - Jaundice, xanthelamsa
Mouth - cyanosis, petechiae, high arch palate
Neck - Pulse alterans
Chest - displaced apex, loud P2, Mitral regurgitation, S3 (systolic dysfucntion) or S4 diastolic dysfunction), Cardiomegaly
Resp - inspiratory Crackles/wheeze, Haemopytosis, rales.
Abdo - normal
Legs - loss of hair
most useful are Left ventricular failure and 3rd heart sound and a displaced and dyskinetic apex beat.

Question 14

Sign of Right sided HR

Answer 14

Weight gain, peripheral cyanosis, peripheral oedema, mitral facies, down’s, Marfan’s
Vital - Low volume pulse, ↓BP, ↑RR, ↑HR, BMI, BSL, Temp
Hand - Palmer erythema, xanthomata, hepatic flap, Reduced perfusion
Face - Jaundice (congestive cardiac failure), xanthelamsa, Mouth - cyanosis, petichiae, high arch palate
Neck - ↑JVP with lg V waves
Chest - panastolic murmur - Functional tricuspid regurgitation, RV Heave, S3. B - Cardiomegaly
Resp - Sacral oedema, pleural effusion
Abdo - Ascites, hepatomegaly pustule liver, visible veins, tenderness of liver
Legs - symmetrical peripheral oedema, venous status, ulcer.

Question 15

Signs of mild HF

Answer 15

Mildly elevated JVP, basal inspiratory crepitations, mild peripheral or sacral oedema

Question 16

Signs of severe HF

Answer 16

Markedly ↑JVP, Crepitations beyond the mid-zones of lungs, Oedema above the mid tibia, pulsatile hepatomegaly, ascites

Question 17

Work up for HF

Answer 17

Chest xray
ECG
Blood test - Cardiac enzymes, electrolytes, renal function test, LFT, FBC, Iron studies, TFT
ECHO

Question 18

What are the CXR findings in HF

Answer 18

Commonly-
1 cardiomegaly and
2 pulmonary Venous redistribution with upper lobe blood diversion )are common
Worsen -
3 Pulmonary oedema- train tracks in peribilar region with prominent vascular markings, kerley B lines = interstitial oedema. Fluid in the horizontal fissure.
4Effusion (L atrium P)
5 Intra alveolar oedema: bat wing perihilar shandowing.
6 left atrial enlargement

Question 19

ECG findings in HF

Answer 19

ID arrthythmia, tachycardia and evidence of previous MI (Q waves)
or PE, Conduction and electrical alternans
LBBB, 1st Heart block, LAHB, non-specific intraventricular delays
LV hypertrophy, Previous MI, Tachycardia, AF

Question 20

What cardiac enzymes to ask for in HF

Answer 20

CK, Troponin, D-dimer, ProBNP (improves Dx accuracy in patient presenting with Dyspnoea)

Question 21

What electrolyte imbalance would you expect to find in HF

Answer 21

advanced CHF - dilution hyponatraemia, increase plasma potassium (potassium sparing diuretics, ACEIs or aniogtensin II receptor antagonists and aldosterone antagonists), Hypokalaemia (more common, 2rd to thiazide or loop), reduced Mg due to diuretic,

Question 22

What is the indication and frequency for Renal function test in HF

Answer 22

initial workup and 6monthly in monitoring. eGFR falls - worsened by drug therapy e.g. ACEIs, diuretic, angiotensin 2 receptor antagonists

Question 23

Expected findings on a LFT in HF

Answer 23

^ AST, ALT, LDH. ^ bilirubin if severe, ↓Albumin

Question 24

Expected findings on FBC

Answer 24

Anaemia, Mild thrombocytopenia (due to 2rd chronic liver dysfunction or adverse effect to diuretics)

Question 25

Why do a TFT in HF

Answer 25

Hyper and hypothyroidism are uncommon causes

Question 26

Finding on an Echo of pt in HF

Answer 26

Chamber dimensions 
Systolic function – regional and global 
Diastolic function 
Valvular function 
Pulmonary pressure 
Peri and extacardiac

Question 27

Mx of Acute HF

Answer 27

Systemic hypoperfusion due to depressed cardiac output and systemic arterial hypotension
Acute Pulmonary Oedema: O2 , Nitrates (SL or IV), Frusemide ( 0.5 -1mg/kg IV), Morphine, CPAP, Ventilation
Hypovolaemia: Fluids / blood +/- vasopressors 
Low-output cariogenic shock : Vasopressors
Positive Inotropes: Dobutamine, Dopamine, Noradrenaline, Adrenaline
Dysrhythmia: Tachy or bradycardia

Question 28

Mx of Chronic HF

Answer 28

Non pharmacological

Sodium restriction

Question 29

What education to give the pt with HF

Answer 29

effect of CHF on personal energy level, mood, depression, sleep disturbance and sexual function (ER or exertion) and develop strategies to cope with changes and emotions related to family, work and social roles
Support services Heart Support australian

Question 30

First line medication in HF

Answer 30

ACEIs - Systolic LV dysfunction
Beta Blocker - early after an MI whether or not the pt has systolic ventricular dysfunction
Diuretic - symptoms control not improve survival. Need regularly reassessment
Spironolactone - in severely symptomatic, despite appropriate dose of ACEI and diuretic

Question 31

Other medications to consider in HF pt

Answer 31

Statin - Prevent ischeaemic events

Iron tablets if needed

Question 32

Counselling a pt on ACEIs use in their HF

Answer 32

Indicated for all class of CHF
- Improve LV dysfunction and following MI
- reduces mortality
- slow CHF progression
- Neurohormonal control
Start at low dose and titrated over 3-4 weeks
Check renal function and electrolytes within 2 weeks then 1 month, and again at 3 & 6 months
stop if potassium levels exceed 5. 5mmol/L or
if creatinine increases by more than 20%
AE - Cough, symptomatic hypotension (may be avoided by taking it nocte) and
renal or electrolyte imbalance

Question 33

Indication for use of B Blockers in HF

Answer 33

Indications - early after an MI whether or not the pt has systolic ventricular dysfunction

Question 34

Contraindication in B Blocker in HF

Answer 34

Contraindication - No signs of fluid retention,

Question 35

Which B blocker in HF

Answer 35

Choice - Carvedilol, bisoprolol, nebivolol, extended release metoprolol

Question 36

AE of B Blocker in HF

Answer 36

↓BP, Fatigue, bronchoconstriction in pt with reversible airway obstruction, Mild worsening of CHF symptoms initially (warn pt)

Question 37

Benefit of B blockers in HF

Answer 37

Benefit - Improves symptoms, mortality reduction, slow CHF progression, Neurohormonal control.

Question 38

How to use B Blocker in HF pt

Answer 38

Start at small doses when pt is euvolaemic and titrated upward over a 1-2month period
pt must be >85mmHg without symptomatic postural drop, minimal peripheral oedema and no pulmonary crackles (rales).
Rapid uptitration = AE and inappropriate discontinuation of the drug
Monitor
if HR

Question 39

Aldosterone antagonists role in HF

Answer 39

Spironolactone indicate and benefits class 3/4 CHF
Eplerenone - selective aldosterone antagonist - reduced mortality in post MI LV dysfunction.
lower risk of gynaecomastia then spironolactone

Question 40

Diuretic use in HF, Indication,

Answer 40

Indicated with persistent symptoms despite above drugs
show to improve symptoms and reduce hospitalisation but no effect on mortality
good if patient has AF