Heart Failure

Question 1

What is heart failure?

Answer 1

When cardiac output in not sufficient enough to supply the body

Question 2

Describe systolic failure.

Answer 2

When ventricles are not contracting enough during systole resulting in reduced CO

EF will be low

Question 3

Describe diastolic failure.

Answer 3

The inability of ventricles to relax during diastole and fill normally causing fluid to back up into lungs and peripheries

EF will be normal

Question 4

What can cause diastolic failure?

Answer 4

Constricitve pericarditis
Constrictive cardiomyopathy
Tamponade
Hypertension

Question 5

Does systolic and diastolic failure exist together?

Answer 5

Usually yes

Question 6

What is it called when right sided and left sided heart failure exists together? Why does right heart failure occur?

Answer 6

Congestive cardiac failure

Mainly due to Left sided failure

Question 7

What is systolic heart failure caused by?

Answer 7

Mainly ischaemic heart disease that causes damage to the heart
Diabetes
Cardiomyopathy

Question 8

Complications of heart failure?

Answer 8

Renal failure

Valve dysfunction

Stroke

Question 9

Pathophysiology - what is lost in heart failure that a normal healthy heart should have? Why is it lost?

Answer 9

When cardiac muscle is stretched more, it will contract more but this is lost

Lost because due to an increased workload on the heart due to damage, circulatory volume increases so the heart dilates to compensate (dilatation) which reduces CO and Force of contraction

Question 10

What are the “compensatory” measures that activate when the heart begins to get dilated and weaker - but actually end up making things worse?

Answer 10

RAAS activates which increases vasoconstriction and water retention

Sypmathetic NS activates and releases NA and adrenaline increasing HR and vasoconstriction - increases afterload

Myocyte size increases and fibrosis occurs

These all worsen heart failure and start a cycle towards worsening heart failure

Question 11

What is the end results of these measures?

Answer 11

Failing heart

Retention of salt and water leading to peripheral and pulmonary oedemas

Myocytes death and fibrosis

Question 12

What are the risk factors for heart failure?

Answer 12

Age
Smoking
Diabetes
Obesity
Hyperlipidaemia
Alcoholism
Heart diseases - CAD, HT, Valves

Question 13

What are the main symptoms of heart failure?

Answer 13

Fatigue
Reduced exercise capacity
Dysnpnoea
Paroxysmal nocturnal dysnpnoea
Orthopnea

Usually due to oedemas

Question 14

Main signs of heart failure? What will be observed on an examination?

Answer 14

Oedeam
Tachycardia
Raised JVP
Displaced/abnormal apex beat

Question 15

What will be heard on auscultation?

Answer 15

Chest crackles or effusion

3rd heart sound

Question 16

What is the framingham criteria’s MAJOR signs of congestive heart failure?

Answer 16

PAINS

Paroxysmal nocturnal dysnpnoea

Acute pulmonary oedema

Increased heart size and CVP

Neck vein dilatation

S3 gallop

Question 17

What is the framingham criteria’s MINOR signs of congestive heart failure?

Answer 17

PAIN

Pleural effusion
Ankle oedema
Increased HR >120
Nocturnal cough

Question 18

How is heart disease confirmed using the framingham criteria?

Answer 18

2 major
or
1 major and 2 minor

Question 19

What are the two main investigations, that if normal NICE suggests look for another diagnosis rather than heart failure?

Answer 19

ECG

BNP levels

Question 20

What is an ECG looking for?

Answer 20

LV systolic function

If a normal ECG unlikely to be heart failrure

Question 21

What is the BNP test?

Answer 21

Brain natriuretic peptide - suggests how far myocytes have been stretched

If conc is over 400pg/ml or 160pmol/l = heart failre

BNP is also cardioprotective as it aids water secretion and vasodilation

Question 22

What else can be looked for in bloods?

Answer 22

FBC
U's and Es
LFTs - liver congestion
TFTs (thyroid function)
Lipid profile

Question 23

What is looked for in a CxR?

Answer 23

ABCDE

Alveolar oedema

kerly B lines

Cardiomegaly

Dilated upper lobe vessels

plearual Effusion

Question 24

Why are echo’s done?

Answer 24

Identify cause of heart failure and look at heart function

Systolic function 
Diastolic function 
Valve dysfunction 
LVH
Ejection fraction

Question 25

What is ejection fraction ranges?

What does a reduced EF mean? And what does a normal EF mean but patient still has symptoms of heart failure?

Answer 25

50-80% - normal
40-50% - mild
30-40% moderate
<30% - severe

A reduced EF means the heart is in systolic failure

A normal EF but patient shows symptoms means it is in diastolic failure

Question 26

Describe the New York heart association classification for stages of heart failure.

Answer 26

1 - no limitation and no symptoms

2 - mild limitation but comfortable on mild exertion

3 - moderate limitation, comfortable at rest

4 - severe limitation - any activity brings on symptoms

Question 27

What treatment can be given?

Answer 27

Diuretics 
ACE Inhibitors 
ARBs - for ACE. I intolerance
ARB(Valsartan)/Sacubitril combination drug 
Beta blockers 
Ivabradine
Digoxin - pos inotrope
Anticoagulants

Question 28

What main type of diuretic is used?

Answer 28

Loop diuretic - furosemide

Question 29

How do loop diuretics work?

Answer 29

Remove excess salt and water by inhibiting the Na-Cl-K transporter in loop of henle

Work at very low GFRs

Question 30

What would you do in a diuretic resistant patient?

Answer 30

Combine with a thiazide like diuretic - metolazone

Question 31

Adverese drug reactions of diuretics?

Answer 31

Dehydration
Hypotension
Hypokalaemia
Hyponatraemia
Gout
Impaired glucose tolerance/diabetes

Question 32

Drug-drug interactions of diuretics?

Answer 32

Antihypertensives - hypotension

These cause renal toxicity:
NSAIDs
Lithium 
Vancomycin
Aminoglycosides
Frusemide

Question 33

What diuretic would be used in a resistant oedema if patient has hypokalaemia?

Where does this drug work?

Answer 33

Potassium sparing diuretic - spironolactone

Works in distal tubule

Question 34

When are ACE inhibitors given? Name a ACE inhibitor

Answer 34

In patients with LV systolic dysfunction as it improves symptoms by reducing preload and afterload

Ramapril

Question 35

Adverse drug reactions of ACEIs?

Answer 35

Hypotension
Cough
Hyper-kalaemia
Angioedema
Renal imparment

Question 36

Drug-drug interactions of ACEIs?

Answer 36

Potassium supplements or spironolactone causes hyperkalaemia

NSAIDS cause acute renal failure

Question 37

What can be given instead if patient is ACE inhibitor intolerable or a cough is a problem?

Answer 37

ARBs - candesartan

Question 38

How do ARBs work?

Answer 38

Block AT1 receptor - stops vasoconstriction and aldosterone secretion

Question 39

What it the ARB/Neprilysin inhibitor called and how does it work?

Answer 39

Valsartal/Sacubitril

ARB Valsartan blocks AT1

Sacubitirl stops breaksown of ANP (atrial) and BNP so they can stay and increase vasodilation and water and sodium discharge

Question 40

What beta blocker is given and why?

Answer 40

Carvedilol

Blocks sympathetic system so NA and adrenaline can’t cause increased HR and vasoconstriction anymore - this increases afterload

Question 41

Are beta blockers routinely given?

Answer 41

No - can be harmful and patients must be selected carefully

Question 42

How does Ivabradine work?

Answer 42

Inhibits SA node, limiting HR

Doesn’t affect FoC or intracardiac conduction between myocytes

Question 43

How does digoxin work?

Answer 43

Positive inotrope -

increases the availability of Ca in a myocyte

Question 44

What can digoxin toxicity cause?

Answer 44

Arrhythmias
Nausea
Confusion

Question 45

Why are anticoagulants given/considered? What anticoagulant is given?

Answer 45

Dilated ventricle makes it easier for thrombosis or thromboembolisms to happen

Warfarin

Question 46

Summarise the treatment plan

Answer 46

Diruetic treatment Furosemide +/- thiazide metolazone

ACEIs/ARBs

Valsartan/Sacubitril

B.Blockers +/- Ivabardine

MRA-Spironolactone

Digoxin

Warfarin