Heart Failure

Question 1

3 symptoms of heart failure in the definition

Answer 1

Dyspnoea
Fatigue
Oedema

Question 2

Systolic dysfunction

Answer 2

1. Circulatory volume increases, heart dilates, force of contraction decreases and CO decreases
2. Decreased CO activates RAAS which increases H20 and water retention
3. RAAS activated = circulatory volume increases and cardiac performance decreases further
4. Heart dilates = cardiac myocytes undergo hypertrophy which leads to fibrosis = further weakened heart

Question 3

Heart failure usually occurs (when)…

Answer 3

• Following sustained hypertension (diastolic dysfunction/preserved ejection fraction HF)
• Following myocardial damage i.e. an MI (systolic dysfunction)

Question 4

In heart failure, RAAS and Activation of sympathetic system…

Answer 4

RAAS
- causes release of angiotensin II and aldosterone
- Result is salt and water retention, vasoconstriction and hypertrophy of cardiac myocytes
ACTIVATION OF SYMPATHETIC SYSTEM
- causes release of noradrenaline and adrenaline
- Result is vasoconstriction, stimulates renin release which feeds into RAAS and myocyte hypertrophy

Question 5

Risk factors for HF

Answer 5

Age 
Hypertension (LVH)
Obesity
Chronic Heart disease
Hyperlipidaemia
Coronary artery disease
Valvular heart disease
Alcoholism
Infection (viral)
Congenital heart defects
Smoking
High or low haematocrit level
Obstructive sleep apnoea

Question 6

Causes of LVSD

Answer 6

Ischaemic heart disease (usually MI)
Dilated cardiomyopathy (DCM)
Severe aortic valve disease or mitral regurgitation

Question 7

Dilated cardiomyopathy is an umbrella term

Answer 7

Inherited
Toxins e.g. alcohol
Viral (acute myocarditis or chronic DCM)
Other infective; HIV, Lymes Disease
Systemic disease e.g. sarcoidosis
Muscular dystrophies
Peri-partum cardiomyopathy
Hypertension
Isolated non-compaction
Hypertension
Tachycardia related cardiomyopathy
Right ventricular pacing induced cardiomyopathy 
End stage hypertrophic cardiomyopathy
End stage arrythomogenicity RV cardiomyopathy

Question 8

Heart failure is a systemic disorder which involves

Answer 8

• Cardiac dysfunction
• Renal dysfunction
• Skeletal muscle dysfunction
• Systemic inflammation
• Neurohormonal activation (mostly maladaptive)

Question 9

Symptoms of HF

Answer 9

Oedema
Tachycardia
Raised JVP
Chest crepitations or effusions
3rd heart sound
Displaced or abnormal apex beat

Question 10

Diagnosing someone with LVSD;

Answer 10

DETAILED HISTORY:
- Hillwalkers (lymes disease)
- IVDA (HIV test)
- Consider familial DM
?Antibodies/viral serology; ferritin
Exclude renal failure, anaemia, TFTs
Consider other causes; sarcoid, muscle dystrophy etc
ECG
ECHO
sometimes CXR
?Coronary angiogram
CT coronary angiogram
Need to exclude phaeochromytoma 
Cardiac MRI
Most patients should be assessed by a cardiologist

Question 11

Positive diagnosis of HF

Answer 11

Symptoms and signs of HF (rest or exercise)
Objective evidence of cardiac dysfunction
Response to therapy (diuretics)

Question 12

Investigations for HF

Answer 12

12 lead ECG
ECHO
Radionucleotide venticulography (RNVG/MUGA)
MRI
Left ventriculography
BNP screening (elevated in heart failure)

Question 13

LVEF levels

Answer 13

Normal 50-80%
Mild 40-50%
Moderate 30-40%
Severe <30%

Question 14

Pharmacological treatment of HF (due to LVSD)

Answer 14

Diuretics
ACE inhibitors or ARBs
Beta blockers
Aldosterone receptor blockers
Some patients ARNI (angiotensin receptor nephilysin inhibitor: sacubitril valsartan)

Question 15

Types of Heart failure

Answer 15

Systolic Heart failure: HFrEF
Diastolic heart failure: HFpEF
Chronic heart failure

Question 16

The aims of treatment

Answer 16

To improve symptoms
- Diuretics
- Digoxin
To improve symptoms and survival
- ACE inhibitors
- Spironolactone (special diuretic)
- valsartan 
To improve survival
- Beta-blockers
- Ivabradine

Question 17

Symptomatic Treatment regimes for HF

Answer 17

Inhibition of detrimental neurohormonal adaptations
Enhancement of beneficial neurohormonal adaptations
Enhancement of cardiac function
LOOP DUIRETICS: furosemide
Blocking detrimental hormone changes: sympathetic activation by beta blockers (e.g. bisoprolol)
ACE inhibitors: Ramparin
Angiotension antagonists: Valsartan
Enhancement of cardia function: Positive inotropes (Digoxin)

Question 18

Vasodilators

Answer 18

ISOSORBIDE MONO OR DI NITRATE

Question 19

Adverse Drug Reactions of Loop Diuretics used in combination with thiazide diuretics

Answer 19

Dehydration
Hypotension
Hypokalaemia, hyponatraemia
Gout
Impaired glucose tolerance, diabetes

Question 20

Drug drug interactions of loop diuretics

Answer 20

Frusemide and:

1. Aminoglycoside (aural and renal toxicity)
2. Lithium (renal toxicity)
3. NSAIDs (renal toxicity)
4. Antihypertensives (profound hypertension)
5. Vancomycin (renal toxicity)

Question 21

Reducing mortality in HF

Answer 21

Angiotensin blockade
Beta receptor blockade
Aldosterone blockade
ANP/BNP enhancement

Question 22

Adverse drug reactions of ACEI

Answer 22

First dose hypotension
Cough
Angiooedema
Renal impairment
Renal failure
Hyperkalaemia

Question 23

Drug-drug interactions with ACEIs

Answer 23

NSAIDs
Potassium supplements
Potassium sparing diuretics

Question 24

Angiotensin II effects on it’s receptors

Answer 24

AT1: vasoconstriction, vascular proliferation, aldosterone secretion, cardiac myocyte proliferation, increased sympathetic tone
AT2: vasodilation, antiproliferation, apoptosis

Question 25

So treatment option regime summary for HF

Answer 25

Furosemide (+possibly thiazide)
Furosemide (+possibly pulsed metolazone)
ACE inhibitors
ARNI
Beta blockers (+possibly ivabradine)
MRA - Spironolactone 25mg
Digoxin: TDM
Warfarin: TDM