Heart Failure

Question 1

What are the symptoms of heart failure?

Answer 1

Fatigue/exhaustion
Breathlessness
Lack of exercise capacity
orthopnoea
paroxysmal nocturnal dyspnoea

Question 2

What are the signs of heart failure?

Answer 2

Oedema
Tachycardia
Raised JVP
Crepitations 
Pleural effusions
Bi basal crackles
3rd heart sound
Displaced or abnormal apex beat
Cardiomegaly
Tender hepatomegaly

Question 3

What do you need for the diagnosis of heart failure?

Answer 3

Symptoms or signs of heart failure
And
Objective evidence of cardiac dysfunction
And
Response to therapy (diuretics)

Question 4

What investigations can be carried out to help diagnose heart failure?

Answer 4

Blood test
Chest Xray
ECG
ECHO
Stress cardiography
radionucleotide scan
Left ventriculogram
Cardiac MRI
Cardiac catheterisation
Cardiac biopsy

Question 5

BNP is a highly sensitive test for heart failure

However you have to be cautious because BNP can be elevated due to what?

Answer 5

atrial fibrillation
Old age (in the elderly)
Valve disease

Question 6

When taking a history, what might you ask to rule out any causes?

Answer 6

Hillwakers? (Lyme disease)
HIV?
post partum?
Alcohol?
High blood pressure?
Previous MI?
Familial dilated cardiomyopathy?

Question 7

Why can the ejection fraction be difficult to quantify accuratly and reproducibly by echo?

Answer 7

Quality of images
Experience of operator
Calculation method
Use of contrast agents
Time consuming to perform accuratly

Question 8

What are values for severity of ejection fraction?

Answer 8

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

Question 9

Why is ejection fraction not the best indicator of heart failure?

Answer 9

Becauze someone with LV systolic dysfunction causing heart failure can still have a normal ejection fraction

Question 10

Describe the bilane modified simpsons rule for measurement of ejection fraction.

Answer 10

Divides Left ventricle into multiple slices of known thickness and diamter
Volune of each slice is equal to the area x thickness

Question 11

What makes the simpsons rule for measurement of ejection fracture more accurate?

Answer 11

Thinner cut slices of the ventricle

Question 12

What is the disadvantage of MUGA?

Answer 12

Ionising radiation

No additional structural information

Question 13

What are the benefits of MRI for left ventricular ejection fraction?

Answer 13

Gold standard for assesment of LVEF
greater reproducability
Added information about aetiology such as fibrosis, infiltration and oedema
Information about valves

Question 14

What are the disadvantages about MRI for LVEF?

Answer 14

Time consuming- approx 1 hour
Patient compliance - breath holds, claustrophobic, ability to lie flat
Specialist centers
Long waiting lists

Question 15

What is thr modern pharmacological treatment of heart failure due to LV systolic dysfunction?

Answer 15

Diuretics
ACE inhibitors
Beta blockers
Aldosterone receptor blockers
ARNI’s

Question 16

What are the 2 possible screening tests for heart failure?

Answer 16

12 lead ECG

BNP

Question 17

Name causes of left ventricular systolic dysfunction.

Answer 17

Ischaemic heart disease
Secere attioventricular AV disease or mitral regurgitation
Dilated cardiomyopathy DCM
Inherited
Toxins
Viral
Systemic diseases i.e sarcoidosis
Peri partum cardiomyopathy
Hypertension
End stage hypertrophic cardiomyopathy
End stage arrythmigenic RV cardiomyopathy
RV pacing induced cardiomyopathy

Question 18

By taking a blood test for diagnosis what do you want to exclude?

Answer 18

Anaemia
Renal failure
Hypo or hyperthyroidism

Question 19

When is a coronary angiography required in the diagnosis for the cause of heart failure?

Answer 19

If the patient has heart pain

Question 20

Why is an ECHO an essential investigation in the diagnosis ?

Answer 20

An ECHO identifys and quanitfys;
LV systolic dysfunction
Valvular dysfunction
Pericardial effusion/ tamponade
Diastolic dysfunction
Left ventricular hypertrophy
Atrial/ventricular shunts/ complex congenital heart
Pulmonary hypertension
Right heart dysfunction

Question 21

Diagnosis of heart failure with LV diastolic dysfunction requires what conditions to be satisfied?

Answer 21

symptoms typical of HF
signs typical of HF
reduced left ventricular ejection fraction

Question 22

Describe the algorithm for the diagnosis of heart failure.

Answer 22

signs and symptoms of heart failure then get an ECG and chest-Xray
If its abnormal then do ECHO
If abnormal then assess aetiology, degree of HF and type of cardiac dysfunction with other tests as appropriate.
Then choose treatment

Question 23

What are the risk factors for heart failure?

Answer 23

Hypertension
Coronary artery disease
Valvular heart disease
Alcoholism
Infection (viral)
Diabetes
Congenital heart defects
Other: age, obesity, smoking, high/low hematocrit levels, obstructive sleep apnoea

Question 24

What is the no.1 risk factor for heart failure and how does this vary with sex?

Answer 24

Hypertension is the no.1 risk factor
It is even more so in women compared to men
(Men have almost equal risk with previous MI whereas women show a much greater risk with having hypertension compared to a previous MI)

Question 25

Myocardial injury causes ……….. stimulation?

Answer 25

Neurohormonal

Question 26

What is frank-starling law?

Answer 26

If the muscle of a healthy heart is stretched it will contract with greater force and pump out more blood.
Therefore C0 is proportional to the initial stretch of the muscle

Question 27

Sustained hypertension usually causes what type of dysfunction to the heart?
And what type of heart failure is this termed?

Answer 27

Diastolic dysfunction

Preserved ejection fraction heart failure

Question 28

How does Heart failure result in oedema?

Answer 28

Failure in the heart to pump efficiently results in a decrease in CO.
The body registers this a reduction in blood volume which stimulates the RAAS system and release of ASH.
This triggers progressive vasodilation and salt and water retention resulting in oedema and pulmonary oedema.
The failure of the heart to pump also causes blood to back up in the atria and then subsequently into the pulmonary and systemic circulations.

Question 29

What causes the myocyte hypertrophy?

Answer 29

Sympathetic stimulation

Question 30

What are the 2 main aims of treatment for heart failure?

Answer 30

To improve symptoms

To improve survival

Question 31

Which drugs improve survival?

Answer 31

Beta blockers
Ivabradine
ACE inhibitors 
ARB’s
Spironolatone
Vallarta’s-sacubitril

Question 32

What is the action of spironolactone?

Answer 32

Blocks aldosterone

Question 33

What type of drug is digoxin?

Answer 33

Possitive ionotrope

Question 34

What is the function of the loop diuretic furosemide?

Answer 34

Removes excess salt and water by inducing profound dieresis

Inhibits the Na-K-Cl transporter in the loop of Henle