Heart Failure

Question 1

What is heart failure

Answer 1

Cardiac output is inadequate to meet body’s requirements

Question 2

What are the classifications of heart failure

Answer 2

Systolic, Diastolic

Right, Left, congestive

Acute, Chronic

Low output, High output

Question 3

What is systolic failure

What are it’s causes

Answer 3

Inadequate CO due to failure to contract
Ejection fraction <40%
IHD, MI, cardiomyopathy

Question 4

What is diastolic failure

What are the causes

Answer 4

Inadequate CO due to failure to relax and fill
Heart failure with preserved ejection fraction (>50%)
Ventricular Hypertrophy, Restrictive cardiomyopathy, constrictive pericarditis, Cardiac tamponade

Question 5

How does left ventricular failure present

Answer 5

Dyspnoea 
Poor exercise tolerance 
Orthopnoea
Paroxysmal nocturnal dyspnoea
Wheeze 
Nocturnal cough
Pink frothy sputum
Bibasal crackles 
Cold peripheries

Question 6

How does right ventricular failure present

What are the causes

Answer 6

Peripheral oedema, ascites, raised JVP, facial engorgement, anorexia

LVF (most common), lung disease(cor pulmonale), pulmonary stenosis

Question 7

What is acute failure

Answer 7

New onset acute heart failure
Decompensated chronic heart failure
Characterised by pulmonary/peripheral oedema +/- peripheral hypoperfusion

Question 8

What is chronic heart failure

Answer 8

Heart failure develops gradually

Characterised by venous congestion but arterial pressure maintained

Question 9

What is low output heart failure

What are the causes

Answer 9

Cardiac output low and cannot increase to meet needs
Excessive preload: mitral regurge, fluid overload
Pump failure: systolic, diastolic, chronotropy (post mi, heart block, beta blocker), negative inotropic Drugs
Excessive afterload: AS, HTN

Question 10

What is low output heart failure

What are the causes

Answer 10

Normal cardiac output but cannot meet significantly increased needs

Anaemia, pregnancy, thyrotoxicosis, Paget’s disease

Question 11

What are signs of heart failure

Answer 11

Cyanosis
Hypotension 
Pulsus Alternans: beat to beat alternating pulse pressure 
Third heart sound
Displaced apex beat
RV heave 
Murmur

Question 12

How do you assess severity of heart failure symptoms

Answer 12

New York classification of heart failure:
I: no dyspnoea from ordinary activity
II: dyspnoea from ordinary activity
III: dyspnoea from less than ordinary active
IV: dyspnoea at rest

Question 13

What is required for diagnosis of HF

Answer 13

Symptoms 
Objective evidence:
BNP
ECG
Echo - further Ix if either are abnormal

Question 14

What investigations do you order for heart failure

Answer 14

FBC, U+E, BNP
ECG
CXR
Echo

Question 15

What are possible ecg changes

Answer 15

Ischaemia
Past MI
Ventricular Hypertrophy
Rarely normal in chronic HF

Question 16

What are findings on CXR for heart failure

Answer 16

Alveolar oedema: perihilar shadowing, batwing appearance
Kerely B lines - septal lines, interstitial oedema
Cardiomegaly - cardiothoracic ratio >50%
Dilated upper lobe veins
Pleural Effusion

Question 17

What will you assess on echocardiography

Answer 17

Cause: MI, cardiomyopathy, valve disease 
LV dysfunction (EDV - high = systolic failure)

Question 18

What is BNP

What is its role

Answer 18

Brain natriuretic peptide, hormone released from Ventricular myocardium when stretched

Assist stretched ventricles:
Increase GFR, decrease Na reabsorption, decrease fluid load - decrease preload
Vasodilation - decrease afterload

Question 19

What is the clinical use of BNP

Answer 19

Biomarker: distinguish from other causes of dyspnoea/LV ejection fraction
Diagnosis of heart failure: >100ng diaonstic
Levels correlate with mortality

Question 20

What are steps of management of acute heart failure

Answer 20

Sit patient upright
High flow O2 (if hypoxic)
Diamorphine IV
Furosemide IV
GTN spray/SL tablets
Nitrate infusion (keep BP >90) 
CPAP (if worsening on furosemide)

Question 21

What are differential diagnoses of acute heart failure

How do you manage this

Answer 21

Pneumonia
COPD
Asthma

Treat for all three: amoxicillin, IV furosemide, salbutamol nebuliser

Question 22

What is pharmacological management of chronic heart failure

Answer 22

Diuretics 
ACE-Inhibitor
Beta-blocker
Mineralocorticoid receptor antagonists 
Digoxin 
Vasodilator

Question 23

What diuretics are used

Why

Answer 23

Furosemide P.O.
Add on metolazone if refractory oedema
Add on spironolactone if hypokalaemic

Improves symptoms

Question 24

What is the role of ace inhibitors

Answer 24

For all with LVSD

Improves mortality

Question 25

What is the role of beta blockers

What caution do you need to take

Answer 25

In all with LVSD
Improves mortality

Start Low go slow
2 weeks bw each dose increment

Question 26

What are indications of spironolactone

What is its role in Hf management

Answer 26

Refractory symptoms despite optimal therapy
Post MI with LVSD

Improves mortality

Question 27

What are indications of digoxin

Answer 27

LVSD with refractory symptoms on optimal therapy

AF

Question 28

What vasodilators are used

What are indications of vasodilators in HF management

Answer 28

Hydralazine + isosorbide dinitrate combination

Intolerant to ACE-I/ARB
Add on therapy in black patients

Question 29

How do you manage intractable Heart failure

Answer 29

Na and fluid restrict
Switch furosemide to bumetanide
Add thiazide 
Inotropes
Cardiac resynchronisation
Transplantation

Question 30

What is involved in palliative care

Answer 30

Treat comorbidities: pneumococcal vaccine, flu vaccine
Nutrition
Opiates (pain from liver capsule stretch, dyspnoea)