Heart failure

Question 1

What is heart failure?

Answer 1

The inability of cardiac output to meet the physiological demands of the body.

Question 2

What are the different classifications of heart failure?

Answer 2

Left ventricular failure (LVF), right ventricular failure (RVF), low output and high output heart failure.
Framingham criteria for congestive heart failure.
New York Heart Association classification for heart failure.

Question 3

What are the symptoms of left ventricular failure?

Answer 3

Paroxysmal nocturnal dyspnoea
Wheeze
Nocturnal cough with pink sputum caused by pulmonary oedema

Question 4

What are the symptoms of right ventricular failure?

Answer 4

Usually caused by left ventricular failure or lung disease
Peripheral oedema
Ascites

Question 5

What is low output and high output heart failure due to?

Answer 5

Excessive afterload, excessive preload, or pump failure.

Question 6

What are the causes of heart failure?

Answer 6

Anything that causes myocardial damage.
Coronary artery disease
Hypertension
Atrial fibrillation
Valve disease
Cardiomyopathies
Infective endocarditis
Anaemia
Endocrine disorders
Cor pulmonale (RVF secondary to pulmonary disease)

Question 7

What is the Framingham criteria for congestive heart failure?

Answer 7

2 major criteria or 1 major criteria and 2 minor criteria.
Major criteria: PAINS.
-Paroxysmal nocturnal dyspnoea
-Acute pulmonary oedema
-Increased heart size, increased central venous pressure
-Neck vein dilation
-S3 gallop
Minor criteria: PAIN.
-Pleural effusion
-Ankle oedema (bilateral)
-Increased heart rate >120bpm
-Nocturnal cough

Question 8

What is the New York Heart Association Classification for heart failure?

Answer 8

I: No limitation of physical activity.
II: Slight limitation of physical activity.
III: Marked limitation of physical activity.
IV: Inability to carry out physical activity.

Question 9

What are the complications of heart failure?

Answer 9

Renal failure.
Valve dysfunction.
Stroke.

Question 10

What is the conservative treatment for heart failure?

Answer 10

Smoking cessation advice
Weight loss
Promotion of healthy diet and exercise

Question 11

What is the medical treatment for heart failure?

Answer 11

Angiotensin converting enzyme (ACE) inhibitors.
Beta-blockers: bisoprolol and carvedilol.
Candesartan: angiotensin receptor blocker (if intolerant to ACEi).
Digoxin: cardiac glycoside.
Diuretics, e.g. furosemide.
Spironolactone: aldosterone receptor antagonist.

Question 12

What is the surgical treatment for heart failure?

Answer 12

Heart transplantation.

Question 13

What investigations should be performed for suspected heart failure?

Answer 13

Bloods: FBC, U&Es, LFTs, TFTs, lipid profile, brain natriuretic peptide (BNP): suggests how much the myocytes are stretched, concentration of >400pg/mL (116pmol/L) is suggestive of heart failure.
CXR: Alveolar oedema, Kerley B lines, Cardiomegaly, Dilated upper lobe vessels, pleural Effusion.
ECHO: aims to identify cause and assess function of the heart.
ECG.

Question 14

What are the causes of left sided heart failure?

Answer 14

Coronary artery disease
Hypertension
Aortic valve disease
Mitral valve disease
Myocardial disease

Question 15

What are the causes of right sided heart failure?

Answer 15

Left sided heart failure
Tricuspid valve disease
Pulmonary valve disease
Pulmonary vascular disease

Question 16

What is the pathophysiology of congestive heart failure?

Answer 16

Left or right sided heart failure results in ischaemic injury and reduced myocardial efficiency.
Increased workload, decreased cardiac output, decreased contractility.
This activates compensatory mechanisms: activation of the renin angiotensin aldosterone system (RAAS) causes sodium ion and water retention, and peripheral vasoconstriction, increasing preload; activation of the sympathetic nervous system increases heart rate and causes peripheral vasoconstriction, increasing afterload; increased myocyte size.
Chronic activation of these compensatory mechanisms worsens heart failure and leads to increased cardiac damage.

Question 17

What is the cause of cardiac dilation?

Answer 17

Increased end diastolic volume.