HEART FAILURE

Question 1

Define heart failure.

Answer 1

Heart failure occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the needs of the body. Heart failure is not scrictly a diagnosis.

Question 2

What are the two types of heart failure?

Answer 2

Systolic or diastolic heart failure.

Question 3

What is systolic heart failure?

Answer 3

This means that the ventricles of the heart do not contract properly during each heartbeat so blood is not adequately pumped out of the heart. In other words, there is a reduction in the ejection fraction.

Question 4

What is diastolic heart failure?

Answer 4

This occurs when the ventricle does not fill up with blood enough when the heart rests in between each heartbeat. Ejection fraction may be normal or even raised.

Question 5

What are conditions that can lead to heart failure? (Name at least 5)

Answer 5

Ischaemic heart disease (Post MI)
Cardiomyopathy
Hypertension
Valvular heart disease
Pericarditis
Arrhythmias
Duchenne muscular dystrophy
Anaemia
Vitamin B1 deficiency
Hyperthyroidism
Paget's disease
Diabetes
SLE
Heart failure of the other side (most common cause of right sided heart failure is left sided heart failure)

Question 6

What are the (non-medical) risk factors associated with heart failure? (Name at least 3)

Answer 6

Smoking
Alcohol abuse
Drug abuse (such as cocaine)
NSAIDs can worsen CHF by causing fluid retention
All risk factors for hypertension and IHD

Question 7

What are the common symptoms associated with heart failure? (Name at least 6)

Answer 7

Shortness of breath
Peripheral oedema
Poor exercise tolerance
Fatigue
Orthopnea
Paroxysmal nocturnal dyspnoea
Nocturnal cough
Wheeze
Nocturia
Cold peripheries
Weight loss
Muscle wasting
Nausea
Cachexia
Facial enlargement

Question 8

What is the Frank-Starling curve?

Answer 8

It is the relationship between end diastolic volume (x axis) and the stroke volume (y-axis).

Question 9

What is the NYHA grade scale? What are the different grades?

Answer 9

A way of grading heart failure patients to work out prognosis.

Class I (Normal) - Few observable symptoms, no limitation in ordinary physical activity. Prognosis: poor

Class II (Mild) - Mild observable symptoms and slight limitation during ordinary activity. Comfortable at rest. Prognosis: bad

Class III (Moderate) - Marked limitation in physical activity due to symptoms even during less- than-ordinary activity. Comfortable only at rest. Prognosis: awful

Class IV (Severe) - End-stage heart failure. Severe limitations. Experience symptoms even while at rest. Prognosis: terminal

Question 10

What are the drug options in the treatment of heart failure?

Answer 10

Diuretics, ACE inhibitors, Angiotensin-II receptor blockers, Beta-blockers, Spironolactone (Aldosterone antagonist), Hydralazine/Nitrates (Vasodilators), Digoxin.

Question 11

Why do you need to start a patient on a high dose of diuretics?

Answer 11

Because the hypervolaemia will mean that the drug becomes diluted. The more fluid you get rid of the less drug you need.

Question 12

What is the difference between enalapril and ramipril?

Answer 12

The price.

Question 13

Why are beta-blockers quite a new therapy for heart failure?

Answer 13

They can cause heart failure. Some more than others e.g. atenolol.

Question 14

What class of NYHA would you normally give spironolactone to?

Answer 14

Class III-IV

Question 15

What other preventative class of drugs might you put a patient with heart failure on?

Answer 15

Anti-coagulants (warfarin). Poor ejection fraction can lead to the formation of thrombi and hence increase the risk of stroke.

Question 16

What are Framingham criteria for the diagnosis of heart failure? (Name 5 major and 4 minor criteria) How many of each do you need to make a diagnosis of heart failure?

Answer 16

Major:
Paroxysmal Nocturnal Dyspnoea
Neck vein distention
Crepitations
Acute pulmonary oedema
S3 gallop
Hepatojugular reflux
Cardiomegaly
Increased central venous pressure
Weight loss in response to diuretic treatment

Minor:
Bilateral ankle oedema
Nocturnal Cough
Dyspnoea on ordinary exertion
Hepatomegaly
Tachycardia (>120)
Pleural effusion
Decrease in vital capacity by 1/3

Either 2 major or 1 major and 2 minor

Question 17

What tests and investigations help with the diagnosis of heart failure?

Answer 17

Chest x ray looking for cardiomegaly
Blood tests looking for BNP (B-type Natriuretic Peptide)
ECG
Echo

Question 18

What might you see on an ECG of a patient with left ventricular hypertrophy with regard to the QRS complexes?

Answer 18

Left axis deviation beyond -15˚:
Negative QRS in lead AVF and positive in lead I
Lead AVR is often biphasic

R wave amplitude in V5 or V6 plus the S wave amplitude in V1 or V2 exceeds 35 mm
R wave amplitude in V5 exceeds 26 mm
R wave amplitude in V6 exceeds 18 mm
R wave amplitude in V6 exceeds R wave in V5

Question 19

What might you see on an ECG of a patient with right ventricular hypertrophy with regard to the QRS complexes?

Answer 19

Right axis deviation beyond 100˚:
Negative in lead I and positive in lead AVF
Biphasic in lead II

R wave amplitude in V1 is larger than S wave
S wave amplitude in V6 is larger than R wave

Question 20

What might you see on the ECG of a patient with right atrial enlargement with regard to the P waves?

Answer 20

P waves with an amplitude exceeding 2.5 mm in the inferior leads (II, III and AVF)
No change in the duration of P wave
Possible right axis deviation of P wave (negative in lead I and positive in AVF and lead III)

Question 21

What might you see on the ECG of a patient with left atrial enlargement with regard to the P wave?

Answer 21

Amplitude of terminal component of P wave may be increased and must descend at least 1 mm below the isoelectric line in V1
Duration of P wave is increased, and terminal portion of P wave is at least 0.04s in width.
No significant axis deviation of P wave.

Question 22

What are the secondary repolarization abnormalities that may be seen on the ECG of someone with ventricular hypertrophy?

Answer 22

Down sloping ST segment depression

T wave inversion