Heart Failure

Question 1

Define heart failure

Answer 1

• inability of the heart
• to generate sufficient CO
• to meet demands of body
• without increased filling pressure
• secondary to an underlying cause

Question 2

Most common cause of HF

Answer 2

coronary artery disease

hypertension

Question 3

Age group common HF

Answer 3

Over 70

Question 4

Presentation of chronic HF

Answer 4

• breathlessness with impaired exercise tolerance
• slowly progressive
• periods of acute decompensation
• state of fluid retention and overload

Question 5

Acute HF Presentation

Answer 5

• flash pulmonary oedema
• precipitating ischaemia, arrhythmia, intercurrent infection
• OR gradual deterioration = fluid accumulates, exercise tolerance falls, orthopnoea, PND

Question 6

Systolic HF alternative name

Answer 6

HFrEF

HF with mildly rEF

Question 7

Severities of systolic HF

Answer 7

• mild = 46-55% EF by Echo
• moderate = 36-45%
• severe = <35%

Question 8

Diastolic HF alternative name

Answer 8

HFpEF

- stiffness of ventricular wall with impaired filling and reduced CO

Question 9

Echo signs of diastolic HF

Answer 9

• LVH
• L atrial dilatation
• abnormal relaxation

Question 10

Right HF features

Answer 10

• fluid overload

- secondary to L. heart disease, cor pulmonale, congenital heart disease, cardiomyopathy

Question 11

Left HF Features

Answer 11

HFrEF

Question 12

Low output HF

Answer 12

• common

Question 13

High Output HF

Answer 13

• overworked heart

- physiological or pathophysiological

Question 14

What does HF result in?

Answer 14

• decreased SV and CO

Question 15

What is the neurohormonal response to HF?

Answer 15

• sympathetic system activated
• RAAS system activated
• both result in vasoconstriction and sodium and fluid retention
• further stress of ventricular wall and dilatation (remodelling)
• worsening ventricular function
• further HF

Question 16

Explain the RAAS mechanism?

Answer 16

• liver, vessels and brain produce angiotensinogen
• renin produced by JGA in kidney when blood flow to kidney is low
• renin converts angiotensinogen to angiotensin I
• ACE from lungs converts angiotensin I to II
• angiotensin II = vasoconstriction and enhanced sympathetic activity as well as aldosterone release
• aldosterone = salt and water retention

Question 17

What does the sympathetic nervous system do?

Answer 17

• RAAS
• vasoconstriction
• increased HR and contractility
• direct cardiotoxicity

Question 18

What does direct cardiotoxicity result in?

Answer 18

• myocyte damage

Question 19

What does increased HR and contractility result in?

Answer 19

• increased myocardial oxygen demand = decreased contractility

Question 20

What does vasoconstriction and RAAS result in?

Answer 20

RAAS = fluid retention = increased wall stress = myocardial hypertrophy and decreased contractility as increased myocardial oxygen demand
Vasoconstriction = increased wall stress = myocardial hypertrophy and decreased contractility

Question 21

What does CO =?

Answer 21

SV x HR
HR increases via autonomic systemic
SV dependent on ventricular performance

Question 22

What is Starling’s Law of the heart?

Answer 22

• contractile function depends on velocity of muscle contraction, load being moved and amount of stretch
• pre-stretch improves relationship

Question 23

Main causes of HF?

Answer 23

• IHD
• Dilated cardiomyopathy
• hypertensive heart disease

Question 24

Infectious causes of HF?

Answer 24

Viral mycoarditis

Question 25

Right HF causes

Answer 25

COPD

Question 26

Metabolic causes

Answer 26

Anaemia Thyrotoxicosis Haemochromatosis

Question 27

Arrhthmic causes

Answer 27

AF | bradycardia

Question 28

Drug causes of HF

Answer 28

EtOH | Chemo

Question 29

Other cardiac causes

Answer 29

Valvular heart disease | Primary heart muscle disease

Question 30

Symptoms

Answer 30

``` Breathlessness - on exertion or rest Orthopnoea PND Tiredness and falling exercise tolerance Peripheral oedema Palpitations Depression Gout ```

Question 31

NYHA Classification of symptoms

Answer 31

``` 1 = none 2= symptoms on exertion 3= symptoms on minimal exertion 4= symptoms at rest ```

Question 32

Signs

Answer 32

``` Raised JVP 3rd heart sound pulmonary crepitations hepatomegaly peripheral or sacral oedema cachexia ```

Question 33

Routine bloods

Answer 33

``` FBC Iron studies U&E Glucose Cholesterol LFTs TFTs BNP Uric acid Ferritin CK Immunoglobulins Autoimmune profile Viral titres Genetics ```

Question 34

What diagnostic tests are done?

Answer 34

Routine bloods ECG CXR Transthoracic echocardiography Others = holter monitoring, lung function, cardiopulmonary exercise testing, cardiac catheterisation, perfusion imaging, cardiac MRI

Question 35

Management of acute pulmonary oedema

Answer 35

- medical emergency - high flow oxygen - morphine and anti-emetic - IV GTN - furosemide if fluid overload - ECG monitor - ventilatory support - find cause

Question 36

Principles of chronic HF management

Answer 36

- prevent decompensation - maintain or improve symptoms - increase longevity

Question 37

Types of management for chronic HF

Answer 37

- drug therapy start low dose then uptitrate - device - surgical - exercise training through cardiac rehab - palliation - remove exacerbating factors

Question 38

Drugs used in HFrEF

Answer 38

1) Symptomatic = ACEi or ARB and Beta blocker 2) MR antagonist add 3) still symptomatic and LVEF <35% = ARNI replace ACEi/HR>70 = ivabradine 4) resistant symptoms = digoxin, heart transplant, LVAD

Question 39

Advanced Treatment

Answer 39

Implantable cardiac defibrillators Cardiac Resynchronisation Therapy LVAD Extracorporeal Membrane Oxygenation

Question 40

Surgical Options

Answer 40

Valve Surgery Revascularisation Stem Cells Heart Transplants