Heart Failure

Question 1

Define heart failure

Answer 1

Insufficient supply for the demand due to failure of the heart to pump at normal efficiency.

Question 2

Normal systolic ejection fraction

Answer 2

60-65%

Question 3

Cardiac hypertrophic response is triggered by: (3)

Answer 3

1. Angiotensin 2
2. ET-1 and insulin-like growth factor
3. TGF-b

Question 4

4 types of cardiac failure

Answer 4

1. Systolic failure
2. Diastolic failure
3. Left ventricular failure
4. Right ventricular failure

Question 5

Causes of systolic failure

Answer 5

1. IHD
2. Cardiomyopathy
3. MI

Question 6

Causes of diastolic failure

Answer 6

1. Ventricular hypertrophy
2. Constrictive pericarditis
3. Tamponade
4. Restrictive cardiomyopathy
5. Obesity

Question 7

HFPEF

Answer 7

Heart failure with preserved ejection fraction - typically diastolic heart failure with >50% ejection fraction.

Question 8

Left ventricular failure

Answer 8

Heart unable to pump efficiently to the rest of the body so blood backs up in the lungs - pulmonary congestion. Often leads to right overload.

Question 9

Symptoms of LVF

Answer 9

1. Dyspnoea
2. Reduced exercise tolerance
3. Paroxysmal nocturnal dyspnoea
4. Orthopnoea
5. Fatigue
6. Cold peripheries
7. Weight loss
8. Nocturnal cough
9. Wheeze

Question 10

Right ventricular failure

Answer 10

Leads to venous hypertension.

Question 11

Causes of RVF

Answer 11

1. LVF
2. Pulmonary stenosis
3. Lung disease

Question 12

Symptoms of RVF

Answer 12

1. Peripheral oedema
2. Ascites
3. Nausea
4. Anorexia
5. Facial engorgment
6. Epistaxis

Question 13

CCF

Answer 13

Congestive cardiac failure - both LVF and RVF

Question 14

Causes of low output cardiac failure (fails to increase with exertion)

Answer 14

1. Excessive preload: mitral regurgitation, fluid overlad
2. Pump failure: negatively inotropic drugs, decreased heart rate
3. Chronic excessive afterload: aortic stenosis, HTN

Question 15

Causes of high output cardiac failure

Answer 15

1. Paget’s disease
2. Anaemia
3. Pregnancy
4. Hyperthyroidism

Question 16

Signs of HF

Answer 16

1. Cyanosis
2. Decreased BP
3. Pulsus alternans
4. Displaced apex beat (LV dilatation)
5. RV heave (pulmonary HTN)
6. Pink frothy sputum

Question 17

Investigations for HF

Answer 17

1. ECG
2. Raised BNP
3. CXR - enlarged heart
4. Echocardiography is key investigation
5. FBC - U&E

Question 18

Diagnosis of HF

Answer 18

1. Abnormal ECG/BNP
2. Symptoms/signs
3. NYHA classification

Question 19

NYHA classification

Answer 19

Class I - no dyspnoea present on ordinary activity
Class II - dyspnoea on ordinary activity but not rest
Class III - dyspnoea on less than ordinary activity but not rest - limiting
Class IV - constant dyspnoea

Question 20

Management of acute HF

Answer 20

1. Sit patient upright
2. High flow oxygen if low peripheral capillary oxygen saturation
3. Treat arrhythmia
4. Continue investigations
5. IV diamorphine slowly (caution in COPD, liver failure)
6. Furosemide IV slowly
7. GTN spray 2 puffs
8. If systolic >100mmHg start nitrate infusion
9. If systolic <100mmHg treat as cardiogenic shock, refer to ICU

Question 21

Management of chronic HF

Answer 21

1. Stop smoking, drinking, low salt, optimise weight and nutrition
2. Treat underlying cause
3. Avoid exacerbating factors (NSAIDs, verapamil)
4. Treat exacerbating factors (anaemia, HTN)
5. Drugs

Question 22

Drugs used to treat chronic HF

Answer 22

1. ACE-i (lower BP) or ARB if cough if LVSD
2. Diuretics (furosemide - loop diuretic) relieves symptoms
3. B-blocker - carvedilol
4. Mineralocorticoid receptor antagonists - spironolactone
5. Digoxin - treats arrhythmias
6. Vasodilators - hydrazaline and isosorbide nitrate if intolerant to ace-i/ARB