Heart Failure

Question 1

what are the groups of causes of HF?

Answer 1

ischaemic heart disease, hypertension, valvular disease, pericardial disease, drugs, genetics, inflammation, metabolic, arrhythmias, cardiomyopathies, severe anaemia, pulmonary hypertension

Question 2

what are the pericardial disease causes of HF?

Answer 2

pericarditis, pericardial effusion

Question 3

what drugs can cause HF?

Answer 3

chemotherapeutic drugs, beta blockers, calcium channel blocks, alcohol, radiation

Question 4

what genetic causes can lead to HF?

Answer 4

DCM, HCM, ARVC, non compaction

Question 5

what inflammatory causes can lead to HF?

Answer 5

Myocarditis, rheumatic disease, HIV

Question 6

What metabolic causes can lead to HF?

Answer 6

thyrotoxicosis/myxoedema, phaemotochromaia, anorexia

Question 7

What cardiomyopathies can lead to

Answer 7

congestive, hypertrophic, restrictive (sarcoidosis, amyloidosis, hemochromatosis, endocardial fibrosis

Question 8

what is HF with reduced ejection fraction

Answer 8

o Cardiac output is low and fails to increase normally with exertion

Question 9

what are the causes of HF with reduced ejection fraction?

Answer 9

Pump Failure – systolic and/or diastolic HF, reduced heart rate (b-blockers, heart block, post MI), negatively inotropic drugs (antiarrhytmias), excessive preload (mitral regurgitation or fluid overload – NSAIDS), chronic excessive afterload (aortic stenosis, hypertension)

Question 10

what is HF with preserved ejection fraction?

Answer 10

o Rare, cardiac output is normal or increased in the face of increased needs. Failure occurs when cardiac output fails to meet these needs.

Question 11

what are the causes of HF with preserved ejection fraction?

Answer 11

anaemia, pregnancy, hyperthyroidism, pagets disease, arteriovenous malformation, beri beri

Question 12

What is systolic HF?

Answer 12

inability of ventricle to contract normally resulting in reduced cardiac output. Ejection fraction (EF) is <40%.

Question 13

What is diastolic HF?

Answer 13

inability of ventricle to relax and fill normally causing increased filling pressures. EF is >50%.

Question 14

What are the symptoms of LHF?

Answer 14

dyspnoea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough, wheeze, nocturia, cold peripheries, weight loss, muscle wasting

Question 15

What are causes of systolic HF?

Answer 15

IHD, MI, cardiomyopathy

Question 16

what are the causes of diastolic HF?

Answer 16

constrictive pericarditis, tamponade, restrictive cardiomyopathy, hypertension.

Question 17

what are the causes of RHF?

Answer 17

LVF, pulmonary stenosis, lung disease

Question 18

what are the symptoms of LHF?

Answer 18

peripheral oedema, ascites, nausea, anorexia, facial engorgement, pulsation in neck and face, epistaxis

Question 19

what are the different classifications of HF?

Answer 19

HF with reduced ejection fraction, HF with preserved ejection fraction, HF with mid range ejection fraction, systolic HF, diastolic HF, left HF, right HF, acute HF, chronic HF

Question 20

what is acute HF?

Answer 20

new onset acute or decompensation of chronic heart failure characterised by pulmonary and/or peripheral oedema with or without signs of peripheral hypoperfusion

Question 21

what is chronic HF?

Answer 21

develops or progresses slowly. Venous congestion is common but arterial pressure is well maintained until very late

Question 22

what is the main form of HF?

Answer 22

left ventricular systolic dysfunction

Question 23

what are the symptoms of HF?

Answer 23

o	Dyspnoea
o	Orthopnoea
o	Paroxysmal nocturnal dyspnoea 
o	Fatigue, lethargy, exercise intolerance
o	Peripheral swelling
o	Weight loss
o	Wheeze
o	Cough – “frothy pink sputum”

Question 24

What are the signs of HF?

Answer 24

Fluid overload - Peripheral oedema – ankles+/- sacrum, Ascites, Elevated JVP (right sided HF)
Also: Pulsus alternans, Hypotension, Cardiac heave, Displaced apex beat, Gallop (S3), Cardiomegaly on CXR, Bilateral crpeitations +/- wheeze, Cachexia (decreased appetite, weight loss, lethargy, muscle, atrophy), Hepatic tenderness/hepatomegaly

Question 25

What investigations should be carried out?

Answer 25

ECG, bloods, CXR, BNP, Echo, MRI, angiogram, CPEX

Question 26

what features will be seen in ECG of HF?

Answer 26

q waves, poor r progression, LBBB (if normal >90% that they are fine)

Question 27

which bloods should be done in HF?

Answer 27

Hb, U&E, TFT, Ferritin

Question 28

what features will be seen in CXR of HF?

Answer 28

``` baseline, ensure euvolemic, exclude resp disease/malignancy o Alveolar oedema (Bat wings) o B Kerley B lines (interstitial oedema) o Cardiomegaly o Dilated prominent upper lobe vessels o E Pleural effusion ```

Question 29

what features of BNP will be seen in HF?

Answer 29

high negative predictive value, if elevated ca guide response to treatment o Peptides that cause natriuresis, diuresis and vasodilation.

Question 30

what features will be seen in an Echo of HF?

Answer 30

quantify LVSD, identify valve disease, assess right heart pressures, other causes

Question 31

What is the grading system of HF?

Answer 31

Grade I-IV

Question 32

what is the definition of grade I HF?

Answer 32

limitation of function

Question 33

what is the definition of grade II HF?

Answer 33

Slight limitation. Moderate exertion causes symptoms, but no symptoms at rest

Question 34

what is the definition of grade III HF?

Answer 34

Marked limitation – mild exertion causes symptoms, but no symptoms at rest

Question 35

what is the definition of grade IV HF?

Answer 35

Severe limitation. Any exertion causes symptoms. May also have symptoms at rest – but not always the case

Question 36

What is the lifestyle management of HF?

Answer 36

Smoking Cessation Diet - salt intake, weight loss, stop alcohol Fluid restriction Cardiac rehab

Question 37

which medications are involved in treatment of HF?

Answer 37

``` Loop Diuretics (also thiazides, potassium sparing) B Blockers ACE, ARBS Mineralocorticoid antagonists IV iron Entresto Digoxin ```

Question 38

what are the device therapies of HF?

Answer 38

ICD | CRT

Question 39

what are the advanced therapies of HF?

Answer 39

IABP LVAD ECMO Transplant

Question 40

what is the first line treatment for HF?

Answer 40

ACE inhibitors or ARB

Question 41

what is the second line treatment for HF?

Answer 41

ADD diuretic

Question 42

what is the third line treatment for HF?

Answer 42

ADD betablocker

Question 43

what is the fourth line treatment for HF?

Answer 43

``` ADD aldosterone (then increase all to maximum tolerated doses) ```

Question 44

what other considerations can be added to management of HF?

Answer 44

CONSIDER ARNI (and cease ACE-i) for patients who remain with an EF <40% CONSIDER ivabradine CONSIDER another vasodilator, e.g. isosorbide dinitrate or hydralazine CONSIDER digoxin CONSIDER implantable cardiac devices

Question 45

What are the causes of acute HF?

Answer 45

MI, valve rupture, sustained arrhythmia, weak heart + fluid balance wrong

Question 46

what is the presentation of acute HF?

Answer 46

cold, clammy, pale, murmurs, bilateral crepitations

Question 47

what is the treatment of acute HF?

Answer 47

IV diuretic, oxygen, vasopressors, opiates (opiates dilate veins – reduces pre load)