Heart Failure

Question 1

What is the definition of heart failure?

Answer 1

Inability of heart to maintain adequate cardiac output to meet body’s demand

Question 2

What are the different classifications of heart failure?

Answer 2

1. Systolic failure (HFrEF) - more common
   
   • IHD
   • MI
   • Ventricular dilatation
2. Diastolic failure (HFpEF) - pt normally elderly, overweight, HTN and AF
   
   • ventricular hypertrophy
   • constrictive pericarditis
   • tamponade
   • restrictive cardiomypathy
   • obesity
3. Acute or chronic
4. Right sided or left sided HF

Question 3

What are the sx for LVF? (most common HF)

Answer 3

• dyspnoea
• poor exercise tolerance
• fatigue
• orthopnoea
• PND
• pink frothy sputum

Question 4

What are the causes of RVF?

Answer 4

• LVF
• pulmonary stenosis
• lung disease (cor pulmonale)

Question 5

What are the sx for RVF?

Answer 5

• peripheral oedema
• breathlessness
• raised JVP
• liver congestion
• ascites

Question 6

What is the term used when you have both LVF and RVF?

Answer 6

• Congestive Heart Failure

Question 7

What is acute HF?

Answer 7

• new-onset acute or decompensation of chronic HF
• characterised by pulmonary and/or peripheral oedema
• +/- signs of peripheral hypoperfusion

Question 8

What is the Px of PND?

Answer 8

1. Sleep flat - fluid redistributed across large surface area of lung. Stand up - fluid sinks to base fo lungs, upper lungs clear
2. Respiratory centre in brain less responsive during sleep
3. Less circulating adrenaline during sleep - less CO

Question 9

How would you diagnose HF?

Answer 9

• Clinical presentation
• BNP blood test (specifically “N-terminal pro-B-type natriuretic peptide” – NT‑proBNP)
• Echocardiogram
• ECG

Question 10

What are the causes of HF?

Answer 10

• IHD
• HTN
• Valvular disaese (Rheumatic fever)
• AF
• Chronic lung disease
• Cardiomyopathy
• Previous chemo drugs
• HIV

Question 11

What criteria can you use to diagnose HF?

Answer 11

Framingham criteria

Question 12

Why do you get a raise in BNP during HF?

Answer 12

• BNP produced by ventricles
• BNP released to protect heart from stress
• Act on
  
  • bv: dilate
  • kidney: excrete salt
  • reduce production of adrenaline, angiotensin, aldosterone

Question 13

Describe the New York classification of HF?

Answer 13

• I: Heart disease present, no dyspnoea from ordinary activity
• II: Comfortable at rest, dyspnoea during ordinary activity
• III: Dyspnoea at low activity
• IV: Dyspnoea at rest

Question 14

What are the CXR features of HF?

*use ABCDE

Answer 14

• A: Alveolar oedema (bat wings)
• B: Kerley B lines
• C: Cardiomegaly
• E: Pleural Effusion

Question 15

What are the first line medical treatment for HF?

*use ABAL

Answer 15

• ACE-i
  
  • Ramipril 1.25mg OD
• Beta blocker
  
  • Bisoprolol 1.25mg OD
• Aldosterone antagonist
  
  • Eplerenone 25mg OD
• Loop diuretics
  
  • Furosemide 40-500mg OD

Question 16

How would you tx chronic HF?

Answer 16

1. Diuretics
   
   • If pt has fluid overload
2. If HFpEF:
   
   • Mx HTN, AF, IHD and DM
   • Furosemide
3. If HFrEF:
   
   • ACEi + BB. Add Eleprenone if sx continues
   • ARB if ACEi intolerable
4. Specialist re-assessment +/- second line tx
   
   • Ivabradine
   • Sacubitril
   • Hydralazine + Isosorbide mononitrate
   • Nitrates

Question 17

What physiological mechanisms will a drop in CO trigger?

Answer 17

1. Activation of baroreceptors at carotid sinus
   
   • Increase sympathetic drive
     
     • Inc HR, Inc peripheral resistance
2. Activation of RAAS
   
   • Inc circulating volume
   • Vasoconstriction
   • Enhance sympathetic activity

Question 18

Which medications for HF can prolong life?

Answer 18

• ACEi
• B blocker (bisoprolol, carvedilol, metaprolol)
• Spironolactone

Question 19

What causes acute HF?

Answer 19

• Ischameic heart disease
• Acute valvular disease
• Pericardial tamponade

Question 20

What is chronic heart failure?

Answer 20

• Progressive cardiac dysfunction due to structural and/or functional cardiac abnormalities
• Results in reduced cardiac output and/or elevated intracardiac pressures at rest or on stress

Question 21

What causes chronic heart failure?

Answer 21

• cardiomyopathy
• ischaemic heart disease
• aortic stenosis
• atrial fibrillation

Question 22

If pt remain symptomatic despite optimal tx, what interventional device can you offer?

Answer 22

• Implantable cardiac defibrillator (ICD):
  
  • ​important for primary and secondary prevention of sudden cardiac death (specific indications).
• Cardiac resynchronisation therapy (CRT):
  
  • ​biventricular pacing, which is indicated in certain patients with HFrEF (i.e. ≤ 35%) & prolonged QRS (i.e. ≥ 130 ms). Usually receive combined device with defibrillator.
• Percutaneous coronary intervention (PCI):
  
  • ​patients with ischaemic heart disease may be offered revascularisation therapy if indicated.
• Cardiac transplant: highly specialised
  
  • ​procedure for certain patient groups with heart failure

Question 23

What Ix would you order for HF?

Answer 23

Bedside

• ECG

Bloods

• U&E - renal function
• FBC
• LFT
• TFT
• Ferritin & Transferrin (younger pt)
• NT-proBNP

Imaging

• CXR

Question 24

What lifestyle medification would you offer for HF?

Answer 24

• smoking cessation
• Restrict alcohol consumption
• Salt restriction
• Fluid restriction