Heart Failure

Question 1

Define HF

Answer 1

abnormality of cardiac structure or function leading to a failure of the heart to deliever oxygen at a rate required by metabolising tissues.

It is a clinical syndrome has has the following features

• symptoms of HF
• signs of fluid retention
• evidence of abnormality in cardiac structure or function

Question 2

How is HF classified and what are the types?

Answer 2

According to LVEF which is calculated by Stroke vol(EDV-ESV)/EDV

LVEF <40% = HF with reduced ejection fraction (HF-REF). Here, there is inadequate contraction to eject blood

LVEF >50% = HF with preserved ejection fraction (HF-PEF). Here, there is inadequate relaxation to permit normal LV filling

Question 3

Breifly outline the pathophysiology of HF

Answer 3

The reduction in CO leads to a decrease in MAP (MAP = CO x TPR)

To maintain perfusion the body initiates mechanisms such as the Frank-Starling mechanism, neurohumoral activation and ventricular remodelling

Neurohumoral activation = SNS hyperactivity to increase HR and vasoconstrict. There is also increased AngII to assist vasoconstriciton which activates RAAS and leads to fluid retention.

Ventricualar remodelling leads to increased LV mass and vol

Question 4

How are the S&S of HF classified? What are the major and minor criteria?

Answer 4

The Framingham Criteria

Major

• paroxysmal noctural dyspnoea or orthopnoea
• Increased JVP
• Pulmonary oedema
• S3 gallops
• Cardiomegaly
• Hepatojugular reflux

Minor

• Peripheral oedema
• Night cough
• Tachycardia
• Pleural effusion
• Chest pain

Question 5

what investgations are done in HF?

Answer 5

Echo 
ECG 
CXR 
BNP/NT-pro-BNP levels 
FBC, U&E, Glucose, Lipids, TFTs

Question 6

What are the treatement options for HF?

Answer 6

• lifestyle Mods
• ACEi
• B-blockers
• Diuretics (loop such as furosemide)
• aldosterone antagonist e.g spironolactone
• Nitrate therapy e.g isosorbide dinitrate or hydralazine.(reduces SOB)
• Vasopressin antagonist e.g tolvaptan, in patients with severe hyponatraemia or persistent congestion

Question 7

what are the complications of HF?

Answer 7

Pleural effusions
Anaemia
Acute renal failure
Acute decompensation

Question 8

What is the NYHA classification of HF?

Answer 8

I = no limitation 
II = mild symptoms and slight limitation 
III = significant limitation due to symptoms but comfortable at rest 
IV = severe limitation and symptomatic at rest

Question 9

what drugs should be avoided in HF?

Answer 9

NSAIDs - fluid retention

Verapamil - negative inotrope