Heart Failure: Acute, Chronic

Question 1

CHF

• presentation
• pathophysiology

Answer 1

SOB, orthopnea, PND
Cough - pink, frothy sputum
Cachexia - hidden by edema weight

Bibasal crackles
RHF, high JVP, ankle edema, hepatomegaly

Reduced CO => SNS and RAAS activation

• increased HR, contractility
• aldosterone => VC, Na retention
• ADH => VC, fluid retention
• cardiac remodelling => abnormal contraction, relaxation => vicious cycle

Question 2

Chronic heart failure

-types and their differences

Answer 2

Diastolic - HFPEF (40%+)

• stiff LV => fills less during diastole so CO falls but ejection fraction stays the same
• S4, highly thickened falls
• OFTEN MULTIFACTORIAL

Systolic - HFREF

• weak muscles => normal filling but CO falls, ejection fraction falls
• S3, v thin walls
• past MI, cardiomyopathies, valve disease

Question 3

Management

• CHF
• conservative
• medical

Answer 3

Flu, pneumococcal vaccine
Manage precipitating factors

Reduce cardiac remodelling
1st line - ACEi/ARB + Bb
2nd line - aldosterone ant
3rd line specialist - ivabradine, sacubatril-valsartan/digoxin
-hydralazine nitrate if Afro Carribbean

Question 4

Investigations

-both CHF, AHF

Answer 4

Blood tests, ECG, CXR, Echo => rule out precipitators/differentials
-electrical, effusions, valvular issues

Definitive - BNP
-100+ => specialist assessment and ECHO (valve, LV systolic/diastolic function)

CXR findings

• Alveolar edema
• B lines (interstitial edema)
• Cardiomegaly
• Dilated upper vessels
• Effusion

Question 5

ACEi

Answer 5

Slow cardiac remodelling
Venous, arterial VD => reduce preload, afterload
Diuretic effect

SE - dry cough, low BP, renal failure, highK

CI - renal failure, angioedema, pregnancy

Question 6

ARB

Answer 6

Block Ang2 action

Indications - ACEi induced cough

SE same as ACEi

Question 7

Bb

Answer 7

CARVEDILOL or BISOPROLOL

SE - fatigue, exercise intolerance, hypoglycemia, nightmares, col peripheries

CI - asthma

Question 8

MRA

Answer 8

Spironolactone

SE - gynecomastia (less with eplerenone), high K, renal dysfunction

CI - pregnancy

Question 9

Sacubatril/valsartan

Answer 9

Sacubatril - nephrolysin inh => increase ANP, and Ang2

Valsartan => break down Ang2

Question 10

Digoxin

Answer 10

Positive inotrope
Stimulates vagus => reduced AVN conduction

To be used in worsening/severe HF due to LC systolic dysfunction

Narrow therapeutic window => arrythmias, N+V, anorexia

AB digibin can reverse SE

Question 11

Ivabradine

Answer 11

Lower HR - block If in SAN => increase diastolic period, relieve ischemia

Used in HR 75+ and EF U35%

SE - luminous phenomena, low HR
CI - renal/hepatic impairment, pregnancy, breastfeeding

Question 12

Diuretics

Answer 12

Decreased preload, edema, SOB, increase exercise tolerance

Increase Na, fluid excretion

1st line - loop
-can add thiazide

SE - lowK => arrythmia, low BP
-lowK reduced by ACEi/ARB, MRA

Question 13

Cardiorenal syndrome (CRS)

• pathophysiology
• diagnosis
• management

Answer 13

Coexistance of cardiac and renal injury

• long term venous congestion + low BP => low renal perfusion
• CHF increases inflammation => tubular fibrosis, glomerulosclerosis
• can also be worsened by CHF treatment

V common

Diagnosis - CHF + high creatinine, low GFR

CHF management can make CRS worse

• close renal monitoring and U&Es => watch out for highK
• use minimal dose of diuretics

Question 14

Acute heart failure

• presentation
• types

Answer 14

De-novo AHF - ischemia => low CO
Decompensated AHF 
-ACS
-HTN crisis
-AF
-valve disease

SOB - cyanosed
Reduced exercise tolerance - high HR
Edema - high JVP
Fatigue
Bibasal crackles, wheeze
S3
Displaced apex

Question 15

Management

-AHF

Answer 15

Initial - loop diuretics

• O2 if needed
• CPAP if in resp failure
• dobutamine if low BP/cardiogenic shock
• cont CHF management unless HR v low

After acute phase => same as chronic