Heart failure, Cor pulmonale and HTN

Question 1

Heart failure definition

Answer 1

The inability of the heart to deliver blood with O2 at a rate that is commensurate with the requirement of respiring tissue

Question 2

Causes of heart failure and which are the main 3.

Answer 2

1. Hypertension
2. Cardiomyopathy
3. IHD
   Other causes: valvular heart disease, cor pulmonale, alcohol excess

Question 3

What is systolic failure?

Answer 3

The inability of the ventricle to contract normally.
- Decrease in cardiac output
Causes: IHD, MI and cardiomyopathy

Question 4

What is diastolic failure?

Answer 4

The inability of the ventricle to relax, leading to insufficient filling.
‘Preserved ejection fraction’
Causes: ventricular hypertrophy, cardiac tamponade, pericarditis and HTN

Question 5

What is right ventricular heart failure?

Answer 5

Causes: LVF, pulmonary stenosis, lung disease

Question 6

Symptoms of right ventricular heart failure.

Answer 6

Nausea, fatigue, peripheral oedema, swollen abdomen and facial engorgement

Question 7

Signs of right ventricular heart failure

Answer 7

Raised JVP, hepatomegaly, pitting oedema

Question 8

Symptoms of left ventricular heart failure

Answer 8

SOB on exertion, fatigue, paroxysmal nocturnal dyspnoea

Question 9

Signs of left ventricular heart failure

Answer 9

Tachycardia, additional heart sounds, crepitations in lung bases

Question 10

3 cardinal symptoms of heart failure

Answer 10

1. SOB
2. Fatigue
3. Ankle swelling

Question 11

Explain the NY classification of HF

Answer 11

stage 1: No limitation (asymptomatic)
stage 2: Slight limitation (mild HF)
stage 3: Marked limitation (symptomatic HF)
stage 4: symptomatically severe HF

Question 12

What are the ABCDEs you would expect to see on a chest x-ray of a person with HF?

Answer 12

A - alveolar oedema
B- kerley B lines
C - cardiomegaly
D - dilated upper lobe vessels
E - effusions (pleural)

Question 13

What are you looking for in the blood work of a person with HF?

Answer 13

Raised ANP: NT-pro B-Type Natriuretic Peptide

Question 14

What investigations would be performed on a person with HF?

Answer 14

CXR, Bloods, ECHO, ECG

Question 15

What lifestyle changes are recommended for a person with HF?

Answer 15

lose weight, exercise, stop smoking, the annual flu vaccine

Question 16

Pharmacological management of HF

Answer 16

1. Diuretics (symptomatic) e.g. loop diuretics (furosemide)
2. ACE-inhibitors e.g. ramipril, consider in left ventricular systolic dysfunction
3. Angiotensin II Type 1 receptor antagonists (2nd line to ACE-I)
4. B-Blockers: e.g. bisoprolol, nebivolol, and carvedilol
5. Digoxin
6. Vasodilators

Question 17

Management of acute heart failure

Answer 17

100% oxygen
IV opiates e.g. diamorphine
IV furosemide
Nitrates e.g. GTN
severe - consider inotropic drug

Question 18

Definition of Cor Pulmonale

Answer 18

Right heart failure and abnormal enlargement caused by chronic pulmonary arterial HTN.

Question 19

Causes of cor pulmonale

Answer 19

lung disease - COPD, bronchiectasis, pulmonary fibrosis
pulmonary vascular disease
thoracic cage abnormality
neuromuscular disease
hypoventilation
cerebrovascular disease

Question 20

Symptoms of cor pulmonale

Answer 20

SOB
fatigue
syncope

Question 21

Signs of cor pulmonale

Answer 21

cyanosis
tachycardia
raised JVP

Question 22

If a patient has suspected cor pulmonale what investigations are performed

Answer 22

Bloods: Increased Hb and hematocrit
ABG: Hypoxia +/- hypercapnia
CXR: Enlarged R. atrium and ventricle + prominent pulmonary arteries
ECG: P-pulmonale

Question 23

Management of cor pulmonale

Answer 23

• Treat underlying cause
• Treat resp. failure
• Treat cardiac failure e.g. diuretic
• Heart-lung transplant

Question 24

Definition of hypertension

Answer 24

BP over 140/90mmHG, 2 readings on separate occasions

Question 25

Why is HTN so serious

Answer 25

Major risk factor for cardiac events - causes 50% of vascular deaths

Question 26

Risk factors for HTN

Answer 26

``` Overweight/obese Increased age Afro-Caribbean descent Smoking Sedentary lifestyle Alcohol Diet: High in fat/salt Stress ```

Question 27

Causes of primary hypertension

Answer 27

``` 80-90% of cases Multifactorial aetiology - genetic - obesity - high salt and alcohol intake - metabolic syndrome ```

Question 28

Causes of secondary hypertension

Answer 28

- renal disease (80%) - diabetic nephropathy, PKD, kidney disease - endocrine disease - Cushing's, Conn's, acromegaly - Coarctation of the aorta - pre-eclampsia - drugs - OCP, NSAIDs, steroids

Question 29

Investigations for HTN

Answer 29

Measure BP in both arms Urinalysis - protein, blood Borderline patients - 24hr ABPM

Question 30

Stages of HTN

Answer 30

Stage 1: Clinical BP 140/90 and ABPM 135/85