Heart failure diagnosis and intervention

Question 1

what is heart failure

Answer 1

clinical syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction, either at rest or on exertion, with accompanying neurohormonal activation. not a final diagnosis - “heart failure due to …”

Question 2

one year survival rate for heart failure is worse than that for cancer of

Answer 2

breast, uterus, prostate, bladder

Question 3

readmission rate within first 12 weeks

Answer 3

30%, lessens as the weeks go on

Question 4

morbidity and mortality rates are

Answer 4

high

Question 5

symptoms of heart failure

Answer 5

breathlessness, fatigue, oedema, reduced exercise capacity

Question 6

signs of heart failure

Answer 6

oedema, tachycardia, raised JVP, chest crepitations or effusions, 3rd heart sound, displaced apex beat

Question 7

what is needed for diagnosis or heart failure and why

Answer 7

symptoms, evidence of cardiac dysfunction and response to treatment. because clinical signs are not specific enough and some patients have symptoms only and no signs. diagnosis incorrect in 40-50% of cases

Question 8

obtaining objective evidence of cardiac dysfunction

Answer 8

echocardiogram, radionuclide ventriculography, MRI, left ventriculography

Question 9

screening tests

Answer 9

12 lead ECG, BNP- high level means high likelihood of heart failure, helps to reduce echo waiting lists

Question 10

causes of heart failure

Answer 10

if sufficiently severe almost any structural cardiac abnormality will cause heart failure eg MI, valvular heart disease, cardiac arrhythmia

Question 11

causes of left ventricular systolic dysfunction

Answer 11

ischeamic heart disease or dilated cardiomyopathy which means LVSD not due to IHD or secondary to other lesion ie valves/ VSD

Question 12

diagnostic evaluation of LVSD

Answer 12

detailed history, autoantibodies, viral serology, consider other causes eg sarcoid, muscular dystrophy, do an ECG sometimes CXR always do an echo, consider coronary angiography if chest pain, evaluate for ischaemia or hibernation, cardiac MRI to look for infarction or inflammation or fibrosis, refer to cardiology

Question 13

why is echocardiography essential

Answer 13

identifies and quantifies many illnesses eg LV systolic dysfunction, valvular dysfunction, diastolic dysfunction, shunts, may not identify constriction and may miss shunts but you will see atrial dilatation, reasonably inexpensive

Question 14

LV ejection fraction

Answer 14

disease and physiological changes can both decrease and increase lvef. it may be lower than previous but not pathologically low, analogous to haemoglobin/ anaemia

Question 15

why is LV ejection fraction hard too quantify with echo

Answer 15

quality of images, experience of operator, calculation methods vary- Simpsons biplane is best, use of contrast agents, can be time consuming to perform accurately

Question 16

ejection fraction ranges

Answer 16

normal 55-70%, mild 40-55, moderte 30-40, severe less than 30

Question 17

biplane modified Simpsons rule

Answer 17

divides LV cavity into multiple slices of known thickness and diameter, endocardial border traced accurately. often major technical difficulty with this method but still one of the most accurate methods available and relatively ray to perform but not routinely done

Question 18

LVEF- MUGA scan

Answer 18

much easier to obtain an accurate figure for the LVEF, greater reproducibility, ionising radiation, no additional structural information, centre specific normal range

Question 19

cardiac MRI

Answer 19

more accurate than echo, additional information of tissue characteristics, expensive and time consuming, cannot be done at bedside, requires breathholding, claustrophobia issues

Question 20

left ventricular systolic function is a potent predictor of

Answer 20

death in hospitalised heart failure patients

Question 21

grading of heart failure

Answer 21

NYHA class I no exercise limitation, no symptoms during usual activity, class ii mild limitation, comfortable with rest or mild exertion, III moderate limitation, comfortable only at rest, IV severe limitation, any physical activity brings on discomfort and symptoms occur at rest

Question 22

prognosis for NYH4 compared to NYH3

Answer 22

significantly worse

Question 23

how to grade severity of HF

Answer 23

degree of LV impairment, NYHA class ie severity of symptoms, degree of elevation of BNP

Question 24

heart failure does not equal

Answer 24

reduced cardiac output

Question 25

systemic effects of heart failure

Answer 25

HF is a systemic disorder. cardiac dysfunction, renal dysfunction, skeletal muscle dysfunction, systemic inflammation, neurohormonal activation (mostly maladaptive)

Question 26

effects of heart failure on renin- angiotensin- aldosterone system

Answer 26

salt and water retention, adverse haemodynamics, LV hypertrophy/remodelling and fibrosis, hypokalaemia and hypmagnesaemia

Question 27

effects of heart failure on sympathetic nervous system

Answer 27

arrhythmogenic, adverse haemodynamics, increases renin

Question 28

treatment of heart failure due to LVSD

Answer 28

block the neurohormonal response. using ACE inhibitors, beta blockers, alderosterone receptor blockers, angiotensin receptor and neprolysin inhibitor