Heart Failure Investogation

Question 1

What are the 2 key questions in investigation heart failure

Answer 1

Two Key Questions:
1. Does the patient have heart failure?
– What has the history / clinical examination
told you?
– Differential diagnosis?
2. Why does the patient have heart failure?
– Ischaemia v. non ischaemia

Question 2

What is the NYHA functional classification of the progression of heart failure

Answer 2

• Class I
– No symptomatic limitation of physical activity

• Class II
– Slight limitation of physical activity
– Ordinary physical activity results in symptoms
– No symptoms at rest

• Class III
– Marked limitation of physical activity
– Less than ordinary physical activity results in symptoms
– No symptoms at rest

• Class IV
– Inability to carry out any physical activity without symptoms
– May have symptoms at rest
– Discomfort increases with any degree of physical activity

Question 3

What investigations should be carried out

Answer 3

• Baseline blood tests:
– Full blood count - anaemia is indicative
– Electrolytes and renal function
– Glucose / HbA1C
– Lipid profile 

• Specialist blood test:
– BNP (Brain Natriuretic Peptide)

Question 4

What are natriuretic peptides?

Answer 4

-

Question 5

What does BNP indicate?

Answer 5

LV sits. Dysfunction + LV Diast. Ysfuncion, valvular dysfunctio, RV dysfunction

Question 6

What does teh ECG look like in heart failure?

Answer 6

See slide for eg

Question 7

Describe a chest x ray example in eras failure

Answer 7

See slide

Question 8

Wha rare other tests to undertake

Answer 8

Other ‘tests’ – answering 2nd question - is it something else?
• Thyroid function tests • Viral titres • Specialist cardiac imaging e.g. MRI • Coronary angiography

Question 9

Define starlings law

Answer 9

The force developed in a muscle fibre
depends on the degree to which the fibre
is stretched

Question 10

Describe teh management of acute heart failure

Answer 10

Management of acute heart failure
• Admit to hospital! 
• Oxygen 
• Intravenous loop-diuretic (furosemide)
• Heparin (to prevent DVT) 
• Patient may require:
– Additional ventilator support (CPAP)
– Intravenous ‘nitrates’ 
– preload reduction +/-
coronary vasodilation

Question 11

Describe the action of furosemide

Answer 11

Reduce fluid, reduce end diastolic pressure, back up curve (see slide) - if its overdone, CO will get worse
• Has an immediate venodilatory effect - improves CO - within 5 min
• Onset of diuretic action within 30 minutes
• Peak action about 60-90 minutes
• Higher dose required in renal failure
• Monitoring is key:
– Patient observations PR, RR, BP and O2 Sats.
– Urine output! - if not enough, haven’t given enough
Ppl with renal failure - only drug which u give a higher dose - drug needs to get acros glomerulus to have action

Question 12

What are the key principles in the management of heart failure

Answer 12

• Correct underlying cause 
• Non-pharmacological measures 
• Pharmacological therapy
1. Symptomatic improvement
2. Delay progression of heart failure
3. Reduce mortality 
• Treat complications/associated
conditions/cardiovascular risk factors
– Eg. arrhythmias

Question 13

Describe the neurohormonal activation

Answer 13

• Sympathetic Nervous System
• Renin-Angiotensin-Aldosterone System
Concentrate on first 2

• Natriuretic Hormones
• Anti-Diuretic Hormone
• Endothelin
• Prostaglandins / Nitric Oxide
• Kallikrien System
• Tissue Necrosis Factor - a

Question 14

Descrbe the sympathetic activation on heat failure

Answer 14

See slide

Question 15

Describe the effect of the sympathetic nervous system in heart failure

Answer 15

• Baroreceptor-mediated response
• Early compensatory mechanism to improve CO:
– Cardiac contractility
– Arterial and venous vasoconstriction
– Tachycardia
• However long-term deleterious effects:
– β-adrenergic receptors are down-regulated / uncoupled
– Noradrenaline
• Induces cardiac hypertrophy / myocyte apoptosis and necrosis via
α-receptors
• Induce up-regulation of the RAAS
• Reduction in heart rate variability (reduced paraSNS
and increased SNS)

Question 16

What are the physiological effects of beta blockers in heart failure

Answer 16

1. Reduce heart rate (cardiac beta receptor)
2. Reduce BP (…..reduce cardiac output) 1+2 -> Reduced myocardial oxygen demand
3. Reduce mobilisation of glycogen
4. Negate unwanted effects of catecholamines

Question 17

How to beta blockers affect mortality

Answer 17

See slide

Question 18

How should b blockers be administered

Answer 18

• Care !
• Failing myocardium dependent on heart
rate
• Initiate at low dose
• Titrate slowly
• May have to alter concomitant medication (e.g. diuretic)
Wait until patient is stable. Start low and then uptitrate

Question 19

Describe the raas system in heart failure

Answer 19

See slide

Question 20

How is the raas system targeted for treating heart failure

Answer 20

ACE inhibitors - affect ACE - prevent 70% of angiotensin I-> angiotensin II

Angiotensin R blockers - block the angiotensin 2 from acting on its receptors to reduce effects

Giving one or the other had same clinical impact as giving birth

Question 21

Describe the current management of heart failure

Answer 21

See slide

Question 22

What is the role of aldosterone receptor antagonists.and gove an example

Answer 22

Role of Aldosterone Receptor Antagonists SPIRONOLACTONE
• In spite of ACE inhibitor / ARB therapy,
aldosterone concentration returns to normal
• Aldosterone “escape”
Raising potassium?
Direct benefit - preventing toxicity to heart itself
Add on treatment
See slide

Question 23

Describe intervention for heart failure

Answer 23

Intervention
– Treat underlying cause
   - Valve surgery
   - Revascularisation 
– Heart Transplantation 
– Mechanical assist devices

Implantable Pacemakers
– Biventricular Pacing

Implantable Defibrillators

Question 24

What are lifestyle modifications for heart failure

Answer 24

 Lifestyle Modification
– Reduce salt
– reduce Alcohol
– increase Aerobic exercise
– reduce BP