Heart Failure Presentation and Investigation

Question 1

What is heart failure?

Answer 1

A clinical syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction, either at rest or on exertion, with accompanying neurohormonal activation

HF should be qualified by the underlying structural abnormality and cause

Question 2

What structural abnormalities can cause heart failure?

Answer 2

Almost any structural abnormality will cause HF is sufficiently severe:

Left ventricular systolic dysfunction 
Valvular heart disease
Pericardial constriction or effusion 
LV diastolic dysfunction 
Cardiac arrhythmias 
Myocardial ischaemia or infarction 
Restrictive cardiomyopathy 
Right ventricular failure

Question 3

What are the causes of left ventricular systolic dysfunction?

Answer 3

Ischaemic heart disease
Dilated cardiomyopathy
Severe aortic valve disease or mitral regurgitation

Inherited 
Toxins
Viral
Infective
Systemic disease e.g. sarcoidosis, haemachromatosis 
Muscular dystrophies 
Peri-partum cardiomyopathy 
Hypertension
Isolated non-compaction 
Tachycardia-related cardiomyopathy 
RV pacing induced cardiomyopathy 
End-stage hypertrophic cardiomyopathy 
End-stage arrhythmogenic RV cardiomyopathy

Question 4

What is the prevalence of heart failure?

Answer 4

04-2%

Question 5

What is the prevalence of asymptomatic LVSD?

Answer 5

0.4-2%

Question 6

What are the symptoms of heart failure?

Answer 6

Dyspnoea
Fatigue
Oedema
Reduced exercise capacity

Question 7

What are the signs of heart failure?

Answer 7

Oedema
Tachycardia
Raised JVP 
Chest crepitations or effusions
Third heart sound
Displaced or abnormal apex beat

Question 8

Why is heart failure difficult to diagnose?

Answer 8

Chest crepitations, oedema and tachycardia are non-specific

Third heart sound, increased JVP and displaced apex are insensitive

Many patients only have symptoms e.g. dyspnoea and fatigue which are non-specific

Question 9

What investigations can be used to obtain objective evidence of cardiac dysfunction?

Answer 9

Echocardiography
Radionuclide ventriculography
MRI
Left ventriculography

Question 10

What are the potential screening tests for heart failure?

Answer 10

12 lead ECG - LVSD unlikely if ECG is normal

Brain B-type Natriuretic Peptide (BNP) - elevated in heart failure

Question 11

How is BNP used as a screening test for heart failure?

Answer 11

Highly sensitive test
Stable for up to 72 hours
Bedside testing available
Low BNP effectively rules out heart failure or LVSD, elevated BNP indicates a need for an echo/further cardiac assessment

Question 12

What is/might be used in the diagnostic evaluation of patients with LVSD?

Answer 12

Detailed history - MI, DM, hypertension, alcohol etc.
History of Lyme disease, IVDA or HIV 
Exclude renal failure and anaemia 
Autoantibodies, viral serology, ferritin
Consider pheochromocytoma 
Consider other causes e.g. sarcoid, muscular dystrophy 
ECG, CXR, echo 
Consider coronary angiography/CTCA
Evaluate for ischaemia/revascularisation
Cardiac MRI

Question 13

What can echocardiography identify and quantify?

Answer 13

LV systolic dysfunction 
Valvular dysfunction
Pericardial effusion/tamponade
Diastolic dysfunction 
LVH 
Atrial/ventricular shunts 
Complex congenital heart defects
Pulmonary hypertension 
Right heart dysfunction 
Atrial dilatation

Question 14

What can make left ventricular ejection fraction difficult to quantify accurately and reproducibly?

Answer 14

Quality of images
Experience of operator
Calculation method
Use of contrast agents
Time consuming to perform accurately 
Normal range is centre-specific but LVEF is not routinely measures and normal range is not routinely established

Question 15

How can disease affect the LVEF?

Answer 15

Disease/physiological changes can both decrease and increase the LVEF

Question 16

What is the normal LVEF?

Answer 16

50-80%

Question 17

What is a mildly impaired LVEF?

Answer 17

40-50%

Question 18

What is a moderately impaired LVEF?

Answer 18

30-40%

Question 19

What is a severely impaired LVEF?

Answer 19

< 30%

Question 20

What are the features of Biplane Modified Simpson’s Rule?

Answer 20

Divides LV cavity into multiple slices of known thickness and diameter
Volume of each slice = area x thickness
Thinner slices allow a more accurate volume to be estimated
Endocardial border is traced accurately (often major technical difficulty with this method)
Still one of the most accurate methods available
Relatively easy but not routinely done

Question 21

What are the features of LVEF MUGA (multiple gated acquisition scan)?

Answer 21

Much easier to obtain an accurate figure for the LVEF
Greater reproducibility 
Ionising radiation exposure 
No additional structural information 
Centre-specific normal range