Heart failure presentation & investigation - ND Flashcards
Define what heart failure is
A clinical syndrome compromising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction, either at rest or exertion, with accompanying neurohormonal activation
Why is a diagnosis of a patient with just ‘heart failure’ never made clinically?
(although its always talked about as a diagnosis)
Heart failure is not a final diagnosis and the term should be qualified by the underlying structural abnormality and cause
Basically - Heart failure is not a diagnosis, but an effect of something else like LVSD due to IHD
How common is heart failure in the UK?
1-2% of UK population
What are risk factors for heart failure?
Age
Sex*
Hypertension Diabetes CHD Obesity Hyperlipoproteinaemia (HLP)
Previous Acute MI
How does risk of heart failure change with sex?
At younger ages, it is more common in men but at older ages, more common in women
What is the general prognosis for heart failure?
Poor:
30-40% mortality at 1 year
Worse than cancer of breast, uterus, prostate & bladder
Depends on severity^
Many patients who present to A&E with HF are re-admitted again after discharge
What are the rates of readmission?
10% HF patients readmitted within 1 month of discharge
50% HF patients readmitted over 3 months
One of the main problems to the NHS of heart failure is the length of hospital stays by patients with it
What is the only ‘common’ condition that generally requires a greater stay at hospital?
Stroke
What are the typical symptoms of Heart failure?
Breathlessness
Fatigue
Oedema
Reduced exercise capacity
What is the most common symptom for which people are admitted for heart failure?
Acute breathlessness
What are the signs of Heart failure?
Peripheral oedema Tachycardia Raised JVP Chest crepitations or effusions 3rd heart sound S3 Displaced/abnormal apex beat
Summarise the investigative imaging techniques that may be used for HF
ECG
CXR
ECHO
Coronary angiography (or CTCA)
Radionucleotide scan
Left ventriculogram
Cardiac MRI
Summarise the non-imaging investigative techniques for HF
BNP
Full blood count Fasting blood glucose Serum urea & electrolytes Urinalysis Thyroid function
How would a CXR indicate heart failure?
Enlarged heart shadow
Pulmonary oedema
What is needed to make a diagnosis of Heart failure?
Symptoms / signs
Objective evidence of cardiac dysfunction
Response to therapy (diuretics) - in doubtful cases
How would an ECG indicate heart failure?
ECG can show LVSD (left vent systolic dysfunction) which is a cause of HF
90-95% sensitive
What is BNP and how is testing for it useful?
Brain (b type) natriuretic peptide
Levels of this amino acid are elevated in the blood by heart failure
Potential screening test for HF, but is not routinely done clinically
An elevated BNP level indicates HF, however, more investigation is needed before heart failure can be confirmed
Why?
BNP levels can be elevated due to:
- A fib
- Elderly
- Valve disease
ECHO/cardiac assessment needed if levels are high
Summarise the investigative route for a patient who has presented with suspected HF
History - symptoms
Examination - signs
ECG
(BNP sometimes)
ECHO
Summarise the causes of HF
LVSD
VHD
Pericardial constriction or effusion
LVDD / HF with preserved systolic function / HF with normal Ejection fraction
Cardiac arrhythmias: tachy or brady
Myocardial ischaemia/infarction (usually via LVSD)
Restrictive cardiomyopathy: eg amyloid, HCM
Right ventricular failure: primary or secondary to pulmonary hypertension
LVSD is the main cause of heart failure
What can cause the left ventricle to pump ineffectively?
LVSD
Ischaemic heart disease (usually MI)
Severe Aortic valve disease or mitral regurgitation
Dilated cardiomyopathy (DCM): - umbrella term for all other causes that aren't IHD or lesion (valve) related
What causes of LVSD are covered under DCM?
Inherited DCM Toxins Infection End stage hypertrophic cardiomyopathy End stage arrhythmic RV cardiomyopathy Systemic disease Muscular dystrophies Peri-partum cardiomyopathy Hypertension Isolated non-compaction Tachycardia related cardiomyopathy RV pacing induced cardiomyopathy
What sort of infections can cause DCM?
Acute myocarditis Chronic DCM HIV Chaga's disease Lyme's disease
Why is Echocardiography a necessary test for a patient with suspected HF?
ECHOs allow identification of:
LV systolic dysfunction
Valvular dysfunction
Pericardial effusion / tamponade
Diastolic dysfunction
LVH
Atrial/ventricular shunts / complex congenital heart defects
Pulmonary hypertension / right heart dysfunction
