Heart failure presentation & investigation - ND

Question 1

Define what heart failure is

Answer 1

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

Question 2

Why is a diagnosis of a patient with just ‘heart failure’ never made clinically?

(although its always talked about as a diagnosis)

Answer 2

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

Question 3

How common is heart failure in the UK?

Answer 3

1-2% of UK population

Question 4

What are risk factors for heart failure?

Answer 4

Age
Sex*

Hypertension 
Diabetes 
CHD 
Obesity
Hyperlipoproteinaemia (HLP) 

Previous Acute MI

Question 5

How does risk of heart failure change with sex?

Answer 5

At younger ages, it is more common in men but at older ages, more common in women

Question 6

What is the general prognosis for heart failure?

Answer 6

Poor:
30-40% mortality at 1 year

Worse than cancer of breast, uterus, prostate & bladder

Depends on severity^

Question 7

Many patients who present to A&E with HF are re-admitted again after discharge

What are the rates of readmission?

Answer 7

10% HF patients readmitted within 1 month of discharge

50% HF patients readmitted over 3 months

Question 8

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?

Answer 8

Stroke

Question 9

What are the typical symptoms of Heart failure?

Answer 9

Breathlessness
Fatigue
Oedema
Reduced exercise capacity

Question 10

What is the most common symptom for which people are admitted for heart failure?

Answer 10

Acute breathlessness

Question 11

What are the signs of Heart failure?

Answer 11

Peripheral oedema 
Tachycardia 
Raised JVP 
Chest crepitations or effusions 
3rd heart sound S3 
Displaced/abnormal apex beat

Question 12

Summarise the investigative imaging techniques that may be used for HF

Answer 12

ECG
CXR
ECHO

Coronary angiography (or CTCA)

Radionucleotide scan
Left ventriculogram
Cardiac MRI

Question 13

Summarise the non-imaging investigative techniques for HF

Answer 13

BNP

Full blood count 
Fasting blood glucose 
Serum urea & electrolytes 
Urinalysis 
Thyroid function

Question 14

How would a CXR indicate heart failure?

Answer 14

Enlarged heart shadow

Pulmonary oedema

Question 15

What is needed to make a diagnosis of Heart failure?

Answer 15

Symptoms / signs

Objective evidence of cardiac dysfunction

Response to therapy (diuretics) - in doubtful cases

Question 16

How would an ECG indicate heart failure?

Answer 16

ECG can show LVSD (left vent systolic dysfunction) which is a cause of HF

90-95% sensitive

Question 17

What is BNP and how is testing for it useful?

Answer 17

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

Question 18

An elevated BNP level indicates HF, however, more investigation is needed before heart failure can be confirmed

Why?

Answer 18

BNP levels can be elevated due to:

• A fib
• Elderly
• Valve disease

ECHO/cardiac assessment needed if levels are high

Question 19

Summarise the investigative route for a patient who has presented with suspected HF

Answer 19

History - symptoms

Examination - signs

ECG

(BNP sometimes)

ECHO

Question 20

Summarise the causes of HF

Answer 20

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

Question 21

LVSD is the main cause of heart failure

What can cause the left ventricle to pump ineffectively?
LVSD

Answer 21

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

Question 22

What causes of LVSD are covered under DCM?

Answer 22

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

Question 23

What sort of infections can cause DCM?

Answer 23

Acute myocarditis 
Chronic DCM 
HIV 
Chaga's disease 
Lyme's disease

Question 24

Why is Echocardiography a necessary test for a patient with suspected HF?

Answer 24

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