Heart failure pt.1

Question 1

What is heart failure?

Answer 1

A complex clinical syndrome that results from any structural or functional impairment of ventricular filling (elevated cardiac filling pressure) or ejection of blood (inadequate peripheral oxygen delivery) leading to cardinal manifestations of dyspnea, fatigue, and fluid retention

Question 2

Types of heart failure

Answer 2

Types of HF include:
a. LHF (most common type).
b. RHF
c. biventricular heart failure
d. high-output heart failure (least common heart failure)
Can also be divided based on presentation into:
- Acute heart failure
- Chronic heart failure
Can also be divided into distinct phenotypes based on the measurement of left ventricular ejection fraction (LVEF):
HFrEF (<=40% of patients)
HFmr(mildly reduced)EF
HFpEF

Question 3

Causes of left-sided heart failure

Answer 3

a. Ischemic heart disease, especially myocardial infarction
b. Hypertension
c. A ortic and mitral valvular disease
d. M yocardial diseases, such as cardiomyopathies and myocarditis

Question 4

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Answer 4

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Question 5

HFrEF definition

Answer 5

Patients with a significant reduction in LV systolic function (LVEF ≤40%)

Question 6

HFmrEF definition

Answer 6

Patients with a LVEF between 41% and 49% have mildly reduced LV systolic function

Question 7

HFpEF definition

Answer 7

Patients with symptoms and signs of HF, with evidence of structural and/or functional cardiac abnormalities consistent with the presence of LV dysfunction/raised LV filling pressures and/or raised natriuretic peptides (NPs), and with an LVEF ≥50%.

Question 8

Causes of RV failure

Answer 8

• Main etiology is LV dysfunction-induced pulmonary hypertension
• Other causes include myocardial infarction, arrhythmogenic right ventricular cardiomyopathy, or valve disease

Question 9

When does high output cardiac failure occur?

Answer 9

Occurs in states where demand exceeds normal cardiac output such as pregnancy, anemia and sepsis.

Question 10

Chronic heart failure definition

Answer 10

Patients who have had an established diagnosis of HF or who have a more gradual onset of symptoms

Question 11

Acute heart failure definition

Answer 11

Patients with a rapid onset of heart failure symptoms

Question 12

HF recovery

Answer 12

• Some individuals with HF may recover completely [e.g. those due to alcohol-induced cardiomyopathy (CMP), viral myocarditis, Takotsubo syndrome, peripartum cardiomyopathy (PPCM), or tachycardiomyopathy]
• Other patients with LV systolic dysfunction may show a substantial or even complete recovery of LV systolic function after receiving drug and device therapy.

Question 13

Etiology of heart failure

Answer 13

• Varies according to geography
• In Western-type and developed countries, coronary artery disease (CAD) (about 2/3rd of cases) and hypertension (present in 75% of cases) are predominant factors, diabetes also present in 10-40% of cases
• With regard to ischaemic etiology, HFmrEF resembles HFrEF, with a higher frequency of underlying CAD compared to those with HFpEF
• HIGH VIS is a useful acronym to remember some causes of HF:
  Hypertension (common cause)
  Infection/Immune: Viral (e.g. HIV), bacterial (e.g. sepsis), autoimmune (e.g. lupus, rheumatoid arthritis)
  Genetic: Hypertrophic obstructive cardiomyopathy, dilated cardiomyopathy
  Heart attack: Ischemic heart disease (common cause)
  Volume overload: Renal failure, nephrotic syndrome, hepatic failure
  Infiltration: Sarcoidosis, amyloidosis, hemochromatosis
  Structural: Valvular hear disease, septal defects

Question 14

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Answer 14

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Question 15

Causes of systolic dysfunction

Answer 15

Causes of SHF include:
(a) ischemia caused by atherosclerosis of the CAs (the most common cause of SHF).
(b) post–myocardial infarction (MI), myocarditis, and dilated cardiomyopathy.

Question 16

What is used to describe the severity of heart failure?

Answer 16

The simplest terminology used to
describe the severity of HF is the
New York Heart Association (NYHA)
functional classification

Question 17

Disadvantages of New York Heart Association (NYHA)
functional classification for heart failure

Answer 17

This relies solely on symptoms and
there are many other better
prognostic indicators in
HF. Importantly, patients with mild
symptoms may still have a high risk
of hospitalization and death.

Question 18

NYHA classification

Answer 18

Four classes:
- Class 1: No limitation of physical activity
- Class 2: Slight limitation of physical activity
- Class 3: Marked limitation of physical activity
- Class 4: Unable to carry on any physical activity without discomfort with possible symptoms at rest

Question 19

CHF prevelance

Answer 19

• CHF prevalence is 1-2%, rising to 10% in over 70-year-olds
• More than 80% of cases are over the age of 70

Question 20

Diagnosis of CHF requirement

Answer 20

• Requires the presence of symptoms and/or signs of
  HF and evidence of cardiac dysfunction
• Symptoms and signs lack sufficient accuracy

Question 21

The lifetime risk of HF

Answer 21

The lifetime risk of HF at age 55 years is 33% for men
and 28% for women

Question 22

The mortality rate for heart failure

Answer 22

• In primary care, the overall 5-year survival
  following the diagnosis of HF is ~50%. For patients with severe HF, the 1-year mortality may be as high as 40%
• Following an HF admission, mortality rates range from 8–14% at 30 days to 26–37% at 1 year to up to 75% at 5 years
• Readmission with HF is also common, ranging from 20–25% at 60 days to nearly 50% at 6 months
• With each subsequent admission, the risk of death rises

Question 23

Symptoms fo heart failure

Answer 23

Symptoms of HF include those due to excess fluid accumulation (dyspnea, orthopnea, Paroxysmal nocturnal dyspnoea (PND) (pathognomic for HF), edema, pain from hepatic congestion, and abdominal discomfort due to distention from ascites) and those due to a reduction in cardiac output (fatigue, weakness) that is most pronounced with exertion

Question 24

Clinical findings on CV examination in HF

Answer 24

• Tachycardia at rest
• Hypotension
• Narrowed pulse pressure
• Raised jugular venous pressure
• Displaced apex beat (due to left ventricular dilation)
• Right ventricular heave
• Gallop rhythm on auscultation (pathognomic for CHF)
• Murmurs associated with valvular hear disease (eg, an ejection systolic murmur in aortic stenosis)
• Pedal and ankle edema

Question 25

What is paroxysmal nocturnal dyspnea in heart failure

Answer 25

Attacks of severe shortness of breath in the night that are relieved by sitting up (pathognomonic for CHF).

Question 26

Clinical findings on respiratory examination in patients with HF

Answer 26

Tachypnea
Bibassal end-inspiratory crackles and wheeze on auscultation of the lung field
- Reduced air entry on auscultation with stony dullness on percussion (pleural effusion)

Question 27

Clinical findings on abdominal examination in patients with HF

Answer 27

Hepatomegaly
Ascites