HF part 2

Question 1

Defintion of HF

Answer 1

Cardiac output is not able to meet metabolic demands. This can be new-onset or as an acute decompensation of chronic heart failure.

Question 2

Epidemiology

Answer 2

• In the UK, heart failure is responsible for over 67,000 hospital admissions per year
• > 65 years of age

Question 3

RFs for HF

Answer 3

• Increasing age
• Coronary artery disease
• Hypertension
• Valvular disease: commonly senile calcification of the aortic valve
• Diabetes
• Atrial fibrillation
• Renal insufficiency

Question 4

What is acute decompensated HF?

Answer 4

• either new-onset heart failure without any previous cardiac dysfunction
• or as an acute decompensation of chronic heart failure.

Question 5

What are the causes of acute decompensation of heart failure?

Answer 5

• HT
• Obesity
• AF & Arrhythmias
• Excess alcohol
• NSAIDs

Question 6

What happens when HF starts and as it progresses

Answer 6

• Many systems initiate physiological compensatory changes to maintain CO and peripheral perfusion to negate HF effects
• Overtime compensatory changes become overwhelmed and become pathophysiological

Question 7

General pathophysiology of Acute decompensated HF

Answer 7

• Reduced CO > Sympathetic NS activated
• Causes tachycardia + increased myocardial contractility + peripheral vasoconstriction + RAAS > Leads to increased salt + water retention
• BNP released by ventricular myocytes in response to increased stretching
• Leads to pulmonary + venous congestion

Question 8

Pulmonary oedema and venous congestion presentations

Answer 8

• Pulmonary oedema: shortness of breath
• venous congestion causes peripheral oedema

Question 9

Signs of acute decompensated HF

Answer 9

• Cool peripheries
• Signs of congestive heart failure: peripheral, pitting oedema and raised JVP
• Displaced apex beat
• Hypotension
• Crackles on auscultation: left-sided failure; usually coarse bi-basal crackles
• Third heart sound (S3)

Question 10

Symptoms of acute decompensated HF

Answer 10

• Dyspnoea: due to pulmonary oedema
  
  • Often a history of orthopnea and paroxysmal nocturnal dyspnoea
• Fatigue and weakness
• Cardiogenic wheeze
• Symptoms of congestive heart failure: swelling of the peripheries and ascites

Question 11

Investigations

Answer 11

• FBC
• U&Es
• ABG
• BNP or NT-proBNP
• ECG
• CXR

Question 12

Whats seen on CXR?

Answer 12

• A-Alveolar oedema (batwing opacities)
• B- Kerley Blines
• C-Cardiomegaly
• D-Dilated upper lobe vessels
• E- PleuralEffusion

Question 13

Acute managment for Acute Decompensated HF

Answer 13

• Stabilise the patient: administer oxygen to maintain a SpO2≥94%
• Fluid restriction: fluid intake is usually limited to <1.5L/day
• IV diuretic: usually a loop diuretic e.g. furosemide to relieve fluid overload
• Inotropes or vasopressors e.g. dobutamine: only offer to patients with heart failure and cardiogenic shock (i.e. haemodynamically unstable)
• Non-invasive ventilation (NIV): consider NIV if the patient does not stabilise with initial medical management
  
  • Continuous positive airway pressure (CPAP)
• Intubation and ventilation: if CPAP is unsuccessful

Question 14

Surgical management

Answer 14

• If acute heart failure is due to aortic stenosis: offersurgical aortic valve replacement
• Mechanical assist device: pump that can temporarily help the pumping action of the heart

Question 15

Long term management

Answer 15

• ACE-inhibitor e.g. ramiprilanda cardioselective β-blocker e.g. bisoprolol
  
  • Improved prognosisby slowing, or even reversing, ventricular remodelling
• Fluid restriction: fluid intake is usually limited to <1.5L/day
• Loop diuretic (e.g. furosemide) forsymptomaticrelief of oedema

Question 16

HF complications

Answer 16

Arrhythmias: can both precipitate acute heart failure and occur as a result of it. Atrial fibrillation is one of the most common arrhythmias associated with heart failure.

Question 17

What is Cor Pulmonale?

Answer 17

Right sided heart failure caused by respiratory disease

Question 18

Pathophysiology of Cor Pulmonale

Answer 18

Increased pressure and resistance in the pulmonary arteries (pulmonary hypertension) results in the right ventricle being unable to effectively pump blood out of the ventricle and into the pulmonary arteries.

Leads to back pressure of blood in:
right atrium
vena cava
systemic venous system.

Question 19

Presentation of Cor Pulmonale

Answer 19

• Early - asymptomatic -
• SOB
• Peripheral oedema
• Syncope
• Chest pain

Question 20

Resp causes of Cor pulmonale

Answer 20

COPD is the most common cause
Pulmonary Embolism
Interstitial Lung Disease
Cystic Fibrosis
Primary Pulmonary Hypertension

Question 21

Signs of Cor pulmonale

Answer 21

• Hypoxia
• Cyanosis
• Raised JVP (due to a back-log of blood in the jugular veins)
• Peripheral oedema
• Third heart sound
• Murmurs (e.g. pan-systolic in tricuspid regurgitation)
• Hepatomegaly due to back pressure in the hepatic vein

Question 22

What does HF do to venous return?

Answer 22

• Reduc in vol of blood ejected with each heart beat - increase in vol of blood remaining in systole
• Preload volume stretches myocardial fibres + myocardial contraction is restored since stretching of fibres will increase force of contraction

Question 23

What happens in progressive HF to venous return?

Answer 23

• failing myocardium actually doesn’t contract as much in response to increased preload meaning cardiac output cannot be maintained and may decrease

Question 24

What is afterload?

Answer 24

the load or resistance against which the ventricle contracts

Question 25

What happens when there's an increase in afterload?

Answer 25

- Increase in EDV + Dec in SV Leads to Dec in CO - Causes increased EDV + dilation of ventricles which increases problem of afterload - If ventricles dilated its gotta work harder

Question 26

Sympathetic system activation of heart

Answer 26

- When baroreceptors detect a drop in arterial pressure or an increase in venous pressure (due to back flow of blood) they stimulate sympathetic activation - increases the force of contraction (positively inotropic) of the heart (which increases stroke volume) as well as heart rate - both resulting in an increase in cardiac output

Question 27

What happens in sympathetic system in HF

Answer 27

- Chronic sympathetic activation - down regulation of receptors by SNS resulting in less receptors to act on - so sympathetic activation is diminsed and CO stops inceasing in response to sympathetic activation

Question 28

What does angio tensin 2 do

Answer 28

stimulates the release of aldosterone from the adrenal cortex above the kidneys

Question 29

What does aldosterone do

Answer 29

increased Na+ reabsorption and thus water reabsorption as well as the release of ADH which stimulates water retention increased volume of the blood which in turn increases blood pressure and thus venous pressure which in turn increases pre-load thereby increasing the stretching of the heart and thus force of contraction and thus stroke volume and thus cardiac output

Question 30

Why does ventricular hypertrophy happen?

Answer 30

chronic hypertension which results in increased blood pressure thereby increasing afterload so heart pumps against more resistance and thus cardiac myocytes grow bigger to compensate for this

Question 31

3 cardinal symptoms of HF

Answer 31

shortness of breath, fatigue & ankle swelling

Question 32

Overrall symptoms of HF

Answer 32

- Dyspnoea especially when lying flat (orthopnoea) - Cold peripheries - Raised jugular venous pressure (JVP) - Murmurs and displaced apex beat - Cyanosis - Hypotension - Peripheral or pulmonary oedema

Question 33

Blood tests for HF

Answer 33

BNP

Question 34

CXR for HF

Answer 34

Alveolar oedema Cardiomegaly Dilated upper lobe vessels of lungs Effusions (pleural)

Question 35

What loop diuretics and thiazide diueritcs could you use?

Answer 35

Loop: furosemide Thiazide: bendroflumethiazide

Question 36

What can aldosterone antagonist do?

Answer 36

inhibiting ADH release resulting in water loss spirolactone & epelerone

Question 37

ACEi

Answer 37

Ramipril, enalipril, captopri SE: cough , hypotension, hyperkalaemia and renal dysfunction

Question 38

BBs to use

Answer 38

Bisoprolol, nebvilol, carvedilol Digoxin