HFpEF Flashcards
What is heart failure (HF)?
Heart failure is a complex syndrome in which the ability of the heart to maintain the circulation of blood is impaired as a result of a structural or functional impairment of ventricular filling or ejection.
How does the ejection fraction (EF) differ in HFpEF and HFrEF?
There is no agreement on what level should be used to separate normal from abnormal left ventricular ejection fraction (LVEF). The definition of reduced ejection fraction varies in clinical trials between a LVEF of less than or equal to 35 to 40%.
- Heart failure with reduced ejection fraction (HF-REF): just over half of people with heart failure have evidence of reduced LVEF on echocardiography
- Heart failure with preserved ejection fraction (HF-PEF): nearly half of people with heart failure have preserved LVEF on echocardiography
How does acute and chronic HF differ?
Acute and chronic heart failure are terms used to define the rate of onset and duration of symptoms:
- Acute heart failure may be a new presentation of heart failure or may be a deterioration or ‘decompensation’ in a person with existing chronic heart failure.
- There is no agreed definition of the timescale of chronic heart failure although stable heart failure is a term used to describe a person with treated heart failure and symptoms which are unchanged for at least a month
Briefly describe the The New York Heart Association (NYHA) functional classification of heart failure based on severity of symptoms and limitation of physical activity
Class I- no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness, or palpitations.
Class II- slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.
Class III- marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.
Class IV- unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken discomfort is increased.
Briefly describe the pathophysiology of HFpEF
Inability for the ventricle to relax and fill normally leading to increasing filling pressures.
Known as diastolic failure.
How do the symptoms of right and left HF differ?
Right sided HF: peripheral oedema (up to thighs, sacrum and abdominal wall), ascites, nausea, anorexia, facial engorgement and epistaxis.
Left sided HF: dyspnoea, poor exercise tolerance, fatigue, paroxysmal nocturnal dyspnoea (PND), nocturnal cough (+/- pink frothy sputum), wheeze, nocturia, cold extremities and weight loss.
What are the causes of HFpEF?
- Myocardial disease (e.g. coronary artery disease, hypertension, cardiomyopathies adn ventricular hypertrophy)
- Valvular heart disease
- Pericardial disease (e.g. constrictive pericarditis, pericardial effusion and cardiac tamponade)
- Congenital heart disease
- Arrhythmias
What risk factors are associated with HFpEF?
- Female sex
- >70 years
What are the signs of HFpEF?
- Tachycardia
- Respiratory signs such as tachypnoea, basal crepitations and pleural effusions
- Jugular venous distension
- Hypertension
- Hepatojugular reflux
- Congestive hepatomegaly
- Lower extremity oedema
- Laterally displaced apical impulse
What are the symptoms of HFrEF?
- Exertional dyspnoea
- Orthopnea
- Paroxysmal nocturnal dyspnoea
- Fatigue
- Lightheadedness
What investigations should be ordered for HFpEF?
- Serum electrolytes
- Renal function tests
- Brain-natriuretic peptide (BNP) or N-terminal prohormone brain natriuretic peptide (NT-pro-BNP)
- FBC
- ECG
- CXR
- Doppler echocardiography
Why investigate using serum elecrolytes? And what may this show?
- Hypervolaemic hyponatraemia is common in severe heart failure due to expansion of extracellular volume
- May also show hypokalaemia
Why investigate using renal function tests? And what may this show?
- Renal failure may be the aetiology of fluid overload, or chronic kidney disease may be a risk factor leading to diastolic dysfunction
- Increased creatinine, decreased estimated glomerular filtration rate
Why investigate using BNP or NT-pro-BNP? And what may this show?
- BNP or NT-pro-BNP are raised in patients with heart failure, with concentrations rising in line with the severity of symptoms (New York Heart Association class). In patients presenting with dyspnoea, natriuretic peptide biomarkers should be measured to help diagnose or exclude heart failure.
- Elevated
What factors can increase BNP?
- Age over 70 years
- Left ventricular hypertrophy, myocardial ischaemia or tachycardia
- Right ventricular overload
- Hypoxia.
- Pulmonary hypertension
- Pulmonary embolism
- Chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73 m2)
- Sepsis
- Chronic obstructive pulmonary disease (COPD)
- Diabetes mellitus
- Liver cirrhosis
What features can be seen on a CXR of congestive heart failure?
A- alveolar oedema (bat wing opacities)
B- Kerley B lines
C- cardiomegaly
D- dilated upper lobe vessels
E- pleural effusion
