Presentation and Investigation of Heart Failure

Question 1

What is the definition of heart failure?

Answer 1

Heart failure is a clinical syndrome where the heart cannot meet the body’s demand.

Question 2

Describe what happens in systolic dysfunction.

Answer 2

• Systolic dysfunction - this term is no longer used in favour of HF-REF - heart failure with reduced ejection fraction.
• The heart is unable to pump. It has lost the elasticity of the muscle and it cannot get the blood out of the heart to around the body to meet the demand for oxygen.

Question 3

Describe what happens in diastolic dysfunction.

Answer 3

• Diastolic dysfunction - term no longer used in favour of HF-PEF - heart failure with preserved ejection fraction.
• Heart is pumping adequately, but the muscle is so thick it is not relaxing enough so the heart cannot properly fill with blood.

Question 4

What are the causes of heart failure?

Answer 4

• Damage to the heart muscle
  
  • ​MI
  • Coronary heart disease
  • Dilated cardiomyopathy
  • Myocarditis
• Excessive workload of the heart
  
  • Hypertension
  • Aortic stenosis
  • Hypertrophic cardiomyopathy
  • Severe anaemia
  • Thyrotoxicosis
• Other causes
  
  • ​Diabetes
  • Chemotherapy drugs
  • Alcohol abuse
  • Illegal drug abuse

Question 5

What are the compensatory mechanisms which take effect in heart failure?

Answer 5

• Sympathetic NS
  
  • Tries to increase rate to increase stroke volume and in turn increase cardiac output.
  • We block this, usually with beta-blockers to try to control the heart andmake it pump more effectively.
• RAAS
  
  • ​The job of this system is to retain salt and water to create more circulating volume; but, this will make things worse because the heart already has too much fluid on board and cannot pump effectively.
  • So, we prevent this with ACE-Is, ARBs and MRAs.
• Natriuretic peptide system
  
  • ​New drug on the market for blocking this mechanism of compensation.

Question 6

What are the diagnostic tests for heart failure?

Answer 6

• If a patient presents with fatigue, shortness of breath and some leg swelling, the FIRST investigation should be - ECG!
• If the ECG is normal, the chances the patient has heart failure are extremely slim. An abnormal ECG will give an indication of the problem.
• Bloods
  
  • ​FBC - ?anaemia
  • Ferritin
  • eGFR - THINK before you block the RAAS
    
    • If kidney function is poor you should give diuretic
  • BNP - peptide which is released when the heart muscle stretches
  • TFTs
  • HbA₁C
  • LFTs
• ECHO - this is still the gold standard for diagnosis
  
  • If the BNP is positive you should be prompted to order an ECHO.
  • Shows LV function
  • Shows valve problems

Question 7

What is ejection fraction? How is this affected in heart failure?

Answer 7

• Ejection fraction is a measurement of the percentage of blood leaving your heart each time it contracts.
• ≥50% is normal heart function.
• 40-50% is a grey area.
• ≤40% is heart failure.
  
  • Mild
  • Moderate
  • Severe - <20%

Question 8

What is the role of cardiac CT in diagnosis of heart failure?

Answer 8

• Give a 3D image of the heart and can look at coronary arteries.
• Can also look for calcium deposits to see where (if any) blockage is.

Question 9

What is the role of MRI in diagnosis of heart failure?

Answer 9

• Shows heart function - if there are any parts of the heart which are hypodynamic, it will be shown on MRI.

Question 10

What are the symptoms of right heart failure?

Answer 10

• Congestion of peripheral tissues.
  
  • Dependent oedema and ascites.
  • Liver congestion - signs related to impaired liver function
  • GI tract congestion - anorexia, GI distress

Question 11

What are the symptoms of left heart failure?

Answer 11

• Decreased CO - activity intolerance and signs of decreased tissue perfusion.
• Pulmonary congestion.
• Impaired gas exchange - cyanosis and signs of hypoxia.
• Pulmonary oedema - orthopnoea, cough with frothy suptum, PND.

Question 12

Describe the NYHA scale.

Answer 12

Question 13

Describe the American Heart Association Classification of heart failure.

Answer 13