W9: HF; Congestion; Oedema

Question 1

Explain congestive heart failure: mechanism and consequences; +common signs

Answer 1

Ineffective RV + LV pumping therefore
=> ↓CO, ↓GFR = RAAS+ => Na+H20 RETENTION

Secondary in nature.

Venous backflow and pressure 
* pulmonary oedema
* tachy
* CENTRAL VENOUS CONGESTION: ↑JVP, hepatomeg
=> NUTMEG LIVER (central vein dmg)

Hepatic Cirrhosis d/t portal congestion. Chronic gut congestion.
* portal shunt and ↑portal venous pressure

Question 2

NUTMEG LIVER

Answer 2

complication of RH failure

“speckled” like a grated nutmeg kernel, from the dilated, congested central veins (dark spots) and paler, unaffected surrounding liver tissue

Question 3

Define the terms exudate and transudate.

Answer 3

TRANSUDATE: ↓protein+albumin, ↑water + electrolytes
=> oedema

EXUDATE: inflamm component. ↑PROTEINS AND CELLS

Question 4

Causes of Oedema

Answer 4

1. ABN. RENAL
2. HYPOPROTEINAEMIA: oncotic pressure
3. LV Failure, RH FAILURE, CONGESTIVE HF;
4. lymphatic blockage
5. PERMEABILITY OEDEMA = exudate d/t porous nature

Question 5

Signs of Chronic HF

Answer 5

syndrome of 
DYSPNOEA
FATIGUE
FLUID RETENTION
NEUROHORMONAL ACTIVATION
\+Af (common)

Question 6

Chronic Hf Diagnosis

Answer 6

1. CXR: effusion and cardiomeg.
2. LV FUNCT.: ECHO, MUGA (radiated LVEF scan), MRI,
3. Response to Diuretics

Question 7

Structural Aetiology of HF & Diagnosis

Answer 7

1. DILATED CARDIOMYOPATHY: inherited, infective cause, systemic (sarcoid), muscular dystrophy; lyme disease

=> ECHO: LV Ejection Fraction
=> MUGA Scan = accurate LVEF
=> Cardiac MRI
=> Simpson’s Biplane (gold standard in ECHO)

Question 8

LV Function Assessment for HF Classification

Answer 8

70+: ?pathology

55% - 70%: NORMAL (HFpEF)

40 - 55%: MILD

30 -40%: MODERATE (HFrEF)

<30%: SEVERE

Question 9

HFrEF: hallmarks & pathophys

Answer 9

HF with ↓EF ( <40%): chronic HF, 60y/o+, RF: HT+MI = diastolic dysf. + progressive syst. progressive

• ↓CO = RAAS++ = retention d/t HT and myocardial dmg.
• ↑↑circulatory vol. = oedema

Question 10

HFrEF Tx

Answer 10

(1) FUROSEMIDE: NaKCl transporter inhibition @ ascending limb (LoH), ↓GFR and prevents reabs. via diuresis+++

• ↓fatigue and improving exercise capacity
• hypoelectrolyte balance, hypotension consideration w/ D-D.

+THIAZIDE (indapamide): distal voncoluted NaCl symporter in RESISTANT HFrEF
* GOUT, DM risk, Impotence

(2) ACEI: ↓preload (post-diuretics too)
/ARB

BB: bisoprolol
*SFX: bronchospasm,cold peripheries, fatigue

(3) VALSARTAN-SACUBITRIL (ARNI): combined aRB + neprilysin inhib (↑BNP); LVEJ <35%
* hypoT

+ IVABRADINE: ↓HR via Sinus Node
+ BB

(4) ALDOSTERONE ANT. (SPIRONOLACTONE)
+/- DIGOXIN
+/- WARFARIN