3. Heart Failure (Cardiac SOB)

Question 1

Define heart failure

Answer 1

Failure of the heart to maintain the cardiac output required to meet the body’s requirements
- Cardiac Output Low
OR
- High Cardiac Output State

NB: LHF and RHF often come together –> CHF –> mixed signs

Question 2

Cardiac Output =

Answer 2

Heart Rate x Stroke Volume

Question 3

Chronic Vs Acute HF

Answer 3

Chronic Heart failure is a long term condition
Develops and progresses slowly
Arterial pressure maintained until later/decompensation

Acute Heart failure is decompensation/exacerbation of chronic disease, or can be new onset
Develops and progresses rapidly
Needs urgent treatment
Evidence of peripheral hypo-perfusion
Peripheral/pulmonary oedema

Question 4

Aetiology of LHF (4 Categories)

Answer 4

HEART VALVES:

• Aortic valve disease (AR – regurg., AS - stenosis)
• Mitral Regurgitation

HEART MUSCLE:

• IHD/MI
• Cardiomyopathy: hypertrophic (HOCM), dilated, restrictive
• Myocarditis
• Arrhythmias e.g. AF

Systemic:

• HTN
• Amyloidosis (RARE)

Drugs: Alcohol, Cocaine

Question 5

Aetiology of RHF (3 Categories)

Answer 5

Lungs

• PE
• Pulm HTN
• Chronic Lung Disease: CF, ILD, pulm fibrosis

LHF

Heart valves:

• Tricuspid Regurg
• Pulm valve disease

Question 6

Define Cor Pulmonale

Answer 6

Enlargement and failure of RV due to increased pressure in the lungs/vascular resistance

Question 7

High output state

Answer 7

Increased systemic demand –> requires more O2 –> heart strain

Question 8

High output state causes (8)

Answer 8

Nutritional - B1/thiamine def = beri beri
Anaemia
Pregnancy

Malignancy e.g. multiple myeloma
Endocrine e.g. hyperthyroidism
AV malformations (abnormal connections b/t A and V)
Liver cirrhosis (GI/general)
Sepsis

Question 9

Risk factors for Heart Failure (6)

Answer 9

Older men
PMH of Heart disease – MI is strongest risk factor
Diabetes
Family history of heart disease
Dyslipidaemia
Drug abuse

Question 10

Epidemiology of heart failure

Answer 10

10% of >65 year olds, 1-3% general population

Question 11

LHF symptoms (6)

Answer 11

• Exertional Dyspnoea
• Orthopnoea
• Paroxysmal Nocturnal Dyspnoea (attacks of SOB/cough, may wake pt up)
• Nocturnal cough (+/- pink frothy sputum)
• Fatigue
• Wheeze (cardiac asthma)

Question 12

LHF signs

Answer 12

Cyanosis
Confusion
Restlessness

Heart

• Increased HR (May be Irreg Irreg)
• Displaced Apex Beat
• S3 Gallop Rhythm -
• Murmur (AS, MR)

Lungs:

• Wheeze
• Bibasal Crackles
• Increased RR

Question 13

S3 HS

Answer 13

• Kentucky
• Best heard at apex
• Use bell
• L Lateral decubitus position

Produced by blood coming into contact with a compliant ventricle

Normal: Young adults, children, pregnancy, athletes

Abnormal: adults and elderly - severe MR/TR, cardiomyopathy, HF

S3 is low pitched, the split S2 is high pitched

Question 14

RHF symptoms (6)

Answer 14

Fluid congestion in system -> peripheral symptoms:

• Swelling – ankles, face, abdomen (ascites)
• Fatigue
• Weight gain (oedema)
• Reduced exercise tolerance
• Anorexia + GI distress e. g. Nausea
• Nocturia

Question 15

RHF signs

Answer 15

1. Face/Neck:
   - Increased JVP (distended jugular veins)
   - Facial swelling
2. Heart/Chest:
   - Parasternal heave
   - TR murmur
   - Increased HR and RR
3. Abdomen
   - Ascites
   - Hepatomegaly/Splenomegaly
4. Other
   - Pitting oedema in ankles/sacrum (dependent oedema - gravity related)

Increased peripheral venous pressure

Question 16

Heart failure investigations

Answer 16

1. Bedside
   - History and Examination
   - ECG (10% normal)
2. Bloods
   - FBC, U&E, LFTs, TFTs, glucose
   - BNP = Brain Natiuritic Peptide (increased = HF)
3. Imaging
   - Transthoracic Echocardiogram
   - CXR

Question 17

Echo is used for…?

Answer 17

• Visualise structure and function of heart
• Determine EJECTION FRACTION to differentiate
  Systolic heart failure vs HFpEF

Question 18

Ejection Fraction

Answer 18

SV/EDV

Stroke Volume= volume of blood pumped from the left ventricle per beat during systole

End Diastolic Volume = volume of blood in the ventricle at the end of diastole/just before systole (“preload”

Question 19

What is a normal EF and what is it in HF?

Answer 19

Normal = 50-70%

<40% = Systolic heart failure- Decreased stroke volumeand strength of contraction

> 50% = Heart failure with preserved ejection fraction (HFpEF)- abnormal diastolic function

Question 20

HF signs on CXR

Answer 20

1. Alveolar oedema - bat-wing appearance
2. Kerley B-lines - septal lines: interstitial oedema
3. Cardiomegaly (CTR>50%)
4. Dilated upper lobe vessels - pulm venous HTN
5. Effusion (pleural) - blunting of the costophrenic angle

Question 21

Chronic heart failure Mx

Answer 21

TREAT THE UNDERLYING CAUSE!

Conservative

• Smoking cessation
• Weight management: exercise
• Diet: reduce salt intake

Medical

1. ACE-inhibitorse.g. enala/perindo/rami- pril
   - ARB if cough = ongoing problem; monitor K+
2. Beta blockerse.g. bisopro/carvedil- lol
3. Diuretics
   - Aldosterone antagonist (Spirolactone)
   - Loop Diuretics (Furosemide)
   - Thiazide (Hydrochlorthiazide)

Question 22

Other drugs/therapies for chronic HF

Answer 22

• Hydralazine + nitrate in Afro Caribbean patients
• Digoxin – +ve inotrope, does not improve survival
• Cardiac resynchronisation therapy (QRS>120ms –> manifests as LBBB)
• Aspirin

Question 23

Acute heart failure Mx

Answer 23

• Sit pt up
• Oxygen 15L via non-rebreathable mask: SpO2 target = 94-98%
• IV access and ECG (bloods + ?arrythmia)
• Diuretic (Furosemide IV)
• Vasodilator (GTN spray 2 puffs sublingual)
• Analgesia: Morphine 2.5mg (but do not give routinely)

Question 24

HF complications and prognosis

Answer 24

Complications

• Pleural effusion,
• Renal failure
• Acute exacerbations
• Death

50% severe heart failure patients die within 2 years

Question 25

1. A 78-year-old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present? A. Pleural effusion on chest x-ray B. Raised jugular venous pressure (JVP) C. Bilateral pedal oedema D. Bibasal crepitations E. Atrial fibrillation

Answer 25

D. Bibasal crepitations Aortic stenosis will first result in left ventricular failure as a result of increased ventricular pressure as the ventricle tries to pump blood across a narrowed valve. Initially the pressure load will cause a backlog of blood into the lungs, resulting in pulmonary oedema – the first sign of which will be bibasal crepitations (D) before enough fluid accumulates as pleural effusions visible on chest x-ray (A). Earlier signs of pulmonary oedema include upper lobe blood diversion and Kerley B lines as fluid infiltrates the interstitium. If the backlog continues back into the right heart, eventually signs of right-sided heart failure will be evident including raised JVP (B) and bilateral pedal oedema (C). Atrial fibrillation (E) may coexist with aortic stenosis, however it is more commonly associated as a result of mitral stenosis as the enlarged atrium disrupts the normal electrical pathways.

Question 26

``` 2. A 60-year-old man presents to his GP with gradually increasing fatigue and some exertional dyspnoea. Blood pressure is 118/74mmHg and pulse rate is 81/minute. There are no abnormal physical findings and on echocardiography the ejection fraction is 47%. However, the clinical impression remains one of early heart failure. Which of the following circulating biomarkers would best support that conclusion? A. Atrial natriuretic peptide B. Brain natriuretic peptide C. Endothelin D. Noradrenaline E. Adrenomedullin ```

Answer 26

B. Brain natriuretic peptide Brain natriuretic peptide (B) is considered to have the greatest power as a diagnostic biomarker of the given answer options. In established heart failure, high levels of endothelin (C) and noradernaline (D) in particular are associated with poor prognosis. All of the given answers, including atrial natriuretic peptide (A) and adrenomedullin (E), may be increased in heart failure.

Question 27

``` 3. A 55-year-old male presents with increasing exertional dyspnoea, fatigue, weight loss and bone pain. Blood results reveal elevated calcium levels and normocytic anaemia. He is treated for heart failure. What is the underlying cause for his heart failure? A. Hyperthyroidism B. Malignancy C. Thiamine deficiency D. Meningitis E. Paget’s disease of the bone ```

Answer 27

B: Malignancy Multiple Myeloma: C – hypercalcaemia, R- renal failure, A - anaemia, B- bone lesions. Hence weight loss, bone pain, anaemia. A. Hyperthyroidism does cause weight loss but would not explain other symptoms C. Thiamine deficiency – no other signs, history of alcoholism, peripheral neuropathy D. Meningitis – no signs of infection E. Paget’s disease – calcium is unaffected, high ALP

Question 28

``` 4. A 74 year old male with a 30 pack year smoking history is admitted to AMU. He has had 2 myocardial infarctions in the last 5 years. On examination he is producing frothy pink sputum, he has bilateral pitting oedema, bibasal crackles and oxygen saturations of 89%. Which of the following is most likely to be identified by auscultating the chest? A. Third heart sound B. Carotid bruit C. Normal lung sounds D. Pericardial rub E. Fourth heart sound ```

Answer 28

A. Third Heart Sound B. Carotid bruit= CA stenosis C. Normal lung sounds - unlikely if fluid overloaded D. Pericardial rub - pericarditis E. Fourth heart sound - can be present, but develops after S3

Question 29

``` 5. A 74 year old man presents to AMU with a history of fatigue, breathlessness and has noticed his ankles to be swollen. On examination, he has an oedematous ankles, his JVP is raised and he has finger clubbing. When you ask about work, he says he used to work as a ship builder. He is diagnosed with acute heart failure. What is the most likely cause of his heart failure? A. Smoking B. Rheumatic Heart Disease C. Interstitial Lung Disease D. Aortic Stenosis E. Aortic Regurgitation ```

Answer 29

C. Interstitial Lung Disease A. Smoking - not mentioned B. Rheumatic Heart Disease - no other features D. Aortic Stenosis - no ESM E. Aortic Regurgitation - no diastolic murmur

Question 30

``` 6. A 85 year old woman is seen in Heart Failure clinic for a review of her long term condition. She is currently taking enalapril and bisoprolol. Which other drug can be added to help control her symptoms? A. Spironolactone B. Amlodipine C. Salbutamol D. Morphine E. Omeprazole ```

Answer 30

A. Spironolactone B. Amlodipine - Ca channel blocker; more used for hypertension C. Salbutamol - β-agonist would worsen symptoms D. Morphine - Pain control more relevant to acute management E. Omeprazole - PPI used for GORD

Question 31

7. Regarding the management of acute heart failure, which of these statements is not true? A. The patient should be given a diuretic, such as IV furosemide. B. High-oxygen is not always recommended C. Opiate analgesia is always recommended D. A vasodilator, such as nitrates, can be given E. An ECG may not show an arrhythmia

Answer 31

C. Opiate analgesia is always recommended A. The patient should be given a diuretic, such as IV furosemide = Mx of oedema B. High-oxygen is not always recommended - if SpO2 adequate, may not be need D. A vasodilator, such as nitrates, can be given - GTN 2 puffs sublingual E. An ECG may not show an arrhythmia (10% = normal ECG)

Question 32

8. Which of these x-ray findings is most likely to be seen on a Chest X-ray of a patient with heart failure? ``` A. Cardiothoracic ratio <50% B. Blunting of the costophrenic angles C. Air bronchograms D. Dilated lower lobe vessels E. Cannon-ball opacities ```

Answer 32

B. Blunting of the costophrenic angles A. Cardiothoracic ratio <50% - >50% C. Air bronchograms = Air spaces made visible by surrounding tissue (ILD/fibrosis) D. Dilated lower lobe vessels --> should be UL E. Cannon-ball opacities --> Round opacities = TB

Question 33

9. You are volunteering at a refugee camp in Calais and you see a 10 year old boy who is acutely breathless, and has fatigue and feels nauseous . His mother tells you he has been having several episodes fevers, elbow pains and difficulty walking for the past 2 years, and has developed a rash. On examination, he has an ejection systolic murmur. He is treated for heart failure. What is the most likely underlying cause of his heart failure? ``` A. Cor pulmonale B. Cystic Fibrosis C. Familial cardiomyopathy D. Rheumatic Heart Disease E. Congenital heart disease ```

Answer 33

D. Rheumatic Heart Disease ``` A. Cor pulmonale: RHF B. Cystic Fibrosis: no other features C. Familial cardiomyopathy: no FHx D. Rheumatic Heart Disease E. Congenital heart disease: no Dx ```