Heart Failure

Question 1

Define Heart Failure

Answer 1

It is when the heart is not capable of providing sufficient cardiac output or can only do so at the expense of elevated filling pressure

Question 2

Epidemiology of HF

Answer 2

1% of 50-59
5-10% of 80-89

1-3% of general population

Question 3

Prognosis of HF

Answer 3

25-50% within 5 years

Poor

Question 4

Whats is congestive cardiac failure

Answer 4

It is when there is both L and R ventricular failure

Question 5

Symptoms of L ventricular failure

Answer 5

PND

Orthopnoea

Dyspnoea

Poor exercise tolerance

Fatigue

Nocturnal cough - +/- pink frothy sputum

Wheeze “cardiac asthma”

Nocturia

Muscle waisting

Weight loss

Question 6

Causes of R ventricular failure

Answer 6

LVF

Pulmonary stenosis

Lung disease

Question 7

Symptoms of R ventricular failure

Answer 7

Peripheral oedema - up to thighs, sacrum, abdominal wall

Ascites

Nausea

Anorexia

Pulsation in neck and face (tricuspid regurgitation)

Epistaxis

Question 8

Investigating HF

Answer 8

NICE:

If ECG and BNP both normal then unlikely to be HF and other causes must be considered.

If either abnormal perform Echo

Question 9

When is heart failure considered acute

Answer 9

It is either for a new onset acute HF or a decompensated chronic heart failure characterized by pulmonary and or peripheral oedema with or without signs of peripheral hypoperfusion

Question 10

What is chronic heart failure

Answer 10

It is when HF is always present but develops or progresses very slowly. venous congestion is common but arterial pressure is affected later on.

Question 11

What is low-output HF

Answer 11

It is when there is reduced cardiac output and fails to increase with exertion

Question 12

What is systolic HF

Answer 12

It is the inability for the ventricles to contract normally resulting in reduced cardiac output

Ejection fraction is <40%

Question 13

Causes of systolic HF

Answer 13

cardiomyopathy

MI

IHD

Question 14

what is diastolic HF

Answer 14

it is when the ventricles are unable to relax and fill normally resulting in increased filling pressure

Ejection fraction is >50%

Question 15

Causes of diastolic HF

Answer 15

Tamponade

constrictive pericarditis

restrictive cardiomyopathy

hypertension

Question 16

Something to remember about Systolic and diastolic HF

Answer 16

They usually co-exist

Question 17

Causes of low-output HF

Answer 17

Pump failure:
Systolic/diastolic HF
Reduced heart rate (B-blockers, heart block, post MI)
Negatively Inotropic drugs (most antiarythmatic agents)

Excessive preload;
mitral regurgitation
fluid overload (NSAID causing fluid retention)

Chronic excessive afterload
aortic stenosis, hypertension

Question 18

High output heart failure

Answer 18

Rare

Here output is normal or increased with increased demand

Failure occurs when the cardiac output fails to meet these demands

consequences are this could develop to RF and ultimately LVF

Question 19

High output heart failure causes

Answer 19

Anaemia

pregnancy

hyperthyroidism

pagets

arteriovenous malformation

beri beri

Question 20

what is beri beri

Answer 20

thiamine (vit B1) deficiency with symptoms

Question 21

What is tamponade

Answer 21

compression of the heart because of fluid in the pericardial sac

Question 22

Other investigations of HF

Answer 22

FBC

U and E

BNP

CXR

ECG - look MI ventricular hypertrophy ischaemia

Echocardiography

endomyocardial biopsy - rarely needed

Question 23

Tell me about the CXR of LVF

Answer 23

Alveolar oedema (bat wings)

B kerley lines (interstial oedema)

Cardiomegaly

Dilated prominent upper lobe vessels

pleural effusion (blunted costophrenic angles)#

http://epomedicine.com/wp-content/uploads/2016/02/pulmonary-edema-mnemonics.jpg

Question 24

What is the Framingham criteria

Answer 24

It is used for diagnosis of congestive cardiac failure

Question 25

conservative management of Chronic HF

Answer 25

Low salt diet

stop smoking

weight and diet control

treat cause

treat exacebrating factors (HTN, anaemia, thyroid)

avoid exacebrating factors (NSAIDs/Verapamil, etc)

Question 26

Medical Management of chronic HF

Answer 26

Diuretics - reduce risk of death and worsening HF, Loop for Sx relief

ACE - consider in all with L ventricular and systolic failure, improves Sx and prolong life

B-blockers, decrease mortality in HF. Benefits are additional to those of ACE. Give after ACE and diuretics

Spironolactone - reduces mortality by 30% when given with above treatment. use when Sx persist despite above Rx

Digoxin - helps Sx even when sinus rythm

Vasodilators

Question 27

What is an alternative if ACE gives Pts cough

Answer 27

Angotensin receptor blocker

Question 28

Tell me about B-blockers and HF

Answer 28

give after ACE-i, be cautious, start slow and go slow

Question 29

Whats the problem with spironolactone in HF

Answer 29

small risk of significant hyperkalaemia even with ACE-i

Question 30

Tell me about the vasodilator therapy for HF

Answer 30

the use of hydralazine (SE drug induced lupus) and isorbide dinitrate should be used if intolert to ACE or ARB

in black patients with HF it reduces mortality when added to standard therapy

Question 31

Treatment of acute HF

Answer 31

Medical emergency

start treatment before investigations

sit patient upright

Oxygen - 100% if no prexisting lung disease

IV access and monitor ECG - Rx any arrythmias

Diamorphine IV - slowly caution with COPD and Liver F

Furosemide IV - slowly, larger dosses required in renal failure

GTN - dont give if systolic BP <90

Review notes, investigate, examine, HX

If BP systolic >100 start nitrate IV

If still worsening -
addition furosemide
consider CPAP
increase nitrate infusion

If systolic BP <100 treat as cardiogenic shock and refer to ICU

Question 32

What is the normal cardiac output

Answer 32

4 to 8 L/min

Question 33

so why do we use ACE-i to treat CHF

Answer 33

because it stops Angiotensin I converting to Angiotensin II, therefore, stop renin from water retention hence reduced BP.
Reduce BP helpfull because vascular resistance against heart pump will be less, thus less work for hear.
Also because aldosterone is blocked as well it cant stimulate NaCl reabsortion and K excretion hence no water retention heeence reduced circulating volume heence reducing preload aswell

Question 34

Why do we use B-blockers then

Answer 34

B1 receptors are found in the heart.
they reduce force of contraction and speed of conduction.
this helps in reducing cardiac work and oxygen demand which therefore stops heart for dialating.