Heart Failure

Question 1

What is the definition of heart failure

Answer 1

A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses.

Question 2

Why are the kidneys associated with heart failure?

Answer 2

Often when the heart fails, the kidneys fail because they won’t be perfused enough (they receive 35-40% of cardiac output)

Question 3

What are two things the consequences of heart failure are linked to?

Answer 3

Inability of the heart to maintain cardiac output and blood pressure

Question 4

What are some of the causes of heart failure?

Answer 4

1) Arrhythmias - mainly tachycardias
2) Valve Disease - mitral or aortic regurgitation or valve stenoses
3) Pericardial Disease - if the pericardium becomes inflamed and fibrotic then the heart can’t relax and pump as well
4) Congenital Heart Disease - if there are holes or misconnections then there is an increased risk of heart failure
5) Myocardial Disease - commonest cause of myocardial disease in this country is coronary heart disease.
6) Cardiomyopathy
7) Some drugs can cause heart failure:
- overdosing on beta blockers can decrease the heart rate so much that you get heart failure type syndrome
- Anti-arrhythmics can cause dysfunction of the heart
- Calcium antagonists
7) Hypertension can cause heart failure

Question 5

What percentage of MI survivors develop heart failure?

Answer 5

50%
Deaths due to MI decreasing but those from heart failure increasing - pop is aging and heart failure is more common in old age

Question 6

What is myocardial remodelling?

Answer 6

The rest of the heart tries to remodel itself to cope with the damage that has occurred. Infarct expansion occurs - the fibrous tissue expands and the rest of the heart tries to remodel to maintain normal pumping activity. This includes cells stretching and loss of cells.It takes place over months or years.

Question 7

What is cardiomyopathy and what are some types?

Answer 7

Cardiomyopathy is a heart disease without a known cause. Includes dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy, arrhythmic right ventricular cardiomyopathy, hypertrophic obstructive cardiomyopathy
and asymmetrical septal hypertrophy. It occurs in 5% of heart failures. Hypertrophic is most common cause of athletes dying suddenly.

Question 8

What are the causes of dilated cardiomyopathy?

Answer 8

• idiopathic
• genetic
• infections: viruses (cocksackie), HIV, bacteria, fungi, parasites
• toxins/poisons: ethanol, cocaine, metals, hypoxia
• drugs: chemotherapeutics, antiviral agents
• metabolic disorders: endocrine disease, nutritional deficiencies
• collagen disorders
• autoimmune
• peripartum cardiomyopathy
• neuromuscular disorders

Question 9

What are the causes of restrictive cardiomyopathy?

Answer 9

restricted means heart can’t dilate as it would. Patients can pump but the heart is slow in relaxing so patients are short of breath.

• infiltrative disorders: amyloidosis (proteins enter heart muscle), sarcoid disease (inflammatory cells clump in heart muscle), neoplasia, inborn errors of metabolism
• storage disorders: glycogen storage disease, Fabry disease, haemochromatosis, haemosiderosis
• endomyocardial disorders (lines inside of heart): carcinoid, metastases, radiation damage, endomyocardial fibrosis
• associated with fibrosis: hypertrophy, ischaemia, scleroderma

Question 10

What causes death in people with heart failure?

Answer 10

Progression of Heart Failure: increased myocardial wall stress, increased retention of sodium and water

Sudden death: oppportunistic arrhythmia (commonest cause of death in heart failure)

Cardiac event e.g. myocardial infarction

Other cardiovascular event e.g. stroke, pulmonary vascular disease

Non-Cardiovascular causes e.g. pneumonia

Question 11

Which hormones are present in heart failure, which are overactive and how can drugs target this?

Answer 11

Constrictors: noradrenaline, renin, angiotensin 2, vasopressin, endothelin

Dilators: prostaglandin E2, dopamine, ANP, EDRF

Growth factors: insulin, NO, catecholamines, angiotensin 2, growth hormone, TNF alpha

All these are switched on.
Body thinks it is bleeding to death so increase in adrenaline and noradrenaline.
To retain salt and water RAS system active.
Vasoconstrictors increased.
Beta blockers block sympathetic drive
ACE inhibitors block RAS system
Aldosterone antagonists

Question 12

Which inflammatory markers and cytokines are present during heart failure?

Answer 12

heart: troponin T/I
Vessel walls: ICAM 1, VCAM 1, E selectin, P selectin
macrophages: lipoprotein associated phospolipase A2, secretory phosphlipase A2

In all cell types: interleukin 1b, interleukin 6, tissue necrosis factor alpha
liver: makes more c reactive protein, fibrinogen, serum amyloid A

All increased in heart failure

Question 13

What is the prognosis of heart failure?

Answer 13

5-year mortality is 50%
Median survival following diagnosis:
Men = 1.7 years
Women = 3.2 years

Question 14

What are the signs/symptoms of heart failure?

Answer 14

patient: ankle swelling, exertinal breathlessness, fatigue, nocturia, anorexia, weight loss, orthopneoa (short of breath when flat), PND (paroxysmal noctural dyspnoea - when they fall flat when asleep can’t breathe)
clinical: tachycardia, low pulse volume, oedema, ascites, hepatomegaly, weak pulses, high jugular venous pressure (pressure in right side of heart are high)

Question 15

What investigations are done to determine whether someone has heart failure and following diagnosis?

Answer 15

• X ray
• echocardiogram
• ambulatory ECG monitoring
• cardiac catheter
• exercise test
• radionuclide ventriculography

Question 16

What does an X ray in a patient with heart failure look like?

Answer 16

• increase in cardio-thoracic ratio
• dilated heart
• normal people shouldn’t have a heart more than 50% the width of the thorax

Question 17

What is the nature of heart failure?

Answer 17

• Patient is breathless, tired and retains fluid
• Heart is damaged
• Heart less effective as a pump
• Marked neurohormonal activation
• Quality of life is poor
• Life expectancy reduced

Question 18

What is the New York heart association classification of functional capacity and why is it used?

Answer 18

Different classes so we can tell if a patient has gotten better/worse after treatment
class 1: no symptoms, heart still dysfunctioning 
class 2: slight limitation in physical activity
class 3: limitation in activity
class 4: person can't get out of chair or is in bed

Question 19

What is the progression of heart failure?

Answer 19

Patients are stable (myocardium loss, BP falls but reflexes and hormones active) before they deteriorate. Downwards slope can happens in weeks or months. An event can cause rapid progression and death. If someone has lots of readmissions to hospital suggests they are unstable.

Question 20

What are the syndromes of heart failure?

Answer 20

• Acute Heart Failure: associated with pulmonary oedema
• Circulatory Shock: sssociated with cardiogenic shock (poor peripheral perfusion, oliguria, hypotension)
• Chronic Heart Failure: untreated, congestive, undulating, treated, compensated

Question 21

What should be done if pulmonary oedema is seen in a chest X ray?

Answer 21

• diuretics to remove fluid

Question 22

Which investigations should be done if heart failure is suspected?

Answer 22

• ECG
• Coronary Angiography - can show where the problem is
• M-mode echocardiogram - not used any more s
• 2D echocardiogram - you can see how the heart is actually pumping
• MRI scanning

Question 23

What is the management algorithm for heart failure?

Answer 23

1) establish if person has heart failure
2) determine aetiology
3) identify associated conditions
4) assess severity
5) prognosis
6) anticipate complications
7) treatment
8) monitor progress and tailor treatment

Question 24

What are the objectives of treatment in chronic heart failure?

Answer 24

1) prevention: myocardial damage, reoccurence
2) relief of symptoms and signs: oedema, increase exercise capacity, reduce fatigue and breathlessness
3) prognosis: reduce mortality

Question 25

What are some common drugs used for heart failure?

Answer 25

• Diuretics
• ACE inhibitors
• Beta Blockers
• Aldosterone Antagonists (Spironolactone)
• Digoxin (for atrial fibrillation)

Question 26

What are the possible treatments for severe heart failure?

Answer 26

• IV drugs e.g. diuretics, nitrates, positive inotropes (dopamine)
• fluid control (haemofiltration, haemodialysis)
• devices (ICD, intraaortic balloon pump, total artifical heart)
• surgery (on valves, transplants, cardiomyoplasty, volume reduction, CABG (coronary artery bypass graft)

Question 27

What is the treatment pathway for heart failure?

Answer 27

• new diagnosis
• start ACE inhibitor and titrate upwards
• add beta blocker and titrate upwards
• add spironolactone if moderate/severely symptomatic
• seek specialist advice

most patients require diuretics
add digoxin if sinus rhythm affected and symptomatic despite ACE inhibitor and beta blocker
add digoxin as first therapy for atrial fibrillation

Question 28

How is atrial natriuretic peptide (ANP) used in the diagnosis of heart failure?

Answer 28

Blood test to check levels of ANP (which comes from the atria). If ANP is raised then you have an impaired heart