cardiac failure

Question 1

definitoon of cardiac failure

Answer 1

Inability of the cardiac output to meet the body’s demands despite normal venous pressures.

Question 2

defintion of acute cardiac failure

Answer 2

new onset acute/decompensation of HF,

characterized by pulmonary and/or peripheral oedema

with or without signs of peripheral hypoperfusion.

Question 3

definition of chronic cardiac failure

Answer 3

Develops or progresses slowly. Venous congestion is common but arterial pressure is well maintained until very late.

Question 4

systolic HF

Answer 4

inability of the ventricle to contract normally = reduced CO, EF <40%

Question 5

diastolic HF

Answer 5

inability of ventricle to relax and fill normally = increased filling pressures.

Typically EF is >50% – HFpEF (heart failure with preserved EF).

Question 6

low output HF

Answer 6

Cardiac output is low and fails to raise normally with exertion.

Question 7

high output HF

Answer 7

rare.

output is normal or increased in the face of increased needs.

Failure occurs when cardiac output fails to meet these needs.

will occur with a normal heart, but earlier in heart disease

Question 8

aetiology of low output LHF

Answer 8

• ischemic heart disease,
• HTN,
• cardiomyopathy,
• aortic valve disease,
• mitral regurg,
• fluid overload

Question 9

aetiology of low output RHF

Answer 9

• secondary to LHF,
• infarction,
• cardiomyopathy,
• pul HTN/embolus/valve disease,
• chronic lung disease (cor pulmonale),
• tricuspid regurg,
• constrictive pericarditis/pericardial tamponade,
• pul stensosis

Question 10

aetiology of low output biventricular failure

Answer 10

arrthmia,

cardiomyopathy (dilated/restrictive),

myocarditis,

drug toxicity

Question 11

aetiology of low output pump failure

Answer 11

systolic +/ diastolic HF,

reduced HR (B blockers, heart block, post MI),

negatively inotropic drugs (eg most antiarrhythmic agents).

Question 12

aetiology of high output HF

Answer 12

anaemia

beriberi

pregnancy

Paget’s disease

hyperthyroidism

arteriovenous malformation

Question 13

aetiology of systolic HF

Answer 13

IHD, MI, cardiomyopathy

Question 14

aetiology of diastolic HF

Answer 14

ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardio myopathy, obesity

Question 15

what is congestive cardiac failure

Answer 15

when R and L ventricular failure occur together

Question 16

effect of preload and afterload on HF

Answer 16

Excessive preload = ventricular dilatation - exacerbates pump failure.

Excessive afterload = ventricular muscle thickening (ventricular hypertrophy), = stiff walls and diastolic dysfunction.

Question 17

epidemiology of HF

Answer 17

1–3% of the general population;

~10% among elderly patients (>65)

Question 18

sx of LHF

Answer 18

symptoms caused by pulmonary congestion

Dyspnoea (New York Heart Associationclassification):

• none
• on ordinary activities
• on less than ordinary activities
• at rest

poor exercise tolerance

orthopnoea

paroxysmal nocturnal dyspnoea

fatigue

nocturia

cold peripheries

weight loss

Question 19

sx of acute LVF

Answer 19

Dyspnoea,

wheeze,

cough

pink frothy sputum

Question 20

sx of RHF

Answer 20

• swollen ankles
• ascites
• fatigue
• increased weight (from oedema)
• reduced exercise tolerance
• anorexia
• nausea
• facial engorgement
• epistaxis

Question 21

sx of high output HF

Answer 21

initially features of RVF;

later LV F becomes evident.

Question 22

signs of LHF

Answer 22

tachycardia

tachypnoea

displaced apex beat (LV dilatation)

bilateral basal crackles

3rd heart sound - gallop rhythm: rapid ventricular filling

pansystolic murmur (functional mitral regurg)

Question 23

signs of acute LVF

Answer 23

tachypnoea

cyanosis

tachycardia

peripheral shut down

pulsus alternans

gallop rhythm

wheeze ‘cardiac asthma’

fine crackles throughout the lung

Question 24

signs of RHF

Answer 24

raised JVP

hepatomegaly

ascites

anklesacral pitting

oedema

signs of functional tricuspid regurg

Question 25

general signs of HF

Answer 25

cyanosis low BP narrow pulse pressure RV heave - pul hypertension severity graded by New York Classification

Question 26

Ix for HF

Answer 26

bloods CXR ECG echo Swan-Ganz catheter *if BNP and ECG normal - unlikely HF, if either not normal - need echo*

Question 27

bloods for HF

Answer 27

FBC, UE, LFT, CRP, glucose, lipid, TFT in acute LVF - ABG, troponin, BNP * raised Plasma BNP suggests the diagnosis of cardiac failure. * A low plasma BNP rules out cardiac failure (90% sensitivity).

Question 28

CXR in acute LVF

Answer 28

cardiomegaly (heart \>50% of thoracic width) prominent upper lobe vessels pleural effusion interstitial oedema - kerley B lines perihilar shadowing - Bat's wings fluid in fissures

Question 29

ECG in HF

Answer 29

may be normal ischemic changes arrhythmia MI LVH - seen in hypertension

Question 30

echo for HF

Answer 30

assess ventricular contraction MI If left ventricular ejection fraction (LVEF)\<40%: systolic dysfunction. Diastolic dysfunction: reduced compliance leading to a restrictive filling defect.

Question 31

Swan-Ganz catheter

Answer 31

Allows measurements of right atrial, right ventricular, pulmonary artery, pulmonary wedge and left ventricular end-diastolic pressures.

Question 32

complications of HF

Answer 32

resp failure cardiogenic shock death

Question 33

Px of HF

Answer 33

Fifty per cent of patients with severe heart failure die within 2 years.

Question 34

Mx of acute LVF

Answer 34

medical emergency cardiogenic shock - severe cardiac failure, low BP = need inotropes eg dopamine, dobutamine and should be managed in ITU pul oedema * **Sit up patient**, 60–100% **O2 and consider CPAP** * **diamorphine** (venodilator and anxiolytic effect) * **GTN infusion** - reduce preload * **IV furosemide** if fluid overloaded (venodilator and later diuretic effect) * monitor BP, RR, sats, urine output, ECG * treat cause

Question 35

Mx of chronic LVF

Answer 35

* treat cause - eg HTN * treat exacerbating factors eg anaemia, thyroid disease, infection, raised BP * stop smoking, drinking, eat less salt, optimise weight * Annual ’flu vaccine, one-off pneumococcal vaccine. * ACEi * B blocker * loop diuretic eg furosemide and salt restriction to treat fluid overload * aldosterone antagonists * angiotensin receptor blockers * hydralazine and a nitrate (visodilators) - reduce mortality * digoxin - positive inotrope - reduces hospitalisation, doesnt improve survival * n-3 polyunsaturated fatty acids - benefit mortality * cardiac resynchronisation therapy * Avoid drugs that can adversely affect patients with heart failure due to systolic dysfunction,e.g. NSAIDs, non-dihydropyridine calcium channel blockers (i.e. diltiazem and verapamil).

Question 36

why ACEi for HF

Answer 36

e.g. enalapril, perindopril, ramipril: Inhibit intracardiac renin-angiotensin system which may contribute to myocardial hypertrophy and remodelling. slow progression of the heart failure and improve survival, improve sx if LV systolic dysfunction SE - high K

Question 37

why B blocker for HF

Answer 37

bisprolol or carvedilol Block the effects of chronically activated sympathetic system slow progression of the heart failure and improve survival The benefits of ACEinhibitors and b-blockers are additive.

Question 38

why loop diuretics for HF

Answer 38

reduce Sx SE - reduce K, renal impairment Monitor U&E and add K+-sparing diuretic (eg spironolactone) if K+\<3.2mmol/L = predisposition to arrhythmias, concurrent digoxin therapy, or pre-existing K+-losing conditions. if refractory oedema - consider adding thiazide eg metolazone

Question 39

aldosterone antagonists in HF

Answer 39

spirinolactone/eplerenone improve survival in pts with classification 3 or 4 use if still Sx, or post MI with LV systolic dysfunction Monitor K+ (may cause hyperkalaemia). * May be used to assist in the management of diuretic-induced hypokalaemia.

Question 40

ARB in HF

Answer 40

candesartan added in pts with persistent symptoms despite ACE inhibitors and B blockers monitor K+ may cause hyperkalaemia

Question 41

hydralazine and a nitrate in HF

Answer 41

May be added in patients (particularly in Afro-Caribbeans) with persistent symptoms despite therapy with an ACE inhibitor and b-blocker

Question 42

cardiac resynchronisation therapy in HF

Answer 42

Biventricular pacing improves symptoms and survival in patients with LVEF \<=35%, cardiac dyssynchrony (QRS\>120msec) and moderate to severe symptoms despite optimal medical therapy. Most patients who meet these criteria are also candidates for an implantable cardiac defibrillator (ICD) and receive a combined device.

Question 43

digoxin in HF

Answer 43

helps sx even if in sinus rhythm give in pts with LV systolic dysfunction of still sx or signs when have standard therapy (inc ACEi or B blocker) or AF monitor UE - low K = risk toxicity

Question 44

Mx of intractable HF

Answer 44

* reassess cause * switch furosemide to butmetanide * minimal exertion * Na and fluid restriction * metolazone and IV furosemide * opiates and IV nitrates - relieve sx * weigh daily * frequent UE - beware low K in extremis - IV ionotropes consider cardiac resynchronisation, LV assist device or transplant

Question 45

palliative care for HF

Answer 45

treat/prevent co-morbidities eg flu vaccine good nutrition tackly dyspnoiea, nausea, constipation, and low mood opiates - pain and dyspnoea ox

Question 46

L ventricular assist devices

Answer 46

bridging therapy while waiting for heart transplant pump force blood through tubing from LV to aorta