Congestive heart failure

Question 1

Define CHF.

Answer 1

A clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.

Question 2

The term ‘congestive heart failure’ is reserved for patients with what symptoms?

Answer 2

Dyspnoea and abnormal sodium and water retention resulting in oedema.

Question 3

What classification criteria is used for CHF?

Answer 3

Framingham criteria - 2 major criteria or 1 major and 2 minor:

Major criteria - PAINS:
· P - PND.
· A - Acute pulmonary oedema.
· I - Increased HR and CVP.
· N - Neck vein dilation.
· S - S3 gallop. 

Minor criteria - PAIN:
· P - Pleural effusion.
· A - Ankle oedema (bilateral). 
· I - Increased HR >120. 
· N = Nocturnal cough.

Question 4

What is the pathophysiology of CHF?

Answer 4

A complex syndrome where an initial myocardial insult results in the over expression of proteins with different effects on the cardiovascular system.

Neurohormonal activation is helpful in the beginning:
· Maintains adequate cardiac output and peripheral perfusion.

But when sustained, it can result in:
· Increased wall stress.
· Dilation.
· Ventricular remodelling - hypertrophy, loss of myocytes and increased interstitial fibrosis.

Due to remodelling, the left ventricle dilates, the heart becomes more globular and mitral regurgitation develops.

This results in an increased volume overload on the left ventricle that further contributes to remodelling.

Question 5

Common causes include…

Answer 5

· CAD.
· HTN.
· Valvular disease.
· Myocarditis.

Question 6

Other causes include:

Answer 6

· Infiltrative diseases, such as amyloidosis and haemochromotosis.
· Congenital heart diseases.
· Endocrine disorders - diabetes, thyroid disease.
· Infection.
· Toxin-induced.

Question 7

What are the typical risk factors?

Answer 7

· Myocardial infarction. 
· Diabetes mellitus. 
· Dyslipidaemia. 
· Old age.
· Male.
· Hypertension.
· Left ventricular dysfunction or hypertrophy.
· Cocaine abuse.
· Renal insufficiency. 
· Valvular heart disease.

Question 8

What are the typical signs and symptoms?

Answer 8

· Dyspnoea.
· Neck vein distension.
· S3 gallop. 
· Cardiomegaly. 
· Hepatojugular reflex. 
· Rales.
· Orthopnoea or PND. 
· Nocturia. 
· Ankle oedema. 
· Night cough.

Question 9

What investigations would you request?

Answer 9

· ECHO.
· ECG.
· CXR. 
· B-type natriuretic peptide (BNP) levels.
· FBC. 
· Electrolytes. 
· Blood glucose.
· LFTS.
· Blood lipids.

Question 10

An echo could distinguish between which two types of heart failure?

Answer 10

· Systolic heart failure - Depressed/Dilated left/right ventricle with low ejection fraction.
· Diastolic heart failure - Left ventricular ejection fraction is normal but LVH and abnormal diastolic filling patterns.

Question 11

CXR - ABCDE stands for what?

Answer 11

· A - Alveolar oedema.
· B - Kerley B lines.
· C - Cardiomegaly.
· D - Dilated upper lobe vessels.
· E - Pleural Effusion.

Question 12

If a patient had CHF their B-type natriuretic peptide (BNP) levels would be?

Answer 12

Elevated.

Question 13

What two full blood count measures are strong prognostic markers of poor survival?

Answer 13

1. Anaemia.

2. High lymphocyte.

Question 14

List some differentials.

Answer 14

· Aging/Physical inactivity.
· COPD/Pulmonary fibrosis. 
· Pneumonia. 
· PE. 
· Cirrhosis.
· Nephrotic syndrome. 
· Pericardial disease.
· Venous stasis.
· DVT.

Question 15

What are the treatment options for CHF?

Answer 15

Lifestyle advice.

Medical - ABCDDS:
· A - ACEi.
· B - Beta blockers.
· C - Candesartan (ARB if intolerant to ACEI).
· D - Digoxin.
· D - Diuretic.
· S - Spironolactone - aldosterone antagonist.

Question 16

Suggest some potential complications.

Answer 16

· Pleural effusion. 
· Chronic renal insufficiency. 
· Anaemia. 
· Acute decompensation of chronic heart failure - pulmonary oedema or cardiogenic shock. 
· Acute renal failure. 
· Sudden cardiac death.