Heart Failure

Question 1

List the 4 key phases of the cardiac cycle

Answer 1

1. Isovolumetric Relaxation
2. Filling Phase
3. Isovolumetric contraction
4. Ejection Phase

(1 + 2 diastole 3 +4 systole)

Question 2

Equation for BP

Answer 2

BP = CO x TPR

Question 3

Equation for CO

Answer 3

CO = SV x HR

Question 4

List the 3 mechanisms in HF that act to preserve BP

Answer 4

1. Frank Starling
2. Neurohormonal (SNS, RAAS, ADH)
3. Ventricular hypertrophy (remodelling)

Question 5

Explain the Frank Starling Mechanism

Answer 5

1. In HF there is ↓ CO and SV
2. leads to ↓emptying, ↑EDV
3. results in ↑stretch, ↑ SV, ↑emptying and CO

UP TO A POINT

Question 6

Explain SNS activation in HF

Answer 6

Baroreceptors in carotid sinus and aortic arch detect ↓ CO and ↑ SNS outflow:

1. ↑cardiac contractility
2. ↑ vasoconstriction (arteries and veins)
3. ↑ Heart rate

Question 7

Explain RAAS activation in HF

Answer 7

Question 8

Explain ADH activation in HF

Answer 8

1. Osmoreceptors in hypothalamus detect high osmolarity
2. ADH released from posterior pituitary
3. ↑ H2O retention
4. ↑ intravascular volume and preload

Question 9

What is heart failure?

Answer 9

Failure of the heart to generate sufficient CO to meet the metabolic demands of the body

Question 10

What are the types of heart failure?

Answer 10

R vs L
Systolic vs Diastolic

Question 11

List 4 symptoms of Right sided heart failure

Answer 11

1. Ankle swelling
2. Weight gain
3. Abdominal distension and discomfort
4. Anorexia / nausea

Question 12

List 4 signs of Right sided heart failure

Answer 12

1. Raised JVP
2. Pitting ankle/sacral oedema
3. Tender smooth hepatomegaly
4. Ascites

Question 13

List 4 symptoms of left sided heart failure

Answer 13

1. Shortness of breath on exertion
2. Orthopnoea
3. Paroxysmal nocturnal dyspnoea
4. Nocturnal cough (± pink frothy sputum)

Question 14

List 4 signs of left sided heart failure

Answer 14

1. Tachypnoea
2. Bibasal fine crackles and wheeze
3. Cyanosis
4. Prolonged CRT
5. Hypotension

Question 15

List 3 less common signs of left heart failure

Answer 15

1. Pulsus alternans (alternating strong and weak pulse)
2. S3 gallop rhythm (filling of a stiffened ventricle)
3. Features of functional mitral regurgitation

Question 16

List 4 causes of Systolic heart failure

Answer 16

• Ischaemic heart disease
• Dilated cardiomyopathy
• Myocarditis
• Infiltration (e.g. in haemochromatosis or sarcoidosis)

Question 17

List 4 causes of diastolic heart failure

Answer 17

1. Hypertrophic obstructive cardiomyopathy
2. Restrictive cardiomyopathy
3. Cardiac tamponade
4. Constrictive pericarditis

Question 18

What is high output cardiac failure?

Answer 18

CO is normal, but there is an increase in peripheral metabolic demands which exceed those that can be met with maximal cardiac output

Question 19

List 4 causes of high output cardiac failure

Answer 19

1. Anaemia
2. Arteriovenous malformation
3. Paget’s disease
4. Pregnancy
5. Thyrotoxicosis
6. Thiamine deficiency (wet Beri-Beri).

Question 20

What classification system is used for heart failure?

Answer 20

New York Heart Association (NYHA) Classification of Heart failure

Grades severity of exertional dyspnoea

Question 21

Explain the NYHA classification

Answer 21

Class I - no limitation in physical activity

Class II - slight limitation of physical activity

Class III - marked limitation in physical activity

Class IV - inability to carry on any physical activity

Question 22

Investigations for heart failure?

(In order)

Answer 22

1. NT-proBNP
2. ECG
3. FBC
4. Chest X-ray
5. Echocardiogram

Question 23

What is NT-proBNP?

List 3 of its actions

Answer 23

Released by ventricles in response to myocardial stretch. Works to balance effects of RAAS:

1. ↑excretion of Na and H2O
2. vasodilation
3. ↓ renin and AT II

Question 24

What values of NT-proBNP, in GP, require specialist referral?

What investigation is performed by the specialist to confirm diagnosis?

Answer 24

• BNP > 2000ng/L - urgent 2 week referral
• BNP 400-2000ng/L - 6 week referral

Referred to specialist for trans-thoracic echocardiogram

Question 25

What is the purpose of an Echocardiogram in HF?

Answer 25

Can show the presence and degree of ventricular dysfunction Measured by the ejection fraction

Question 26

EF values indicative of systolic vs diastolic HF

Answer 26

\< 40% (reduced EF) = systolic \> 40% but raised BNP (preserved EF) = diastolic

Question 27

Blood tests in HF and why

Answer 27

1. U+Es - renal function 2. LFTs - hepatic congestion 3. TFTs - hyperthyroidism 4. HbA1C and lipid profile - modifiable risk factors 5. BNP

Question 28

List 5 chest x-ray findings in heart failure (ABCDEF)

Answer 28

1. **Alveolar** oedema ('batwing' perihilar shadowing) 2. Kerley **B** lines (due to interstitial oedema) 3. **Cardiomegaly** 4. upper lobe blood **diversion** 5. Pleural **Effusions** (bilateral transudates) 6. **Fluid** in the horizontal fissure

Question 29

What value indicates cardiomegaly on x-ray?

Answer 29

cardiothoracic ratio \> 0.5

Question 30

List 3 lifestyle modifications for HF

Answer 30

1. Smoking cessation 2. Salt and fluid restriction 3. Supervised cardiac rehabilitation

Question 31

Pharmacological management for HF (ABAL)

Answer 31

1. **A**CE inhibitor (eg. ramipril) 2. **B**eta Blocker (eg. bisoprolol) 3. **A**ldosterone antagonist (eg. spironolactone or eplerenone) 4. **L**oop diuretics improves symptoms (eg. furosemide)

Question 32

What is Entresto?

Answer 32

Valsartan/sacubitril Used as an alternative to ACEi or ARBs

Question 33

Who is eligible for Entresto

Answer 33

1. Symptomatic heart failure 2. Severe LVSD 3. Stable renal function 4. Good BP 5. Already on decent dose of ACEi or ARB

Question 34

Surgical/device management option for HF

Answer 34

Cardiac resynchronisation therapy in QRS \> 130ms

Question 35

What cannot be used alongside Entresto?

Answer 35

ACEi due to risk of angioedema Requires minimum 36 hour washout period

Question 36

Any of what 3 criteria must be fullfilled for an ICD

Answer 36

1. QRS interval \<120ms, high risk sudden cardiac death, NYHA class I-III 2. QRS interval 120-149ms without LBBB, NYHA class I-III 3. QRS interval 120-149ms with LBBB, NYHA class I

Question 37

What is acute HF?

Answer 37

Sudden onset or worsening of the symptoms of HF due to a reduced CO that results from a functional or structural abnormality

Question 38

What are the two ways in which acute HF may arise?

Answer 38

1. De-novo AHF - no PMH of HF 2. Decompensated AHF (66-75%) - a background history of HF

Question 39

What causes De-novo AHF

Answer 39

Ischaemia → increased cardiac filling pressure and myocardial dysfunction Results in reduced CO → hypoperfusion Can cause pulmonary oedema

Question 40

List one other cause of De-Novo AHF

Answer 40

* Viral myopathy * Toxins * Valve dysfunction

Question 41

List 4 triggers of decompensated AHF

Answer 41

1. Acute coronary syndrome 2. Hypertensive crisis 3. Acute arrhythmia 4. Valvular disease

Question 42

List 4 symptoms of AHF

Answer 42

1. Breathlessness 2. Reduced exercise tolerance 3. Oedema 4. Fatigue

Question 43

List 4 signs of AHF

Answer 43

1. Cyanosis 2. Tachycardia 3. Raised JVP 4. Displaced apex beat 5. Bibasal crackles +/- wheeze 6. S3 heart sound

Question 44

Initial Management of decompensated AHF

Answer 44

1. Sit patient up 2. O2 therapy (aim \>94%) 3. IV furosemide 4. SC morphine 5. Consider nitrites (it hypoxic or hypertensive)

Question 45

Advanced management of AHF (pulmonary oedema) (ITU setting)

Answer 45

1. CPAP 2. Intubation and ventilation 3. Furosemide infusion 4. Dopamine infusion 5. Intra-aortic balloon pump - if in cardiogenic shock 6. Ultrafiltration

Question 46

List 4 s/e of Beta blockers

Answer 46

Bradycardia, hypotension, fatigue, dizziness

Question 47

List 4 s/e of ACEi

Answer 47

Hyperkalaemia, renal impairment, dry cough, lightheadedness, fatigue, GI disturbances, angioedema

Question 48

List 4 s/e of spironolactone

Answer 48

Hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/hair growth in women, changes in libido

Question 49

List 3 s/e of Furosemide

Answer 49

Hypotension, hyponatraemia/kalaemia

Question 50

List 3 s/e of NO

Answer 50

Headache, palpitation, flushing

Question 51

List 3 s/e of Digoxin

Answer 51

Dizziness, blurred vision, GI disturbances