Heart Failure

Question 1

How can HF be classified?

Answer 1

Ejection fraction
Time
Left/Right

Question 2

How do you measure ejection fraction?

Answer 2

Echocardiography
Reduced left ventricular ejection fraction is defines as < 35-40%
= HF-rEF

Question 3

What % of patients with HF have HF-rEF?

Answer 3

50%

Remaining have HF-pEF

Question 4

What causes HF-rEF?

Answer 4

Systolic dysfunction e.g. 
IHD
Dilated cardiomyopathy
Myocarditis
Arrhythmias

Question 5

What causes HF-pEF?

Answer 5

Diastolic dysfunction e.g. 
HOCM
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis

Question 6

How do we classify HF by time?

Answer 6

Acute - exacerbation

Chronic

Question 7

How do we classify HF by side?

Answer 7

Left/Right

Typically lefy

Question 8

What can cause left sided heart failure?

Answer 8

Increased ventricular afterload
e.g. arterial hypertension or aortic stenosis

Increased left ventricular preload
e.g. aortic regurgitation causing backflow

Question 9

What can cause right sided heart failure?

Answer 9

Increased right ventricular afterload e.g.
Pulmonary HTN

Increased right ventricular preload
e.g. Tricuspid regurgitation

Question 10

What are the symptoms of left-sided heart failure?

Answer 10

pulmonary oedema

• dyspnoea
• orthopnoea
• paroxysmal nocturnal dyspnoea
• bibasal fine crackles

Question 11

What are the symptoms of right-sided heart failure?

Answer 11

peripheral oedema
- ankle/sacral oedema
raised jugular venous pressure
hepatomegaly
weight gain due to fluid retention
anorexia ('cardiac cachexia')

Question 12

What is high output HF?

Answer 12

situation where a ‘normal’ heart is unable to pump enough blood to meet the metabolic needs of the body

Question 13

What are some causes of high output HF?

Answer 13

anaemia
arteriovenous malformation
Paget's disease
Pregnancy
thyrotoxicosis
thiamine deficiency

Question 14

What is AHF?

Answer 14

Acute HF
sudden onset or worsening of the symptoms of heart failure
Usually in pts >65

Question 15

What usually causes AHF?

Answer 15

Reduced cardiac output that results from a functional or structural abnormality

Question 16

What can cause de-novo AHF?

Answer 16

Increased cardiac filling pressures
Myocardial dysfunction
Usually both caused by ischaemia 
Decreased CO 
Hypoperfusion

Question 17

What are the most common precipitating causes of AHF?

Answer 17

Acute coronary syndrome
Hypertensive crisis
Acute arrhythmia
Valvular disease

Question 18

What are the symptoms of AHF and corresponding signs?

Answer 18

Breathlessness - Cyanosis

Reduced exercise tolerance - Tachycardia

Oedema - Raised JVP

Fatigue - displaced apex beat

S3 heart sound

Bibasal crachles +/- wheeze

Question 19

What investigations are done for AHF?

Answer 19

Bloods - anaemia, electrolytes, infection

CXR - oedema, cardiomegaly

Echo - pericardial effusion and cardiac tamponade

BNP

Question 20

What BNP levels indicates myocardial damage?

Answer 20

> 100mg/L

Question 21

What is the treatment for HF?

Answer 21

IV loop diuretics e.g. furosemide

+/-
O2
Vasodilators e.g. nitrates

Question 22

What is done for HF pts with resp failure?

Answer 22

CPAP

Question 23

When should beta blockers be stopped inHF?

Answer 23

Brady
2nd/3rd degree heart block
Shock

Question 24

What are the investigations for chronic HF?

Answer 24

BNP
hormone produced mainly by the left ventricular myocardium in response to strain

Gold-standars is echo

Question 25

What factors increase BNP?

Answer 25

``` Left ventricular hypertrophy Ischaemia Tachycardia Right ventricular overload Hypoxaemia (including pulmonary embolism) GFR < 60 ml/min Sepsis COPD Diabetes Age > 70 Liver cirrhosis ```

Question 26

What would decrease BNP?

Answer 26

``` Obesity Diuretics ACE inhibitors Beta-blockers Angiotensin 2 receptor blockers Aldosterone antagonists ```

Question 27

What are the signs and symptoms of chronic HF?

Answer 27

``` Dyspnoea Cough - worse at night, pink frothy sputum Orthopneoa/Paroxysmal nocturnal dyspnoea Wheeze Weight loss - can be hidden by gain 2ry to oedema Bibasal crackles Raised JVP Ankle oedema S3 gallop ```

Question 28

What is the first line treatment for chronic HF?

Answer 28

ACEi Betablocker e.g. bisoprolol Start one at a time Does not work in HF-pEF

Question 29

What is second line treatment for chronic HF?

Answer 29

Aldosterone anatagonist | e.g. spironolactone

Question 30

What must be monitored in patients on ACEi and Aldosterone antagonsists?

Answer 30

Potassium | Can induce hyperkalaemia

Question 31

What is myocarditis?

Answer 31

myocardial inflammation in the absence of predominant acute or chronic ischaemia

Question 32

What are some key diagnostic features of myocarditis?

Answer 32

Prior viral infection Autoimmune disease Infectious disease

Question 33

What are some presenting features of myocarditis?

Answer 33

``` Chest pain Dyspnoea Orthopnea Fatigue Palpitations S3 gallop ```

Question 34

What would be seen on an ECG in myocarditis?

Answer 34

non-specific ST-segment and T-wave abnormalities