Heart Failure

Question 1

Heart failure definition

Answer 1

Failure to maintain an adequate cardiac output to meet the demands of the body

Structural or functional abnormality - impairs ability of ventricles to eject blood or fill

Question 2

CO

Answer 2

HR x SV

Question 3

Preload

Answer 3

Is affected by venous blood pressure and the rate of venous return to the heart

This, in turn, is affected by venous tone and volume of circulating blood

Preload increases with increasing blood volume and vasoconstriction

Preload decreases with blood volume loss and vasodilatation

Question 4

Frank-Starling Law

Answer 4

An increase in volume of blood filling the heart stretches the heart muscle fibres causing greater contractile forces which, in turn, increases the stroke volume

Question 5

Afterload

Answer 5

It is the pressure in the aorta/pulmonary artery that the left/right ventricular muscle must overcome to eject blood

The greater the aortic/pulmonary pressure, the greater the afterload on the left/right ventricle respectively

Afterload increase with hypertension and vasoconstriction

Afterload decreases with vasodilatation

As the afterload increases, cardiac output decreases

Question 6

LOHF

Answer 6

Systolic heart failure

Diastolic heart failure

Question 7

HOHF

Answer 7

The heart itself is functioning normally but cannot keep up with the unusually high demand for blood to one or more organs in the body

Causes: thyrotoxicosis, profound anaemia, pregnancy, pagets disease, acromegaly, sepsis

Question 8

Systolic heart failure

Answer 8

Progressive deterioration myocardial contractile function

Ischaemic injury
Volume overload
Pressure overload

Question 9

Diastolic heart failure

Answer 9

Inability of the heart chamber to relax, expand and fill sufficiently during diastole to accommodate an adequate blood volume

Significant left ventricular hypertrophy (LVH) e.g HCM
Infiltrative disorders
Constrictive pericarditis
Restrictive cardiomyopathy

Question 10

HF causes

Answer 10

Coronary Heart Disease
Hypertensive Heart Disease
Valvular Heart Disease
Myocardial Disease/ Cardiomyopathies
Congenital Heart Disease

Question 11

Activation of neurohormonal system

Answer 11

Release of Noradrenaline – increases heart rate and myocardial contractility. Causes vasoconstriction
Release of ANP/BNP
Activation of renin-angiotensin – aldosterone system

Question 12

Compensatory mechanisms

Answer 12

Vasoconstriction
Na and water retention
Excessive Tachycardia

Question 13

Pressure Overload

Answer 13

Concentric left ventricular hypertrophy
E.g. Hypertension or aortic stenosis
Augmented muscle may reduce the cavity diameter
Cross sectional areas of the myocytes are increased

Question 14

Volume overload

Answer 14

Chamber dilatation with increased ventricular pressure
E.g. mitral or aortic regurgitation
Deposition of new sarcomeres
Increased cell length and width
Muscle mass and wall thickness are increased in proportion to chamber diameter

Question 15

Left side HF

Answer 15

Blood backs up progressively from the left atrium to the pulmonary circulation

Causes:
Ischaemic heart disease
Hypertension
Valvular heart disease
Myocardial disease

Question 16

Left side HF - lungs

Answer 16

Breathlessness
Orthopnoea
Paroxysmal nocturnal dyspnoea

Question 17

Left side HF - kidneys

Answer 17

Decreased cardiac output

Reduction in renal perfusion

Activation of renin - angiotensin – aldosterone system

Retention of salt and water with consequent expansion of interstitial fluid and blood volumes

Question 18

Left side HF - brain

Answer 18

Hypoxic encephalopathy
Irritability
Loss of attention
Restlessness
Stupor and coma

Question 19

Right side HF

Answer 19

Usually as a consequence of left sided heart failure (congestive cardiac failure

Cor-pulmonale:
Right sided HF due to significant pulmonary hypertension due to increased resistance within the pulmonary circulation
Usually as a result of respiratory disease e.g. COPD or pulmonary emboli

Question 20

Right side HF- Cor Pulmonale

Answer 20

Right sided HF due to significant pulmonary hypertension due to increased resistance within the pulmonary circulation
Usually as a result of respiratory disease e.g. COPD or pulmonary emboli

Question 21

Right side HF - other causes

Answer 21

Valvular heart disease

Congenital heart disease

Question 22

RHF - liver and portal system

Answer 22

Congestive hepatomegaly
Centrilobular necrosis when severe
Cardiac cirrhosis

Question 23

RHF - spleen

Answer 23

Congestive splenomegaly

Question 24

RHF - abdomen

Answer 24

Ascites - accumulation of transudate in peritoneal cavity

Question 25

RHF - subcutaneous tissue

Answer 25

Peripheral oedema of dependent portions of the body esp. ankle and pretibial oedema Sacral oedema if bedridden

Question 26

RHF - Pleural and pericardial space

Answer 26

Effusions

Question 27

RHF systemic effects

Answer 27

``` Liver and portal system Spleen Abdomen Subcutaneous tissue Pleural and pericardial space ```

Question 28

Biventricular failure

Answer 28

Either due to the same pathological process on each side of the heart OR Consequence of left heart failure leading to volume overload of the pulmonary circulation and eventually the right ventricle causing right ventricular failure

Question 29

HF clinical presentation

Answer 29

``` Due to excess fluid accumulation Dyspnoea Orthopnoea, paroxysmal nocturnal dyspnoea Oedema Hepatic congestion Ascites ``` Due to reduction in cardiac output Fatigue Weakness

Question 30

HF clinical presentation - due to excess fluid accumulation

Answer 30

``` Dyspnoea Orthopnoea, paroxysmal nocturnal dyspnoea Oedema Hepatic congestion Ascites ```

Question 31

HF clinical presentation - Ddue to reduction in cardiac output

Answer 31

Fatigue | Weakness

Question 32

Classification of HF

Answer 32

I: No limitation II: Slight limitation III: Marked limitation IV: Severe limitation

Question 33

Clinical signs of cardiac failure

Answer 33

``` Cool, pale, cyanotic extremities Tachycardia Elevated JVP Third heart sound (S3) – gallop rhythm Displaced apex (LV enlargement) Crackles or decreased breath sounds at bases on chest auscultation Peripheral oedema Ascites Hepatomegaly ```

Question 34

Acute Pulmonary Oedema

Answer 34

``` Acute Breathlessness Pallor Cyanosis Sweating Rapid Pulse Hypoxia Crackles in Lungs ```

Question 35

Clinical tests in HF

Answer 35

``` CXR ECG Blood investigations Echocardiogram / Cardiac MRI or CT / CT-PET CTCA / Coronary angiography ```

Question 36

Current drug treatment

Answer 36

``` Aldosterone antagonists ARNI ACEi/ARBs Beta-blockers SA Node Blockade ```

Question 37

Current drug treatment - ACEi / ARBs

Answer 37

Enalapril, Ramipril, Perindopril | Losartan, Candesartan, Irbesartan

Question 38

Current drug treatment - ARNI

Answer 38

Sacubitril Valsartan

Question 39

Current drug treatment - Aldosterone antagonists

Answer 39

Spironolactone, Eplerenone

Question 40

Current drug treatment - Beta-blockers

Answer 40

Carvedilol, Bisoprolol, Metoprolol

Question 41

Current drug treatment -SA Node Blockade

Answer 41

Ivabradine

Question 42

Current drug treatment - Diuretics

Answer 42

Loops – Furosemide, Bumetanide Thiazides – Bendrofluamethiazide, Indapamide Quinazolines - Metolazone

Question 43

Loop diuretics

Answer 43

FRUSEMIDE, BUMETANIDE Inhibit Na+ re-absorption from the proximal tubule K+ loss from distal tubule Can be given iv or orally Potent – can lead to: electrolyte abnormalities hypovolaemia and diminished renal perfusion

Question 44

Mineralocorticoid Receptor Antagonists

Answer 44

EPLERENONE, SPIRONOLACTONE Acts on distal tubule Promotes Na+ excretion and K+ re-absorption Reduces hypertrophy and fibrosis Principle Side-Effects Gynaecomastia (esp. Spironolactone) Electrolyte (K+ high) and renal function abnormalities

Question 45

ACE Inhibitors

Answer 45

RAMIPRIL, PERINDOPRIL, ENALAPRIL, CAPTOPRIL, LISINOPRIL Act on activated renin - angiotensin system Given orally in small doses with slow titration Block production of angiotensin: Vasodilatation BP lowering Reduce cardiac work Principle Side-Effects: cough, hypotension, renal impairment

Question 46

ARNI

Answer 46

SACUBITRIL VALSARTAN Acts on activated renin - angiotensin system Also blocks breakdown of ANP/BNP Block production of angiotensin: Vasodilatation, BP lowering, reduce cardiac work Promote natriuresis Sodium excretion, vasodilatation, reduce hypertrophy and fibrosis Principle Side-Effects: hypotension, renal impairment

Question 47

Beta blockers

Answer 47

BISOPROLOL, CARVEDILOL, METOPROLOL Block the action of adrenaline and noradrenaline on adrenergic beta receptors Slow HR, reduce BP Given orally in small doses with slow titration (treat arrhythmias) Principle Side-Effects Bronchospasm Claudication

Question 48

SAN blockade

Answer 48

IVABRADINE Blocks the If channel within the SA node Slow HR, no effect on BP Given orally with dose titration Principle Side-Effects Visual aura Bradycardia

Question 49

Digoxin

Answer 49

Action: Increases myocardial contractility Slows conduction at the AV node (use in AF) Excreted by kidney - Toxicity important Given: Acute HF especially in AF Chronic HF in selected cases

Question 50

Treatment of Acute Pulmonary Oedema - Immediate

Answer 50

High flow oxygen IV Morphine IV Nitrates IV Frusemide +/- Assisted Ventilation

Question 51

Treatment of Acute Pulmonary Oedema - Definitive

Answer 51

Identify Cause Oral diuretics Medical Therapy Revascularisation if appropriate

Question 52

Other therapies

Answer 52

``` Cardiac Resynchronisation Therapy (CRT) Implantable Cardioverter Defibrillator (ICD) Dialysis & Ultrafiltration Ventricular Assist Device (LVAD/RVAD) Intra-aortic balloon pump Cardiac transplantation (Stem cell therapy) ```

Question 53

CRT (Biventricular pacing)

Answer 53

Standard pacemakers equipped with two wires (or "leads") conduct pacing signals to specific regions of heart. Biventricular pacemakers have an additional third lead designed to conduct signals directly into the left ventricle. Combination of all three leads promote synchronised pumping of ventricles, increasing efficiency of each beat and pumping more blood on the whole.