Heart Failure

Question 1

How is heart failure classified?

Answer 1

1) Time course of failure
2) Side of the heart affected
3) Effect on the ejection fraction
4) Symptomatic severity

In the majority of cases, heart failure will develop slowly and is more of a chronic condition.
Acute failure can occur independently or can occur to due to de-compensation of chronic heart failure; decompensation can be triggered by:
- MI
- Arrhythmia
- Pneumonia
- Uncontrolled hypertension

Question 2

Causes of left heart failure:

3 categories of 1) CVS 2) Volume overload and 3) high output states

Answer 2

1) Coronary heart disease, hypertension, valve disease, arrhythmia, cardiomyopathy
2) Chronic kidney disease, nephrotic syndrome
3) Anaemia, sepsis, liver failure

Question 3

Presentation of left heart failure?

Answer 3

Symptoms:

• Fatigue, reduced exercise tolerance, weight loss
• SOB, orthopnoea, paroxysmal nocturnal dyspnoea,
• Productive cough (pink frothy sputum)

Signs:

• S3 (ventricular gallop)
• Bibasal crepitations
• Displaced apex beat.

S3 is a heart sound heard directly after S2 that is associated with heart failure.

Question 4

Causes of right heart failure:

Answer 4

• secondary to left sided failure

- Cor pulmonale (pulmonary hypertension leading to right heart failure)

Question 5

Presentation of right heart failure:

Answer 5

• Peripheral oedema
• Ascites
• Facial engorgment

Signs:

• Raised JVP
• Hepatomegaly
• Chest vein dilatation
• Ascites

Question 6

Effect on ejection fraction, turn over for explanation:

Answer 6

Left heart failure can be associated with either reduced or preserved ejection fraction:

HF-REF: Heart failure with reduced ejection fraction. Reduced cardiac output due to failure of the ventricles to properly contract.

HF-PEF: Heart failure with preserved ejection fraction. Thought to be associated with atrial dysfunction that results in reduced ventricular filling and therefore reduced cardiac output.

Question 7

Investigations of heart failure:

Answer 7

Bloods: raised BNP (if BNP normal largely rules out heart failure, released in response to ventricular dilatation)

• Measure serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) in patients with suspected heart failure without previous MI.

ECG: LVH, left bundle branch block, pathological Q waves, AF.

Echo: should be carrier out if either of the above are abnormal

CXR: Left ventricular failure:

• Cardiomegaly
• Pleural effusion
• Kerly B lines
• Alveolar oedema (bats wings)

Note: CXR normal in right sided failure

Question 8

Pharmacological management of heart failure:

Answer 8

• Aim to treat underlying cause if possible
• Loop diuretics: provide symptomatic relief (furosemide)
• ACEi - prolongs life as prevents cardiac remodelling.m
• B Blocker (bisoprolol) - reduce mortality but need to be started at low dose as can worsen failure before making it better.