Heart Failure Presentation and Investigations

Question 1

Definition of Heart Failure

Answer 1

a clinical syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction, either at rest or on exertion, with accompanying neurohormonal activation

Question 2

What is neurohormonal activation

Answer 2

Defence mechanisms designed to preserve arterial volume and circulatory homeostasis during periods of low cardiac output. This includes the sympathetic system, RAAS and vasopressin

Question 3

Is HF the final diagnosis? why

Answer 3

No, needs to qualified by the underlying structural abnormality

Question 4

Increasing risk of CHF (7)

Answer 4

	Treatment of AMI
	Ageing population
	Hypertension
	CHD
	Obesity
	Diabetes
	HLP

Question 5

Decreasing risk of CHF (6)

Answer 5

	HLP
	Hypertension
	CHD
	Diabetes
	Obesity
	Treatment of CHF

Question 6

What group of diseases does HF have a similar mortality to?

Answer 6

Cancers

Question 7

Heart Failure Hospital Admissions (8)

Answer 7

1. Acute breathlessness
2. Stable HF
3. Acute MI/unstable angina
4. Rapid atrial fibrillation
5. Asymptomatic cardiac dysfunction
6. Ventricular arrhythmia
7. Cardiogenic shock
8. Cardiac arrest

Question 8

What 3 things are needed for a diagnosis

Answer 8

1. Symptoms or signs of HF
2. Objective evidence of cardiac dysfunction
3. Response to therapy (diuretics)

Question 9

Symptoms of HF (4)

Answer 9

• Breathlessness
• Fatigues
• Oedema
• Reduced exercise capacity

Question 10

Signs of HF (6)

Answer 10

• Oedema
• Tachycardia
• Raised JVP
• Chest crepitations
• 3rd heart sound
• Displaced or abnormal apex beat

Question 11

What would a CXR show in HF (4)

Answer 11

• Cardiomegaly
• Dilation of vessels due to pressure
• Increased cardiothoracic ratio
• Pleural effusions

Question 12

Objective evidence of cardiac dysfunction

Answer 12

• ECHO
• Radionucleotide Scan
• Left ventriculogram
• Cardiac MRI

Question 13

Potential Screening tests

Answer 13

• 12 lead ECG

* BNP (brain (B-type) natriuretic peptide)

Question 14

if 12 lead ECG is normal what is very unlikely

Answer 14

LVSD

Question 15

BNP is elevated/reduced in heart failure?

Answer 15

Elevated

Question 16

What are the other reasons BNP can be elevated

Answer 16

• AF
• Elderly
• Valve Disease

Question 17

Diagnostic evaluation of patients with LVSD (8)

Answer 17

1. Detailed history
2. Exclude renal failure, anaemia
3. Autoantibodies/viral serology, ferritin levels
4. Exclude pheochromocytoma (neuroendocrine tumour of the medulla of the adrenal glands)
5. ECG, CXR, always do ECHO
6. Consider coronary angiogram if there is chest pain in younger patients
7. Evaluate for ischaemia/hibernation
8. Cardiac MRI

Question 18

Why is an ECHO essential (7)

Answer 18

•	Identify and quantify
	LV systolic dysfunction
	Valvular dysfunction
	Pericardial effusion/tamponade
	Diastolic dysfunction
	LVH
	Atrial/ventricular shunts/complex congenital heart defects
	Pulmonary hypertension/right heart dysfunction

Question 19

What may a ECHO not idnetify

Answer 19

Constriction

Question 20

Biological variable

Answer 20

LVEF

Question 21

What can decrease and increase the LVeF

Answer 21

Disease and physiological changes

Question 22

Why can LVEF be difficult to quantify accurately using ECHO (^)

Answer 22

•	Quality of images
•	Experience of operator
•	Calculation method
	M-mode
	Simpson’s biplane
•	Use of contrast agents
•	Time consuming to perform
•	Normal range is centre specific, but LVEF not routinely measured

Question 23

LVEF 50-80%

Answer 23

Normal

Question 24

LVEF 20-50%

Answer 24

Mild

Question 25

LVEF 30-40%

Answer 25

Moderate

Question 26

LVEF <30%

Answer 26

Severe

Question 27

Biplane Modified Simpson's Rule

Answer 27

Divides LV cavity into multiple slices of known diameter and thickness

Question 28

Biplane Modified Simpson's Rule- Volume of each slice =

Answer 28

area x thickness (πr2 x thickness)

Question 29

Biplane Modified Simpson’s Rule- thinner slices mean

Answer 29

More accurate volume estimate

Question 30

Left ventricle ejection fraction depends on

Answer 30

LV contractility, pre-load, afterload and HR

Question 31

LVEF =

Answer 31

EDV-ESV/EDV

Question 32

Pros of MUGA for LVEF (2)

Answer 32

Can obtain accurate figure | Greater reproducibility

Question 33

Cons of MUGA for LVEF (2)

Answer 33

Ionising radiation | No additional structural information

Question 34

Pros of MRI for LVEF (3)

Answer 34

Gold standard Reproducible Added information about- fibrosis,oedema, infiltration and valves

Question 35

Cons of MRI for LVEF (3)

Answer 35

Time consuming Dependent on patient compliance Specialist centres Long waiting lists

Question 36

NYHA class I Heart Failure exercise tolerance and symptoms

Answer 36

No limitation | No symptoms during usual activity

Question 37

NYHA Class II Heart Failure exercise tolerance and symptoms

Answer 37

Mild limitation | Comfortable with rest or mild exertion

Question 38

NYHA class III heart failure exercise tolerance and symptoms

Answer 38

Moderate limitation | Comfortable only at rest

Question 39

NYHA class IIII exercise heart failure tolerance and symptoms

Answer 39

Severe limitations | Any physical activity brings on discomfort and symptoms occur at rest

Question 40

Does HF equal reduced CO (YN)

Answer 40

No

Question 41

In a normal heart if the EDV is 100mls with 60% EF and a HR of 60bpm what is the CO

Answer 41

CO= SV X HR 60% of 100mls = 60mls (SV) 60mls X 60bpm= 3600ml 3.6 Litres

Question 42

In a dilated heart if the EDV is 200ml with only 30% EF and a HR of 60bpm what is the CO

Answer 42

CO= SV X HR 30% of 200mls = 60mls 60mls X 60bpm = 3.6 Litres

Question 43

Modern Pharmacological Treatment of Heart Failure (6)

Answer 43

``` Diuretics ACEI/ARB B Blockers Aldosterone receptor blockers ARNIs ```

Question 44

Diuretics

Answer 44

-Furosemide/Bumetanide

Question 45

ACEI/ARB

Answer 45

- Ramipril, Enalapril | - Candesartan/Valsartan

Question 46

B Blockers

Answer 46

-Carvedilol/Bisoprolol

Question 47

Aldosterone receptor blockers

Answer 47

Spironolactone/Eplerenone

Question 48

ARNIs

Answer 48

-Entresto