HF Part 1

Question 1

Definition of HF / CF

Answer 1

An inability of the heart to deliver blood (and O2) at a rate proportionate with the requirements of the metabolising tissues, despite normal or increased cardiac filling pressures

Congestive cardiac failure describes a combination of left and right-sided ventricular failure.

Question 2

Epidemiology of CF

Answer 2

• M>F
• More prevalent with increasing age
  Common: 2-10 (20) %
  Costly: 2% of the NHS expenditure in the UK
  Disabling: The worst quality of life.
  Treatable - not really curable
  25-50% of patients die within 5 years of diagnosis

Question 3

RFs

Answer 3

• Prev MI - greatest RF
• Male, age
• IHD
• HT
• DIabetes
• Renal failure
• AF

Question 4

Causes of HF

Answer 4

• Myocardial dysfunction - greatest cause
• HT
• Alcohol
• Cardiomyopathy
• valvular

Question 5

What is HFrEF?

Answer 5

HF with reduced ejection fraction

Question 6

What is HFpEF?

Answer 6

HF with preserved ejection fraction

Question 7

Phenotypes of HF

Answer 7

HF due to severe valvular heart disease (HF-VHD)
HF with pulmonary hypertension (HF-PH)
HF due to right ventricular systolic dysfunction (HF- RVSD)

Question 8

Classes of HF (NYHA)?
Used for assessment of severity of symptoms

Answer 8

Class I: No limitation (Asymptomatic)
Class II: Slight limitation (mild HF)
Class III: Marked limitation (Symptomatically moderate HF)
Class IV: Inability to carry out any physical activity without discomfort (symptomatically severe HF)

Question 9

What is systolic HF

Answer 9

Inability of the ventricle to contract normally resulting in a
decrease in cardiac output

Question 10

Systolic HF

Answer 10

• Cardiac output = stroke volume x heart rate
• The ejection fraction is not preserved: an ejection fraction of 40% or less would indicate systolic heart failure.
• The low stroke volume is due to the ventricles not pumping enough blood out.
• HFrEF

Question 11

Diastolic HF

Answer 11

• Cardiac output = stroke volume x heart rate
• In this case, the stroke volume is low but the ejection fraction is preserved. The reason for the low stroke volume is due to reduced filling of the ventricle (reduced preload)
• HFpEF

Question 12

Why does right sided HF occur?

Answer 12

• usually occurs as a result of left-sided heart failure.
• Blood starts backing up into the lungs causing pulmonary oedema and congestion
• pulmonary hypertension puts pressure on the right ventricle (cor pulmonale) and causes right-sided heart failure

Question 13

Causes of systolic failure 1

Answer 13

• Ischaemic heart disease: as less blood and oxygen get to the myocardium, the myocytes start to die
• Hypertension: as arterial pressure increases in the systemic circulation, it gets harder for the left ventricle to pump blood out into that hypertensive systemic circulation.

Question 14

Causes of Systolic failure 2

Answer 14

• Left ventricular hypertrophy: increased muscle mass requires increased oxygen supply - making it more likely for that the muscle will die
• Dilated cardiomyopathy: heart chambers dilate and thin out, leading to weaker contractions.

Question 15

Causes of diastolic failure

Answer 15

• Left ventricular hypertrophy: causes the ventricular chamber to decrease in size which means less blood can enter.
• Restrictive cardiomyopathy: ventricle can’t stretch enough to accommodate the blood
• Valvular disease: e.g. aortic stenosis causes LVH or mitral regurgitation means blood doesn’t enter the ventricles in the right amount as it leaks back into atria
• Arrhythmias e.g. atrial fibrillation

Question 16

Normal heart mechanism

Answer 16

Increased ventricular filling results in increased contraction via the Frank-Starling law→ increased cardiac output

In HF mechanism fails

Question 17

Pathophysiology of Congestive HF

Answer 17

• As the heart continues to fail →compensatory mechanismsare activated, including anincrease in heart rate,catecholamine releaseandRAAS activation (due to decreased blood flow to kidneys)
• These mechanisms are useful in theinitialperiod but are usuallyoverexpressed, thus instigating avicious cycle.
• Compensatory mechanisms are usually responsible for the fluid retention and fluid overload symptoms experienced by the patient

Question 18

Signs of Left sided Heart failure

Answer 18

• Tachypnoea and tachycardia
• Cool peripheries
• Peripheral or central cyanosis
• Displaced apex beat
• Stony dull percussion
• Third heart sound (S3)

Question 19

Symptoms of Left sided HF

Answer 19

• Dyspnoea: particularly exertional
• Orthopnoea (SOB when lying flat) and paroxysmal nocturnal dyspnoea (SOB at night)
• Fatigue and weakness
• Cough with pink, frothy sputum
• Cardiogenic wheeze

Question 20

Right sided HF signs

Answer 20

• Due to backing up of fluid:
  
  • Raised JVP
  • Peripheral pitting oedema
  • Hepatosplenomegaly
  • Ascites

Question 21

Symptoms of Right sided HF

Answer 21

• Fatigue and weakness
• Due to backing up of fluid
  
  • Swelling in the legs
  • Distended abdomen

Question 22

Investigations

Answer 22

• NT-proBNP: increased in chronic heart failure
• ECG:broad QRS complexes; evidence of left ventricular hypertrophy
• CXR
• Transthoracic echocardiogram

Question 23

What is shown on an Chest X ray?

Answer 23

• A-Alveolar oedema (batwing opacities)
• B- KerleyBlines
• C-Cardiomegaly
• D-Dilated upper lobe vessels
• E- Pleural effusion

Question 24

1st line management

Answer 24

BB (Bisoprolol) + ACEi (Ramipril)
If ACEi intolerant - ARB (Losartan) or hyrdalazine with nitrate

Question 25

2nd line management

Answer 25

Aldosterone antagonist (e.g. spironolactone) if symptoms not controlled with 1st line management

Question 26

3rd line management

Answer 26

- **Digoxin**: an alternative option, particularly for patients with AF and heart failure due to its inotropic effects. - **Ivabradine**: an alternative option if HR >75 bpm and LVEF <35%; slows the heart rate so the heart can pump more blood through the body each time it beats. - **Cardiac resynchronisation therapy (CRT):** involves biventricular pacing and forces both ventricles to contract in synchrony, thereby improving cardiac output

Question 27

Complications of HF

Answer 27

- **Pleural effusion:** heart failure causes an elevated pulmonary capillary pressure, usually resulting in bilateral transudative pleural effusions - **Acute decompensation of chronic heart failure:** patients usually present with acute respiratory distress due to significant pulmonary oedema - **Arrhythmias** - **Acute renal failure:** reduced cardiac output and drug overuse (ACE inhibitors, aldosterone antagonists, diuretics) results in poor renal perfusion