JC09 (Medicine) - Exertional Heart Failure

Question 1

Define heart failure

Answer 1

HF:

Unable to pump blood at a rate to match requirement of metabolizing tissues

Due to forward failure (adequate filling pressure) or backward failure (congestion with high filling pressure to distend myocardium for higher CO)

Question 2

S/S low cardiac output/ forward heart failure

Answer 2

Question 3

S/S of right heart failure (backward HF)

Answer 3

Question 4

S/S of left heart failure

Answer 4

Question 5

Describe the Frank Starling Law

Answer 5

Question 6

Mechanism of Orthopnea/ PND

Answer 6

Question 7

Mechanism of pulmonary edema in left heart failure

Answer 7

Question 8

Symptoms/ Signs of HF

• Which ones are the most specific/ sensitive?

Answer 8

Question 9

Name two criteria for Dx of heart failure

Answer 9

Framingham criteria

Boston criteria

Question 10

Name one criteria for severity of LV dysfunction

Answer 10

Question 11

CXR Lung features of left heart failure

Answer 11

Upper lobe diversion/ Cephalization - pulmonary venous hypertension, pulmonary edema in the lower lobe compresses on lower lobe vessels and distends upper lobe vessels, exacerbated by hypoxia-vasoconstriction in lower lobe vessels

Kerley B lines (Septal lines) - Interstitial edema, develops at LA pressure > 15-20mmHg

Peribronchial cuffing - Interstitial fluid accumulate around bronchi causing thickening of bronchial wall, doughnut-like densities in parenchyma, LA pressure > 15-20mmHg

Question 12

Biomarkers for heart failure

Levels for severities of HF

Physiological function of the marker

Answer 12

Brain Natriuretic Peptide (BNP) and NT-proBNP

Endogenous function: BNP from cardiomyocytes to resist fibrosis and myocardial hypertrophy by decreasing BP, sympathetic tone, RAAS activation

Question 13

Cardiac causes of high BNP

Answer 13

Question 14

Confounding/ Non-cardiac causes of high BNP

Answer 14

Question 15

Surgical Treatment options for HF

Answer 15

Devices:

• Cardiac Resynchronization therapy (CRT) (biventricular pacing)
• Cardiac assist devices: Pacemaker
• Implantable Cardioverter Defibrillator (ICD)

Revascularization:

• Cardiac Transplant
• CABG for ischemic cardiomyopathy
• Valvular surgery
• Left ventricular assist device (LVAD)

Question 16

Outline history taking questions for HF (apart from S/S)

Answer 16

Symptoms of HF: Characterize all symptoms in detail

Past history of CAD, PVD, Stroke

Etiologies:

• Risk factors of CVS: Smoking, Metabolic syndrome (HT, DM,HL)
• Valvular diseases: CTD, Rheumatic fever…etc
• Systemic diseases: Thyroid storm, Pheochromocytoma …etc
• Cardiotoxic drugs: Chemo/RT, Substance abuse

Family history:

• Sudden death at young age, FHx of myopathies, arrhythmias, premature CVD

Question 17

First-line investigations for HF ***

Answer 17

Blood:

• CBC
• Serum K, Ca, PO4, glucose
• RFT, Serum Urea and Cr
• TSH, fT4
• BNP, Pro-BNP

Urine microscopy and urinalysis

CXR: Features of HF

ECG

Further confirmation: CT/ MRI, Nuclear scans e.g. MIBG, Exercise/ pharmacological stress testing, Cardiac catherization

Question 18

Outline the NYHA Functional Classification to stage HF

Answer 18

Question 19

Outline the clinical course of HF over time

Answer 19

Question 20

Causes of HF

Answer 20

Question 21

Myocardial disorders that cause HF

Answer 21

Question 22

Classes of HF according to ejection fraction

Answer 22

Heart failure with Reduced Ejection Fraction (HFrEF)/ Systolic HF - LVEF <40%

Heart failure with Preserved Ejection Fraction (HFpEF)/ Diastolic HF - LVEF >50%

Other classes: HFmrEF (41-49%), HFpEF (>40%)

Question 23

Compare HFrEF and HFpEF

• Demographics
• Risk factors
• Difference in CXR

Answer 23

Question 24

Approach to Dx heart failure

Answer 24

1. Clinical diagnosis by S/S and diagnostic criteria
2. Unclear clinical diagnosis >> use BNP or Pro-BNP concentration with clinical context to Dx

Question 25

Causes of acute HF

Answer 25

Respiratory causes: * Acute respiratory failure * Pulmonary embolism Circulation emergency: * Cardiogenic shock * Hypertension emergency/ Malignant hypertension Cardiac causes: * Acute Coronary syndrome/ MI * Arrhythmia * Acute mechanical cause e.g. VHD, LVOTO Systemic: * Anemia * Endocrine: e.g. thyroid storm, pheochromocytoma * Adverse drug effects

Question 26

Approach to treat hemodynamic profiles of heart failure \*

Answer 26

Congestion (both left or right heart) (Yes or No) \>\> S3, peripheral edema, orthopnea and PND, high JVP, Pulmonary edema Perfusion (Adequate or poor) \>\> low peripheral temp and pulse **HF with congestion (Wet profile)** 1. **Adequate peripheral perfusion** - Wet and Warm - Treat hypertension and congestion with **Vasodilators, Diuretics** 2. **Poor peripheral perfusion** - Wet and Cold - **Inotropes, Vasopressors, Diuretics for low SBP**; **Vasodilators, Diuretics for normal SBP** **HF without congestion (Dry profile)** 1. **Adequate peripheral perfusion** - Dry and warm - **Compensated HF, adjust medication** 2. **Poor peripheral perfusion** - Dry and cold - treat hypoperfusion with **Fluid Challenge, Inotropic agent**

Question 27

General management and monitoring metrics for acute HF

Answer 27

General: * Bed rest * O2 supplementation: NIV, NI-cPAP, Intubation, Mech. ventilation * Low salt diet * Fluid restriction Monitor: * Vitals: Orthostatic BP, O2 saturation, HR * Fluid I/O, Weight * Clinical: signs of peripheral congestion, symptoms of HF * Electrolytes and renal function

Question 28

Drug management of acute HF All options

Answer 28

BP Stable: * IV Frusemide (diuretic) * IV nitrate * Morphine (pain) BP unstable or deterioration: * Moderate: Inotropes: Dopamine and Dobutamine * Severe: Intra-aortic balloon pump, ECMO

Question 29

Drug management for CHRONIC HF (HFrEF) All options

Answer 29

4 main pillars: 1. ACEi/ ARB + Beta Blocker 2. Mineralocorticoid receptor antagonist 3. Angiotensin receptor neprilysin inhibitor (ARNI), Ivabradine 4. Surgical: e.g. Cardiac resynchronization therapy (CRT) Additional: * Nitrate + Hydralazine if cannot tolerant ACEi and ARB * Diuretics for volume overload * Anti-coagulants, Digoxin, PCI for A-fib * CABG/ PCI for CAD

Question 30

Examples of ACEi and ARB Indications for HF

Answer 30

ACEi - Captopril, Ramipril Recommended for all HFrEF patients ARB - Valsartan, Losartan For ACEi refractory patients with intractable cough, angioedema

Question 31

Effect of Beta blocker in HF

Answer 31

Cardioprotective effect, block SNS stimulation Short-term decrease contractility, increase EF gradually after 1-3 months of use Increase the dose with time Long-term symptomatic improvement

Question 32

Effect of MRA on HF

Answer 32

Spironolactone - reduce HF mortality and morbidity Eplerenone - reduce MI, HF mortality with less hormonal side effects e.g. gynaecomastia

Question 33

Effect of Ivabradine on HF

Answer 33

Funny Channel blocker - reduces SA node firing frequency and slows HR For patients intolerant to Beta-blockers

Question 34

Treatment options for CHRONIC HF HFpEF/ Diastolic HF\*\*

Answer 34

SGLT-2 inhibitor + ACEi/ ARB = major drugs Additional: * Slow HR, BP control: BB, CCB * Diuretics for volume overload * CAD - coronary revascularization