Working Problem 2- Heart failure

Question 1

What is heart failure

Answer 1

Heart failure is a condition in which the heart is unable to generate a cardiac output sufficient to meet the demands of the body without increasing diastolic pressure.

Question 2

What do you ask for in the history?

Answer 2

A history of hypertension; diabetes mellitus; dyslipidemia; tobacco use; coronary, valvular, or peripheral vascular disease; rheumatic fever; heart murmur or congenital heart disease; personal or family history of myopathy; mediastinal irradiation; and sleep-disturbed breathing should be enquired about.

Question 3

What are clinical features on physical examination?

Answer 3

• Dyspnoea on exertion or at rest
• tachycardia,
• peripheral oedema
• neck vein distension as an indicator of elevated jugular venous pressure
• third heart sound (S3)
• Pulmonary rales
• Hepatomegaly
• Right ventricular heave

Question 4

What investigation do you carry out for someone with Heart failure

Answer 4

• ECG
o evidence of underlying CAD, LVH, or atrial enlargement; may be conduction abnormalities and abnormal QRS duration

• transthoracic echocardiogram
o systolic heart failure: depressed and dilated left and/or right ventricle with low ejection fraction; diastolic heart failure: left ventricular ejection fraction (LVEF) normal but left ventricular hypertrophy (LVH) and abnormal diastolic filling patterns

CXR

• May reveal pulmonary congestion(vascular redistribution,kerly B lines)
• Cardiomegaly(increased cardiothoracic ratio or —-
• pleural effusions(usually right sided or bilateral)

BNP

• elevated in HF
• Increased BNP associated with increased LV filling ,acute MI and ischemia
• Increased BNP support dx of abnormal ventricular fucniton
• Decreased BNP rules out decompensated HF and points to pulmonary cause

FBC
Serum creatinine and BUN
-Rule out renal disease
Blood glucose
-diabetes
LFT
-reflects abdominal congestions
TFTs
-hypo and hyperthyroidism
Blood lipids
-metabolic syndrome

Question 5

How do you manage heart disease disease?

Answer 5

1. Identification and correction of the underlying condition causing heart failure
2. Elimination of the acute precipitating cause of symptoms in a patient with heart failure who was previously in a compensated state
3. Management of heart failure symptoms
   a. Treatment of pulmonary and systemic vascular congestion – diuretics, salt restriction, fluid management
   b. Measures to increase forward cardiac output and perfusion to vital organs – ACE inhibitors(FIRST LINE), angiotension II receptor blockers, nitrates and hydralazine, beta-blockers, inotropes, digoxin
   c. Treatment of atrial and ventricular arrhythmias – amiodarone, cardiac resynchronisation
4. Modulation of the neurohormonal response – aldosterone antagonists, beta-blockers, ACEi, ARBs
5. Improvement of long-term survival

Question 6

What is cardiomyopathy?

Answer 6

heterogeneous group of heart muscle diseases that make a significant contribution to morbidity and mortality. They are associated with mechanical and/or electrical dysfunction. Inappropriate ventricular hypertrophy or dilatation is usually present.

Question 7

How do you assess cardiomyopathy?

Answer 7

History of present illness
• The most common symptoms associated with cardiomyopathy are dyspnoea, chest discomfort, palpitations, and syncope.
Medical history
• History of coronary artery disease
• History of any causes of secondary cardiomyopathies
Family history
• Family history of premature cardiac death or arrhythmia
• hereditary causes of secondary cardiomyopathy

Question 8

What do you find in physical examination?

Answer 8

• Examination is directed towards seeking signs of cardiac dysfunction.
• A sustained prominent apical impulse on palpation
• diffusely palpable cardiac impulse with apical displacement
• murmurs, an S4 gallop or an S3 gallop
• Auscultation of the lungs may demonstrate crackles
• Pedal and leg oedema, and jugular venous distension

Question 9

What are the initial tests done in diagnosing cardiomyopathy?

Answer 9

• Designed to find cause.
• ECG
• FBC, metabolic panel, and thyroid function
• B-type natriuretic peptide
• cardiac markers including troponins or CK-MB
• chest x-ray
• Echocardiography, cardiac MRI and cardiac CT
• Other specific testing