CCF

Question 1

Definition of CCF

Answer 1

Heart failure is a clinical syndrome in which the heart is unable to pump blood effectively to meet the metabolic demands of the body, or does so only at elevated filling pressures.

“Congestive” refers to fluid accumulation in the lungs and/or peripheral tissues due to impaired forward flow and/or elevated venous pressures.

Question 2

Left sided heart failure clinical features

Answer 2

Dyspnoea, orthopnoea, PND
Cough, pink frothy sputum
Pulmonary oedema (crackles)
Fatigue, exercise intolerance

Question 3

Right sided heart failure clinical features

Answer 3

Peripheral oedema
Hepatomegaly (congestive)
Elevated JVP
Ascites

Question 4

Pathological/Histological findings in CCF

Answer 4

Gross:
Cardiomegaly
Pulmonary congestion/oedema
Nutmeg liver (chronic passive hepatic congestion)

Histology:
Pulmonary: haemosiderin-laden macrophages (“heart failure cells”)
Myocyte hypertrophy and interstitial fibrosis
Congested sinusoids in liver

Question 5

Pathophysiology of CCF

Answer 5

1. ↓ Cardiac output
2. Neurohormonal activation:
   ↑ SNS: tachycardia, vasoconstriction
   ↑ RAAS: salt/water retention → ↑ preload
   ↑ ADH: water retention
3. Remodelling: hypertrophy, fibrosis
4. Congestion

Question 6

Description of systolic heart failure

Answer 6

HFrEF
Impaired contraction
eg Dilated cardiomyopathy

Question 7

Description of diastolic heart failure

Answer 7

HFpEF
Impaired relaxation
eg LVH, restrictive cardiomyopathy

Question 8

What histological findings occur in compensated pressure loaded cardiac hypertrophy?

Answer 8

diffuse fibrosis
a decrease in the capillary myocyte ratio
an increase in the number and mutations of the sarcomeres
synthesis of abnormal and dysfunctional proteins
extreme hypertrophy

Question 9

In pressure loaded cardiac hypertrophy what happens to the ventricle wall and how does this compare to volume loaded cardiac hypertrophy ?

Answer 9

In response to pressure loaded cardiac hypertrophy there is the development of a concentric increase in the ventricular wall.

In contrast to volume loaded cardiac hypertrophy where there is a dilation of the ventricle

Question 10

Causes of high out put failure

Answer 10

Anaemia including iron deficiency, vitamin B12, folate deficiency and Sickle cell disease. Renal failure (lack of erythropoietin).
Pregnancy
beriberi (vitamin B1/thiamine deficiency),
thyrotoxicosis,
Paget’s disease,
arteriovenous fistulae and arteriovenous malformations,
morbid obesity,
cor pulmonle,
carcinoid syndrome,
multiple myeloma,
beta-thalassemia intermedia
cirrhosis.

Question 11

Define dilated cardiomyopaty

Answer 11

Dilated cardiomyopathy (DCM) is characterised by progressive cardiac dilation and contractile dysfunction, usually with concomitant hypertrophy.

Question 12

causes of DCM

Answer 12

Genetic
toxicities - alcohol, chemotherapeutics, p
eripartum cardiomyopathy (occurring late in pregnancy or up to 5 months after delivery)

Question 13

what is end stage DCM

Answer 13

End stage DCM often has an ejection fraction (EF) of <25%.

Question 14

Survival rate of DCM

Answer 14

50% of patients die within 2yrs and the 5yr survival rate is 25%.

Question 15

Age group mostly effected by DCM

Answer 15

20-50 y/o

Question 16

causes of diastolic heart failure

Answer 16

hypertension (commonest), diabetes mellitus, obesity, bilateral renal artery stenosis.

mostly in patients>65yrs. It is more common in women

Question 17

with diastolic heart failure what happens to cardiac output at rest

Answer 17

cardiac output is relatively preserved at rest.

Question 18

a complication of diastolic heart failure

Answer 18

pulmonary oedema

Because the left ventricle is unable to expand, any increase in filling pressure is immediately referred back into the pulmonary system causing (flash) pulmonary oedema

Question 19

In a man with congestive heart failure, which of the following occurs?

A Increased atrial pressure
B Prolonged decrease in sodium reabsorption in the proximal convoluted tubule
C Increased albumin
D Increased renin secretion

Answer 19

A Increased atrial pressure

Congestive cardiac failure results in an increase in ventricular and atrial pressures.

Question 20

what are the renal effects caused by ANP

Answer 20

Increased GFR
decreased Na reabsorption
inhibition of renin secretion
inhibiting RAAS

Question 20

How/why is ANP released in CCF

Answer 20

Atrial stretch stimulates ANP release

Question 21

Which features are consistent with a patient with diastolic heart failure?

A Increased diastolic filling, increased stroke volume
B Decreased diastolic filling, decreased stroke volume
C Decreased diastolic filling, increased stroke volume
D Increased diastolic filling, decreased stroke volume

Answer 21

B Decreased diastolic filling, decreased stroke volume