Heart Failure

Question 1

Cause of Heart Failure

Answer 1

1. Hypertension
2. IHD
3. Alcohol
4. Cardiomyopathy
5. Valvular
6. Pericardial causes

Question 2

How does HF effect Venous return

Answer 2

1. Myocardial failure leads to reduction of blood ejected with each beat + increase in volume remaining after systole
2. Increased diastolic volume stretches myocardial fibres (increased force of contraction) - compensation mechanism
3. Myocardium eventually fails and can’t be compensated for

Question 3

How does HF effect Afterload

Answer 3

After load - resistance against which LV contracts (increase decreases CO)

As volume of blood ejected increases, after load increases which exacerbates problem

Question 4

How does HF effect Myocardial contractility

Answer 4

1. HF activates sympathetic NS via baroreceptors - maintains CO
2. Chronic sympathetic activation causes myocyte apoptosis even if there is temporary increase in contractility

Question 5

Acute Decompensated CHF vs AHF

Answer 5

Generally effects <70 vs 71-76

Male vs Female dominance

LVEF < 40% vs LVEF> 40%

Question 6

How is LVSD commonly caused

Answer 6

IHD, VHD and hypertension

Question 7

What is diastolic heart failure

Answer 7

Heart Failure where stiffness in Lv increases and compliance decreases - impaired LV diastolic filling so decreased CO

Question 8

Symptoms of HF

Answer 8

1. Dyspnoea
2. Fatigue
3. Tachycardia
4. Cardiomegaly
5. Pleural effusion
6. Fourth heart sounds
7. Ascites

Question 9

How is HF investigated in blood tests

Answer 9

1. Full blood count, thyroid function, cardiac enzymes

Question 10

How is Hf diagnosed

Answer 10

Echocardiography

Question 11

How does an electrocardiogram help with AF

Answer 11

Identifies Ischaemia, hypertension

Question 12

CXR in HF diagnosis

Answer 12

Looks for pulmonary congestion

Question 13

What two systems are involved in the heart failure syndrome

Answer 13

1. Sympathetic system
2. RAAS
3. Inflammation

Question 14

How does the sympathetic system lead to HF

Answer 14

1. Increased NE released from cardiac cells
2. SHort-term increase of CO
3. B-receptor transduction is altered
4. Progressive myocardial dysfunction
5. HF

Question 15

How does the RAAS system cause HF

Answer 15

1. Increase in venous pressure occurs when ventricles fail cause retention of Na and water and accumulation in interstitium
2. Reduced CO causes reduced renal perfusion
3. RAAS activated
4. RAAS causes more salt and water retention
5. Increased ANP to antagonise salt retention

Question 16

How is RAAS system treated in patients with HF

Answer 16

1. Given Neprilysin inhibitor (sacubitril) which stops angiotensin II -> AT-II (1) - NO VASOCONSTRICTION OR RETENTION
2. Causes production of AT-II (2) which is vasodilatory

Question 17

Non-specific symptoms of HF

Answer 17

1. SOB
2. Fatigue
3. Ankle swelling

Question 18

Specific signs of HF

Answer 18

1. JVP
2. S3
3. Displaced apex beat

Question 19

What is the NYHA classification

Answer 19

Class I: No Limitation (asymptomatic)
Class II: Slight Limitation (mild HF)
Class III: Marked Limitation (moderate HF)
Class IV: Inability to carry out any physical activity without discomfort (sever HF)

Question 20

Stages of HF

Answer 20

1, High risk

2. Asymptomatic
3. Symptomatic HF
4. End-stage HF

Question 21

Causes of acute decompensation of CHF

Answer 21

1. NSAIDS
2. treatment noncompliance
3. Excess alcohol
4. Obesity
5. Uncorrected high BP

Question 22

Complications of ADCHF

Answer 22

1. Renal dysfunction
2. Rhythm disturbances
3. Hepatic dysfunction
4. DVT

Question 23

Why are diuretics (thiazides) given in AF

Answer 23

Promotes renal excretion of Na and water by blocking Na/Cl co-transporters (will cure oedema and dyspnoea)

Question 24

How does ACEI (angiotensin-converting enzyme inhibitors) help with AF

Answer 24

1, Reduce mortality

2. Less Effective in blacks

Question 25

Name an aldosterone antagonist

Answer 25

Spironolactone

Question 26

side-effects of aldosterone antagonists

Answer 26

Hyperkalaemia | Renal impairment

Question 27

What beta-blocker should be given to AFs

Answer 27

Bisoprolol - increases heart function

Question 28

When should ARBs (angiotensin receptor blockers) be given

Answer 28

If a patient is experiencing side-effects and intolerance to ACEI

Question 29

What arterial and venous dilators should be given

Answer 29

Hydralazine and Nitrates as a combo

Question 30

When is Hydrazine and nitrates given

Answer 30

Patient tolerant to ACEI

Question 31

What do we do with HF that has preserved left ventricular ejection fraction

Answer 31

Diuretics to deal with congestion Aldosterone antagonists possibly (don't write in exams)

Question 32

Consequence of Ankylosing spondylitis and AF

Answer 32

Surgery needs to done

Question 33

What is Hibernating Myocardium

Answer 33

Reversible Left ventricular dysfunction that responds positively to inotropic stress Revascularisation could cause it to recover.

Question 34

how is Hibernating Myocardium caused

Answer 34

Decreased myocardial perfusion allows viability of heart muscles to be maintained

Question 35

Name four common surgeries involved with HF

Answer 35

1. Mitral valve repair 2. Aortic valve replacement 3. Mitral valve replacement 4. Lv re-modelling

Question 36

When should re-synchronisation and defibrillators be used

Answer 36

1. Defibrillator reduces arythmie mortality | 2. Multi-site pacing

Question 37

What is Left-sided heart failure

Answer 37

The left side of the heart is responsible for receiving oxygenated blood from lungs. Inability of LV to pump blood through aorta causes blood to move back into the lungs = congestion Increased pressure in pulmonary circuit = pulmonary oedema Decreased oxygenated blood travelling around the body = cyanosis, dyspnoea, difficulty breathing due to oedema causing pericardium to thicken, increased rate of breathing

Question 38

Heart sounds in left-sided heart failure

Answer 38

1. Laterally displaced apex beat (due to enlarged heart) | 2. S3 gallop due to increased blood flow from atria to ventricles

Question 39

What is right-sided heart failure

Answer 39

COR PULMONALE: Venous system dilates causing oedema in the lower legs Liver can't move blood through hepatic vein back to heart = liver enlargement Jugular venous pressure raised Nocturne Ascites

Question 40

Why does right-sided heart failure cause nocturia

Answer 40

From fluid returning back to blood stream when lying down at night

Question 41

Define acute decompensated heart failure

Answer 41

Sudden worsening of symptoms of heart failure

Question 42

Signs and symptoms of decompensated heart failure

Answer 42

1. Difficullty breathing 2. Epsides of waking up from sleep gasping 3. Pulmonary oedema

Question 43

What causes acute decompensated heart failure

Answer 43

MI Pneumonia AFs Recurrent infections basically

Question 44

Clinical signs of acute decompensated heart failure

Answer 44

Jugular venous distention (most probable sign)

Question 45

Systolic vs diastolic heart failure

Answer 45

Systolic: Reduced ejection fraction Diastolic: Preserved ejection fraction

Question 46

What can causes systolic heart failure

Answer 46

Restrictive pericarditis

Question 47

What can cause diastolic heart failure

Answer 47

Cardiac tamponade and pericarditis

Question 48

Clinical presentation of an aortic dissection

Answer 48

1. Vomiting 2. Sweating 3. SEVERE CHEST OR BACK PAIN (tearing feeling) 4. MI 5. Pleural effusions

Question 49

Risk factors for aortic dissection

Answer 49

1. High BP 2. Ehlers Danlos syndrome (effects connective tissue of blood vessels) 3. Bicuspid aortic valve

Question 50

Pathophysiology of aortic dissection

Answer 50

1. Blood penetrates intimate and enters the media | 2. High pressure rips media tissue apart, forming a false lumen through which blood flows through

Question 51

How is aortic dissection diagnosed

Answer 51

1. D-dimer test 2. Chest X-Ray to see widening mediastinum + Pleural effusions 3. CT angiography 4. MRI 5. Transoesophageal Echocardiogram

Question 52

How is aortic dissection treated

Answer 52

1. Propranolol 2. Nitrates If propranolol is contraindicated, then verapamil or dilitiazem (calcium channel blockers) Open aortic surgery

Question 53

Definition of hypertension

Answer 53

<140/90 mmHG

Question 54

What is primary essential hypertension

Answer 54

Hypertension with no identifiable cause

Question 55

What causes primary essential hypertension

Answer 55

1. Genetic factors | 2. Diet (increased Na, insulin resistance, endothelial dysfunction etc)

Question 56

What is the classic symptoms of peripheral vascular disease

Answer 56

1. Leg pain when walking that resolves with rest - INTERMITTENT CLAUDICATION

Question 57

Clinical presentation of peripheral vascular disease

Answer 57

1. Intermittent claudication (because during exercise, leg needs more oxygen and nutrients) 2. Critical limb ischaemia 3. Gangrene

Question 58

What is critical limb ischaemia

Answer 58

1. Obstruction to blood flow is so bad that the leg can't be oxygenated at rest either

Question 59

Clinical presentation of critical limb ischaemia

Answer 59

1. Pain at rest 2. Cold 3. Numbness 4. Gangrene and ulcers

Question 60

Risk factors for PVD

Answer 60

1. Smoking 2. Diabetes Mellitus (high blood sugar) 3. Hyperlipidaemia 4. Hypertension 5. Black Men

Question 61

Diagnosis of PVD

Answer 61

1. Decreased or absent pulses 2. Muscle wasting 3. Cyanosis 4. Coolness of the limb 5. Thickened nails 6. Hair loss on skin 7. Buerger's test for pallor

Question 62

How is PVD treated

Answer 62

1. SMOKING CESSATION 2. REGULAR EXCERCISE Manage diabetes, hypertension and hyperlipidaemia e.g. simvastatin, warfarin, aspirin and clopidogrel Third line: REVASCULARISATION (angioplasty) Thrombolysis Atherectomy

Question 63

Diagnosis of PVD

Answer 63

1. Ankle, Branchial Index (less than 0.9 is PVD) 2. Then lower limb doppler ultrasound 3. X-ray 4. CT 5. Magnetic Resonance Angiography