Heart Failure Overview Quiz

Heart Failure

• Heart failure (HF) is a clinical syndrome caused by inherited or acquired abnormalities in cardiac structure and/or function.
• Patients experience symptoms like shortness of breath (dyspnea), fatigue, edema, and rales, leading to frequent hospitalizations, poorer quality of life, and shortened lifespan.
• In mild to moderate forms, cardiac output is normal at rest, but impaired during increased metabolic demand (e.g., exercise).
• Heart failure describes a clinical situation where the heart struggles to maintain adequate output, possibly only by increasing ventricular filling pressure.

Learning Outcomes

• Understanding the pathophysiology of heart failure.
• Describing clinical characteristics of different types of heart failure.
• Recognizing factors contributing to heart failure development.
• Identifying targets for drug action on cardiac output.
• Explaining general heart failure management principles.
• Identifying drug categories used in heart failure therapy.

Epidemiology of Congestive Heart Failure (CHF)

• In the U.S., approximately 5 million people have CHF.
• Approximately 550,000 new cases are diagnosed yearly.
• 800,000 patients with CHF are hospitalized each year.
• 250,000 people die of CHF annually.
• 50% of patients with CHF die within five years of diagnosis.
• There's been a 150% increase in the number of CHF cases over the past 20 years.
• 2.6% of the U.S. population has CHF.
• The incidence and the associated morbidity and mortality with CHF are expected to rise.

Etiology of Heart Failure

• Coronary artery disease (CAD) is now the most frequent cause in both men and women.
• CAD is responsible for approximately 60-75% of HF diagnoses.
• Hypertension causes HF in approximately 75% of patients, including most with CAD.
• Diabetes, and interactions between CAD & hypertension, also increase HF risk.

Etiology of Systolic Heart Failure

• Coronary artery disease (CAD)
• Hypertension
• Non-ischemic cardiomyopathy
  • Idiopathic dilated cardiomyopathy.
• Valvular heart disease
• Myocarditis
• Pericardial disease
• Arrhythmias

Etiology of Diastolic Heart Failure

• Coronary artery disease (CAD)
• Hypertension
• Diabetes mellitus
• Aortic stenosis
• Hypertrophic cardiomyopathy
• Infiltrative cardiomyopathy

Etiology (Non-Cardiac)

• Alcohol/thiamine deficiency
• Diabetes mellitus
• Infections
• Shock
• Pregnancy
• Pulmonary embolism
• Anemia
• Drug effects/interactions (e.g., hyper/hypothyroidism, medications)
• Tumors

Functional Status

• Class 1: No limitation of physical activity. Ordinary activity doesn't cause undue fatigue, shortness of breath (dyspnea), or chest pain
• Class 2: Slight limitation of physical activity, but ordinary physical activity does cause symptoms.
• Class 3: Marked limitation of physical activity. Symptoms are elicited with less than ordinary activity.
• Class 4: Symptoms present even at rest.

Pathophysiology (Conceptual basis of heart failure progression)

• Norepinephrine
• Angiotensin
• Aldosterone
• Elevated levels are linked with poor prognosis.
• Interventions to reduce hormone impact improve survival.

Cardiac Examination

• Apex beat: Location, displacement (cardiomegaly), downward and outward shift
• Left parasternal lift
• Third heart sound (S3) - indicates volume overload with tachycardia & tachypnea; suggests severe hemodynamic compromise.
• Fourth heart sound (S4) - common in diastolic dysfunction.

Chest X-Ray

• Acute heart failure often shows pulmonary hypertension, interstitial and/or pulmonary edema.
• Chronic heart failure often does not show such findings. The lymphatic system efficiently removes interstitial and pulmonary fluid.

Echocardiography

• Assess ventricular and atrial size.
• Evaluate LV function (global, regional, ejection fraction (EF), diastolic function).
• Evaluate valve severity (stenosis, regurgitation).

Biomarkers

• B-type natriuretic peptide (BNP) and N-terminal pro-BNP are sensitive markers for HF, particularly with depressed EF- albeit elevated with preserved EF to a lesser degree.
• BNP levels increase with age and renal impairment.
• Women tend to have higher levels, too.

Differential Diagnosis

• Adult respiratory distress syndrome (ARDS)
• Renal failure
• Respiratory diseases
• Other potential causes of leg edema

Differential Diagnosis of Peripheral Edema

• Cardiac issues (right or combined heart failure, pericardial constriction, cardiomyopathy).
• Chronic venous insufficiency
• Hypoalbuminemia
• Nephrotic syndrome
• Liver disease
• Protein-losing enteropathy (often widespread, including arms and face).
• Drugs (sodium retention: fludrocortisone or NSAIDs; permeability increase: nifedipine or amlodipine)
• Idiopathic causes (more common in women)
• Chronic lymphatic obstruction

Heart Failure Stages (Treatment)

• Stage A: High risk of developing HF but no structural heart disease or symptoms yet.
• Stage B: Structural heart disease present, but without HF symptoms.
• Stage C: HF symptoms with structural heart disease.
• Stage D: Refractory HF, requiring special interventions (e.g., transplant) .

Treatment Principles

• Systolic HF: Reduce preload, afterload, increase inotropy; reduce neurohormonal activity. Mainstay drugs: ACE inhibitors, beta blockers, aldosterone antagonists.

General Management

• Education
• Diet (general nutrition, limit salt and alcohol as per symptom severity).
• Cessation of smoking.
• Regular exercise, within symptom limits.
• Vaccines (influenza and pneumococcal)

Drug Therapy

• Diuretics:* (like furosemide) increase urinary sodium and water loss, reducing blood and plasma volume, easing preload and improving pulmonary and systemic venous congestion.
• Vasodilators:* (Angiotensin‐converting enzyme inhibitors, Angiotensin receptor blockers) reduce afterload, ventricular volume and wall tension, and thus improve cardiac efficiency.
• Beta-blockers:* (e.g., bisoprolol, started low and titrated up) counteract enhanced sympathetic stimulation, and reduce the risk of arrhythmias and sudden death.
• Ivabradine:* Used to control heart rate if beta blockers are unsuitable, acts on the SA node to reduce heart rate.
• Digoxin:* Provides rate control in patients with severe HF and atrial fibrillation., but doesn't affect long-term survival.
• Amiodarone:* Potent anti-arrhythmic drug, with little negative inotropic effect. Useful in poor LV function cases.

Other Treatments

• Implantable cardiac defibrillators (for patients with symptomatic ventricular arrhythmias, poor prognosis)
• Coronary revascularization (surgery or intervention to improve function in areas of the heart with poor blood supply, for carefully selected patients with CAD);
• Heart transplantation (for intractable heart failure, CAD and dilated cardiomyopathy are common indications);
• Ventricular assist devices (VADs) are sometimes used as a bridge to transplant or as a long-term option.

Test your knowledge on heart failure, including its causes, symptoms, and diagnostic roles of various peptides. This quiz covers critical aspects of heart failure and helps reinforce your understanding of its pathology and clinical signs.