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Questions and Answers
What level corresponds to mild symptoms with slight limitation during ordinary activity?
What level corresponds to mild symptoms with slight limitation during ordinary activity?
At which level are individuals comfortable only at rest due to significant limitations in activity?
At which level are individuals comfortable only at rest due to significant limitations in activity?
Which level represents severe limitations where symptoms are experienced even while at rest?
Which level represents severe limitations where symptoms are experienced even while at rest?
How would you classify an individual experiencing only mild symptoms during usual activities?
How would you classify an individual experiencing only mild symptoms during usual activities?
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What would be the best description for level 3 symptoms?
What would be the best description for level 3 symptoms?
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Which of the following sets of criteria can confirm a diagnosis of heart failure?
Which of the following sets of criteria can confirm a diagnosis of heart failure?
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What is a characteristic feature of systolic heart failure (HFrEF)?
What is a characteristic feature of systolic heart failure (HFrEF)?
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Which condition is least likely to contribute to diastolic heart failure (HFpEF)?
Which condition is least likely to contribute to diastolic heart failure (HFpEF)?
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Identify the condition that is associated with acute heart failure.
Identify the condition that is associated with acute heart failure.
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Which of the following is a major criterion for diagnosing heart failure?
Which of the following is a major criterion for diagnosing heart failure?
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Study Notes
Heart Failure Overview
- Heart failure is the inability to pump enough blood to meet the body's needs.
- Cardiac disease, severe anemia, hyperthyroidism, pregnancy, and liver failure can increase body demands.
Types of Heart Failure
- Acute heart failure: Characterized by a sudden problem, e.g., myocardial infarction (MI), arrhythmia.
- Chronic heart failure: Develops gradually, often as a result of hypertension.
-
Left-sided heart failure:
- Systolic (HFrEF): Heart failure with reduced ejection fraction.
- Diastolic (HFpEF): Heart failure with preserved ejection fraction.
- Right-sided heart failure
Stages of Heart Failure (NYHA)
- Stage 1: No symptoms, no limitations on activity.
- Stage 2: Mild symptoms, slight limitation on activity.
- Stage 3: Symptoms limit activity, comfortable only at rest.
- Stage 4: Severe symptoms, symptoms present even at rest.
Diagnosis of Heart Failure (Framingham Criteria)
- Diagnosis based on major and minor criteria.
- 2 major or 1 major + 2 minor criteria are needed.
Major Criteria
- Paroxysmal nocturnal dyspnea (PND) or orthopnea
- Neck vein distention
- Pulmonary rales
- Acute pulmonary edema
- Hepatojugular reflux
- Cardiomegaly
- S3 gallop
- 4.5 kg weight loss in 5 days in response to treatment
Minor Criteria
- Nocturnal cough
- Dyspnea on ordinary exertion
- Bilateral ankle edema
- Hepatomegaly
- Pleural effusion
- Heart rate > 120
Etiology (Causes)
-
Systolic Heart Failure (HFrEF):
- Coronary artery disease (CAD)
- Hypertension
- Diabetes mellitus
- Valvular heart disease
- Myocarditis
- Peripartum cardiomyopathy
- Congenital heart disease (TOF/TGA)
- Drugs
- Other (rare)
-
Diastolic Heart Failure (HFpEF):
- Hypertension
- Diabetes Mellitus
- CAD
- Valvular heart disease
- Hypertrophic cardiomyopathy
- Restrictive cardiomyopathy
- Constrictive pericarditis
-
Right-sided Heart Failure:
- Left-sided heart failure is a common cause
- Pulmonary artery hypertension
- Pulmonary valve stenosis
- Pulmonary embolism
- Chronic pulmonary disease
-
Acute Heart Failure:
- Acute valvular regurgitation
- Myocardial infarction (MI)
- Arrhythmias (AF, VT)
- Drugs (e.g., cocaine)
- Sepsis
- Pregnancy
- Iatrogenic (due to treatment)
Symptoms
- Exertional dyspnea
- Orthopnea
- Chest pain
- Palpitations
- Acute pulmonary edema
- Cough
- Wheezing
- Lower limb edema
- Ascites
- Weight gain
- Anorexia
- Nausea
- Cardiac cachexia
- Fatigue
- Bloating
- Oliguria
- Nocturia
- Anxiety
- Decreased memory
- Confusion
- Headache
- Insomnia
- Bad dreams
- Psychosis
- Hallucinations
Signs and Findings
- Orthopnea
- Congested neck veins
- Central cyanosis
- Jaundice
- Malar flush
- Ascites
- Dark skin
- Fever
- Tachycardia
- Diaphoresis
- Rales
- Pulmonary edema
- Hepatojugular reflux
- Bilateral lower limb edema
- Hepatosplenomegaly
- Pleural effusion
- S3 gallop
- Cardiomegaly
- Murmur
- Signs of liver cell failure
Investigations
- Blood tests: BNP/NT proBNP, CBC, electrolytes (Na, K, Ca, Mg), urea, creatinine, urine analysis, ALT, AST, bilirubin, albumin, ABG (arterial blood gases).
- Genetic testing: For specific cardiomyopathies.
- ECG: Comprehensive electrocardiogram
- Exercise ECG: Measures ECG response during exercise.
- Chest X-ray
- Echocardiography: Transthoracic (TTE) and transesophageal (TEE)
- Stress echocardiography
- CT
- MRI
- Catheterization and angiography: Invasive test for detailed heart structure and function.
- Nuclear imaging
Treatment (Systolic HF - HFrEF)
-
Nonpharmacologic:
- Salt restriction (2-3 g/day)
- Water restriction
- Stop alcohol and smoking
- Reasonable exercise
- Weight reduction
- Daily weight measurement
- Home monitoring
- Patient education
- Stop exacerbating drugs
-
Pharmacologic:
- Diuretics (e.g., torsemide)
- ACEIs or ARBs (e.g., ramipril)
- Beta blockers (e.g., bisoprolol)
- SGLT2 inhibitors (e.g., dapagliflozin)
- Vasodilators (e.g., hydralazine, nitrates)
- Inotropics (e.g., digoxin, dopamine)
- Anticoagulation (e.g., aspirin, low dose)
Treatment (Diastolic HF - HFpEF)
- Treat underlying cause (ischemia, obstructive sleep apnea)
- Treat precipitating factors, such as weight loss, exercise, low-sodium diet, restricted fluid intake, and daily weight measurement.
- Treat comorbidities.
- Diuretic therapy is needed to reduce fluid excess and should be used cautiously to avoid hypotension.
- May use ACEIs/ARBs, or Sacubitril/Valsartan,
- Beta-blockers are also indicated to control ventricular rate in AF.
- Avoid the routine use of nitrates or phosphodiesterase-5 inhibitors.
Treatment (Acute Heart Failure)
- ABCs: Airway, breathing, circulation
- Check blood glucose
- Oxygen if hypoxia
- IV diuretics
- ACE inhibitors or ARBs
- Vasodilators (e.g., nitrates)
- Nesiritide (if congestion is significant)
- Inotropics (e.g., dopamine)
- Mechanical support (ECMO)
- Control arrhythmias (defibrillation, drugs)
- Address the underlying cause and/or treat complications
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