Definition and classification
- What is cor pulmonale? A, hl
- What is heart failure? A, hl
- What are the types of heart failure? hl
- What is BNP? A
- What is the functional classification of cardiovascular disease status? A
- What is high output cardiac failure and low output cardiac failure? A
- What is cardiac cachexia? A
- Do you know NYHA classification? H32
- What is dyspnea? H71
- What is orthopnea? H77
Epidemiology
- Q
Etiology and Pathophysiology
- What are the causes of CCF? A, hl
- What are the common causes of heart failure? H83
- What are the factors that may precipitate or aggravate heart failure? hl
- What are the causes of peripheral edema? A
- What are the causes of generalized edema? H99
- What are the causes of non-pitting edema? hl
- What are the causes of lymphedema? A
- What are the causes of tender hepatomegaly? hl
- What are the causes of bilateral leg swelling? A
- What are the causes of unilateral leg swelling? A
- What are the causes of acute unilateral leg swelling? A
- What are the causes of high output cardiac failure and low output cardiac failure? A
- What are the causes of biventricular failure? A
- What are the causes of left-sided heart failure (or pulmonary edema)? A
- What are the causes of RHF? hl
- What are the causes of sudden cardiac failure? A
- What are the causes of acute dyspnea? H72
- What are the causes of chronic dyspnea or dyspnea on exertion? H73
- What are the causes of acute pulmonary edema or acute left heart failure? H74
- What are the characteristics of sputum in acute pulmonary edema? H78
Clinical manifestations
- What are the cardinal signs of congestive cardiac failure? A
- What are the cardinal features of LVF? A, hl
- What are the cardinal features of RVF? Hl
- What are the clinical features of acute pulmonary edema? H76
Examinations
- What are the clinical signs of right ventricular hypertrophy? H86
- What are the clinical signs of RVF? hl
Investigations
- What investigations do you suggest in this case? A, hl
- What are the X-ray findings of pulmonary edema? H80
Diagnosis
- Why do you think this is CCF? Hl, a
- Why so you think ischemic cardiomyopathy? hl
- What are your differential diagnoses? A
- Why is this not a case of cor pulmonale? A, hl
- Why not nephrotic syndrome? A, hl
- Why not cirrhosis of liver? A, hl
- What are the differences between cardiac and bronchial asthma? A
- A 60-year-old man wakes up with shortness of breath at midnight and rushes toward the window. He feels better after several minutes after coughing up small frothy sputum. What is your diagnosis? H75
Treatment
- How to treat CCF? A, hl
- What are the drugs used in heart failure? Hl
- Tell the mechanism of ACE inhibitor in heart failure. Hl
- What are the contraindications of ACE inhibitor? Hl
- What are the contraindications of β-blocker? Hl
- What is the role of digoxin in heart failure? Hl
- What are the complications of digoxin? How to treat if toxicity of digoxin develops? A
- Which drug has survival benefit in heart failure? Hl
- How can you treat a case of chronic heart failure? H92
- How would you manage acute LVF (or acute pulmonary edema)? A
- How can you manage acute pulmonary edema? H79
Complications
- What are the complications of heart failure? hl
Rimikri
SOLVES
Definition and classification
What is heart failure?
Heart failure is the clinical syndrome that develops when the heart cannot maintain an adequate cardiac output, or can do so only at the expense of an elevated filling pressure.
* Pre-exam preparation for medicine, HN Sarker
What are the types of heart failure?
The types of heart failure:
- According to involvement:
- Left heart failure
- Right heart failure
- Biventricular heart failure.
- According to onset:
- Acute heart failure
- Chronic heart failure
- Acute on chronic heart failure.
- According to function:
- Systolic dysfunction
- Diastolic dysfunction.
- According to cardiac output:
- High output failure
- Low output failure.
* Pre-exam preparation for medicine, HN Sarker
What is high output cardiac failure and low output cardiac failure?
As follows:
High output cardiac failure means “the heart fails to maintain sufficient circulation despite an increased cardiac output”. Presentations are same as in low output cardiac failure except tachycardia, gallop rhythm, warm extremities with distended superficial veins. Causes are:
- Severe anemia
- Thyrotoxicosis
- Arteriovenous fistula
- Beriberi
- Gram-negative septicemia
- Paget’s disease of the bone.
Low output cardiac failure means “the heart fails to maintain sufficient circulation with low cardiac output”. Common causes are:
- Ischemic heart disease
- Multiple valvular lesion
- Hypertension
- Cardiomyopathy
- Pericardial disease.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 205
What is the functional classification of cardiovascular disease status? / Do you know NYHA classification?
A close relationship of symptoms and exercise is the hallmark of heart disease. New York Heart Association (NYHA) functional classification of cardiovascular status is as follows:
- Class I: No limitation during ordinary activity. Ordinary physical activity does not cause undue fatigue, dyspnea or palpitation (asymptomatic left ventricular dysfunction).
- Class II: Slight limitation during ordinary activity. Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, and dyspnea or angina pectoris (symptomatically ‘mild’ heart failure).
- Class III: Marked limitation of normal activities without symptoms at rest. Less than ordinary physical activity will lead to symptoms (symptomatically ‘moderate’ heart failure).
- Class IV: Unable to undertake physical activity without symptoms; symptoms may be present at rest. With any physical activity increased discomfort is experienced (symptomatically ‘severe’ heart failure).
* Long Cases in Clinical Medicine, ABM Abdullah; Davidson’s Principles and Practice of Medicine, 22nd edition Page: 539; Pre-exam preparation for medicine, HN Sarker
What is cor pulmonale?
Right ventricular hypertrophy with or without failure due to pulmonary vascular, lung parenchyma or chest wall cause.
* Pre-exam preparation for medicine, HN Sarker
What is dyspnea and orthopnea?
What is cardiac cachexia?
Marked loss of weight or body mass that may occur in some cases of long standing moderate to severe cardiac failure is called cardiac cachexia.
It occurs commonly in patient more than 40 years with heart failure for more than 5 years. It is associated with high morbidity and mortality. Probable mechanisms are as follows:
- Malabsorption, anorexia and nausea due to intestinal venous congestion or edema, congestive hepatomegaly or toxicity of drugs (digoxin).
- Increased metabolic activity.
- TNF-α is increased, which is an important contributing factor for cachexia.
- Natriuretic peptide C is also increased.
- Poor tissue perfusion due to low cardiac output.
* Long Cases in Clinical Medicine, ABM Abdullah Page 206
What is BNP?
B-type natriuretic peptide (BNP) is a 32 amino acid polypeptide secreted by the left ventricle of the heart in response to excessive stretching of heart muscle cells.
- It is elevated in left ventricular systolic dysfunction.
- It may aid in the diagnosis and assess the prognosis and response to therapy in patient with heart failure.
- It helps to differentiate heart failure from other conditions (like bronchial asthma) that might mimic heart failure.
- However, BNP level may be elevated in renal failure (due to low clearance), pulmonary embolism, pulmonary hypertension, atrial fibrillation, acute myocardial infarction, chronic hypoxia and sepsis.
- Originally, BNP was isolated from porcine brain and was called brain natriuretic peptide.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 202
Etiology and Pathophysiology
What are common the causes of CCF?
The common causes of heart failure are:
- Myocardial infarction
- Myocarditis/cardiomyopathy
- Hypertension
- Aortic stenosis
- Mitral stenosis
- Ventricular septal defect
- Atrial fibrillation.
* Short and Long Cases in Clinical Medicine, HN Sarker
Almost all forms of heart disease can lead to heart failure.
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 546
What are the factors that may precipitate or aggravate heart failure?
Factors that may precipitate or aggravate heart failure in pre-existing heart disease
- Myocardial ischaemia or infarction
- Arrhythmia, e.g. atrial fibrillation
- Inappropriate reduction of therapy
- Administration of a drug with negative inotropic (β-blocker) or fluid-retaining properties (NSAIDs, corticosteroids)
- IV fluid overload, e.g. post-operative IV infusion
- Pulmonary embolism
- Intercurrent illness, e.g. infection
- Conditions associated with increased metabolic demand, e.g. pregnancy, thyrotoxicosis, anaemia
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 548
What are the causes of acute left heart failure (or acute pulmonary edema)?
Acute left heart failure due to:
- Myocardial infarction
- Systemic hypertension
- Acute mitral regurgitation due to rupture of chordae tendineae
- Myocarditis.
Acute on chronic heart failure:
- Mitral stenosis
- Aortic stenosis.
* Pre-exam preparation for medicine, HN Sarker
What are the causes of RHF?
The causes of right heart failure are:
- Secondary to left heart failure
- Chronic lung disease (cor pulmonale)
- Multiple pulmonary emboli
- Pulmonary valvular stenosis.
* Pre-exam preparation for medicine, HN Sarker
What are the causes of biventricular failure?
As follows:
- Cardiomyopathy (commonly dilated cardiomyopathy)
- Ischemic heart disease (extensive myocardial infarction)
- Right sided heart failure secondary to left sided heart failure (e.g. MR, AS or AR)
- Myocarditis
- Hyperdynamic circulation (in severe anemia, thyrotoxicosis, arteriovenous shunt, beriberi)
- Myxedema (called myxedema heart)
- Multiple vulvular disease
* Long Cases in Clinical Medicine, ABM Abdullah Page: 205
What are the causes of sudden cardiac failure?
As follows:
- Acute myocardial infarction
- Arrhythmia (especially ventricular fibrillation)
- Accelerated hypertension
- Circulatory overload (transfusion or infusion)
- Severe anemia
- Dissecting aneurysm of aorta
- Massive pulmonary thromboembolism.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 206
Clinical manifestations
What are the cardinal features of LVF?
The cardinal features of left heart failure are:
- Paroxysmal nocturnal dyspnea
- Orthopnea
- Cold perspiration
- Pulsus alternans
- Gallop rhythm
- Bilateral basal crepitations altered after coughing.
* Pre-exam preparation for medicine, HN Sarker
Figure: Clinical features of left and right heart failure. (JVP = jugular venous pressure)
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 549
What are the clinical features of acute pulmonary edema?
The clinical features of acute pulmonary edema are:
- Dyspnea at rest
- Paroxysmal nocturnal dyspnea (PND)
- Orthopnea
- Perspiration
- Cyanosis
- Pulsus alternans
- Gallop rhythm
- Bilateral basal crepitation
- Features of underlying cause.
* Pre-exam preparation for medicine, HN Sarker
What are the cardinal features (typical signs) of RVF?
The cardinal features of right heart failure are:
- Raised JVP
- Enlarged tender liver
- Peripheral pitting edema
* Pre-exam preparation for medicine, HN Sarker
What are the causes of peripheral edema? / What are the causes of generalized edema?
What are the causes of tender hepatomegaly?
The causes of tender hepatomegaly are:
- Congestive cardiac failure
- Viral hepatitis
- Liver abscess
- Hepatoma
- Budd-Chiari syndrome.
* Pre-exam preparation for medicine, HN Sarker
Examinations
What are the cardinal signs of congestive cardiac failure?
It actually means right heart failure. Cardinal signs of CCF are:
- Enlarged and tender liver
- Engorged and pulsatile neck veins
- Dependent pitting edema.
Note
CCF may be associated with:
- Pleural effusion (commonly right sided, may be bilateral)
- Ascites
- Jaundice due to hepatic congestion (or cirrhosis, called cardiac cirrhosis).
* Long Cases in Clinical Medicine, ABM Abdullah Page: 202
What are the characteristics of sputum in acute pulmonary edema?
Frothy sputum may be tingned with blood.
* Pre-exam preparation for medicine, HN Sarker
What are the clinical signs of right ventricular hypertrophy?
The clinical signs of right ventricular hypertrophy are epigastric pulsation and left parasternal heave.
* Pre-exam preparation for medicine, HN Sarker
Investigations
What investigations do you suggest in this case?
As follows:
- X-ray chest PA view (cardiomegaly, pulmonary edema)
- ECG (MI/ ischemia/ LVH)
- Serum urea, creatinine, electrolytes
- Hemoglobin level
- Thyroid function test
- Echocardiogram
- BNP
Note:
Brain natriuretic peptide (BNP) is elevated in heart failure and is a marker of risk; it is useful in the investigation of patients with breathlessness or peripheral oedema.
Echocardiography is very useful and should be considered in all patients with heart failure in order to:
- determine the aetiology
- detect hitherto unsuspected valvular heart disease, such as occult mitral stenosis, and other conditions that may be amenable to specific remedies
- identify patients who will benefit from long-term drug therapy, e.g. ACE inhibitors
* Long Cases in Clinical Medicine, ABM Abdullah; Davidson’s Principles and Practice of Medicine, 22nd edition Page: 549
What are the X-ray findings of pulmonary edema?
The X-ray findings of pulmonary edema are:
- Abnormal distension of the upper lobe pulmonary veins (Upper lobe diversion) with the patient in the erect position.
- Horizontal lines in the costophrenic angles (septal or Kerley’s B line)
- Alveolar oedema cause a hazy opacification spreading from the hilar regions (Bilateral hilar opacities – Bat’s wing appearance)
- Pleural effusion
Figure: Radiological features of heart failure. A Chest X-ray of a patient with pulmonary oedema. B Enlargement of lung base showing septal or ‘Kerley B’ lines (arrow).
* Pre-exam preparation for medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd edition Page: 550
Diagnosis
Why do you think this is CCF?
- A53-year-old man with a history of myocardial infarction presents with PND, breathlessness on exertion with swelling of legs for three months.
- JVP is raised and pulsatile and there is dependent pitting edema. Liver is enlarged and tender.
- There is gallop rhythm and bilateral basal end inspiratory crepitations altered after coughing.
- So, I consider this diagnosis.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 256
Why do you think ischemic cardiomyopathy?
As there is a past history of myocardial infarction, presence of ischemic chest pain on exertion and absence of any other cause like congenital heart disease, valvular heart disease and hypertension, etc.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 256
What are your differential diagnoses?
As follows:
- Chronic cor pulmonale
- Nephrotic syndrome
- Cirrhosis of liver.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 201
Why is this not a case of cor pulmonale?
This is not a case of cor pulmonale, because there is no previous history of lung disease like chronic bronchitis, emphysema (COPD) or ankylosing spondolytis. Also on examination, there is no finding in chest such as kyphosis, scoliosis, barrel shaped chest or no findings in the lung suggestive of COPD.
Also, if any vulvular lesion is present (e.g. MS or MR), mention it, which is against cor pulmonale.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 201
Why not nephrotic syndrome?
In nephrotic syndrome, the face is swollen first, followed by abdomen and legs and ultimately generalized edema. Here facial swelling is absent. Also the engorged pulsatile neck vein and tender hepatomegaly are against NS and bedside urine albumin test is negative.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 201; Short and Long Cases in Clinical Medicine, HN Sarker Page: 256
Why not cirrhosis of liver?
There is no stigmata of chronic liver disease. Liver is soft, enlarged and tender. JVP is raised. There is gallop rhythm and bilateral basal crepitations.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 256; Long Cases in Clinical Medicine, ABM Abdullah Page: 202
A 60-year-old man wakes up with shortness of breath at midnight and rushes toward the window. He feels better after several minutes after coughing up small frothy sputum. What is your diagnosis?
Paroxysmal nocturnal dyspnea due to left ventricular failure.
* Pre-exam preparation for medicine, HN Sarker
A 50-year-old male presents with orthopnoea. Examination reveals BP 190/120 mm of Hg. Bilateral basal crepitations are present. What is the most likely diagnosis?
Acute left ventricular failure.
A patient presented with generalized edema, tender hepatomegaly and elevated JVP. What is your probable diagnosis?
Right heart failure.
A 45-year-old man presented with the complaints of generalized swelling of the body which started in the legs, palpitations with excertional dyspnoea and precordial chest pain. What is the most likely diagnosis?
Congestive cardiac failure.
What are the differences between cardiac and bronchial asthma?
Features | Cardiac asthma | Bronchial asthma |
History | Hypertension, IHD, valvular disease, family history of hypertension | History of previous attack of asthma, allergy or rhinitis, family history of asthma or allergy |
Age | Usually elderly | Young, may be any age |
Symptoms | – Dyspnea, cough with frothy sputum
– Wheeze—rare – Sweating—common |
– Dyspnea, cough with little mucoid sputum
– Wheeze—common – Sweating—less |
Signs | Pulse—may be pulsus alternans
Blood pressure—high (if hypertensive) Heart— – Evidence of cardiomegaly (apex is shifted) – Gallop rhythm – Primary cause may be present (e.g. mitral or aortic valvular disease) Lungs— – Bilateral basal crepitation, later, extensive crepitations – No or little rhonchi |
Pulse—may be pulsus paradoxus
Blood pressure—normal, low in severe cases Heart— – Absent – No – No Lungs— – Plenty of rhonchi all over the lungs – No or little crepitations |
CXR | – Perihilar opacities (bat’s wing appearance)
– Cardiomegaly |
Relatively clear, evidence of infection may be present |
ECG | LVH, myocardial infarction | Normal, only tachycardia may be present |
* Long Cases in Clinical Medicine, ABM Abdullah Page: 206
Treatment
How can you manage acute LVF (or acute pulmonary edema)?
- Urgent hospitalization.
- Sit the patient up in order to reduce pulmonary congestion.
- Give oxygen (high-flow, and/or high-concentration).
- Administer nitrates, such as IV glyceryl trinitrate 10–200 μg/minute or buccal glyceryl trinitrate 2–5 mg, titrated upwards every 10 minute, until clinical improvement occurs or systolic BP falls to < 110 mmHg.
- Administer a loop diuretic such as furosemide 40–80 mg IV.
- Intravenous opiates may be cautiously used when patients are in extremes. They reduce sympathetically mediated peripheral vasoconstriction but may cause respiratory depression and exacerbation of hypoxemia and hypercapnia.
- If these measures prove ineffective—
- Inotropic agents may be required to augment cardiac output, particularly in hypotensive patients.
- Insertion of an intra-aortic balloon pump can be very beneficial in patients with acute cardiogenic pulmonary edema, especially when secondary to myocardial ischemia.
- The patient should be kept on strict bed rest with continuous monitoring of cardiac rhythm, BP, and pulse oximetry.
* Pre-exam preparation for medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd edition Page: 550
How can you treat a case of chronic heart failure?
- General measures:
- Education—Explanation of nature of disease, treatment, and self-help strategies.
- Diet—Good general nutrition and weight reduction for the obese. Avoidance of high-salt foods and added salt, especially for patients with severe congestive heart failure.
- Smoking cessation.
- Exercise—Regular moderate aerobic exercise within limits of symptoms.
- Alcohol—Alcohol moderation or elimination of alcohol consumption. Alcohol-induced cardiomyopathy requires abstinence.
- Vaccination—Influenza and pneumococcal vaccination should be considered.
- Drug therapy:
- Diuretic therapy—Furosemide and spironolactone, usually in combination.
- Vasodilator therapy—Nitrates reduce preload as venodilators and hydralazine reduce afterload as arterial dilators.
- Angiotensin-converting enzyme (ACE) inhibitor therapy—Lisinopril and ramipril.
- Angiotensin receptor blocker (ARB) therapy— Losartan and valsartan.
- β-adrenoceptor blocker therapy—Bisoprolol and metoprolol
- Digoxin and amiodarone.
- Coronary revascularization.
- Heart transplantation.
Figure: Neurohumoral activation and sites of action of drugs used in the treatment of heart failure.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 257; Davidson’s Principles and Practice of Medicine, 22nd edition Page: 550
What are the drugs used in heart failure?
- Diuretic therapy—Furosemide and spironolactone usually in combination.
- Vasodilator therapy—Nitrates reduce preload and arterial dilators, such as hydralazine, reduce afterload.
- Angiotensin-converting enzyme (ACE) inhibition therapy—Lisinopril and ramipril.
- Angiotensin receptor blocker (ARB) therapy— Losartan and valsartan.
- β-adrenoceptor blocker therapy—Bisoprolol and metoprolol.
- Digoxin and amiodarone.
* Pre-exam preparation for medicine, HN Sarker
Which drug has survival benefit in heart failure?
Spironolactone has survival benefit in heart failure.
* Pre-exam preparation for medicine, HN Sarker
Tell the mechanism of ACE inhibitor in heart failure.
ACE inhibitor interrupts the vicious circle of neurohumoral activation that is characteristic of moderate and severe heart failure by preventing the conversion of angiotensin I to angiotensin II, thereby preventing salt and water retention, peripheral arterial and venous vasoconstriction, and activation of the sympathetic nervous system.
* Pre-exam preparation for medicine, HN Sarker
What are the contraindications of ACE inhibitor?
The contraindications of ACE inhibitor are pregnancy, bilateral renal artery stenosis, and hyperkalemia.
* Pre-exam preparation for medicine, HN Sarker
What are the contraindications of β-blocker?
The contraindications of β-blocker are bronchial asthma, COPD, heart block, and peripheral vascular disease.
* Pre-exam preparation for medicine, HN Sarker
What is the role of digoxin in heart failure?
There is little role of digoxin in heart failure if the patient is in sinus rhythm but improves heart failure if atrial fibrillation is present.
* Pre-exam preparation for medicine, HN Sarker
What are the complications of digoxin? How to treat if toxicity of digoxin develops?
As follows:
- Extracardiac:
- Gastrointestinal: anorexia, nausea, vomiting, diarrhea
- Altered color vision (xanthopsia)
- Others: weight loss, confusion, headache, gynecomastia.
- Cardiac:
- Bradycardia
- Multiple ventricular ectopics
- Ventricular bigeminy
- Atrial tachycardia with variable block
- Ventricular tachycardia (bidirectional VT is mainly due to digitalis)
- Ventricular fibrillation.
Treatment of digoxin toxicity:
- Digoxin should be stopped
- Serum electrolytes, creatinine and digoxin level should be checked.
- Correction of electrolytes, if any
- If bradycardia: IV atropine, sometimes pacing may be needed
- Correction of arrhythmia.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 203
Complications
What are the complications of heart failure?
The complications of heart failure are:
- Renal failure
- Caused by poor renal perfusion due to low cardiac output and may be exacerbated by diuretic therapy, ACE inhibitors and angiotensin receptor blockers.
- Hypokalemia
- Result of treatment with potassium-losing diuretics or hyperaldosteronism caused by activation of the renin–angiotensin system and impaired aldosterone metabolism due to hepatic congestion.
- Hyperkalemia
- Due to the effects of drugs which promote renal resorption of potassium, in particular the combination of ACE inhibitors (or angiotensin receptor blockers) and mineralocorticoid receptor antagonists. These effects are amplified if there is renal dysfunction.
- Hyponatremia
- Caused by diuretic therapy, inappropriate water retention due to high ADH secretion, or failure of the cell membrane ion pump.
- Impaired liver function
- Caused by hepatic venous congestion and poor arterial perfusion.
- Thromboembolism
- Due to the effects of a low cardiac output and enforced immobility.
- Arrhythmias—Atrial and ventricular
- May be related to electrolyte changes (e.g. hypokalaemia, hypomagnesaemia), the underlying cardiac disease, and the pro-arrhythmic effects of sympathetic activation
* Pre-exam preparation for medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd edition Page: 549