0730 - intro management to heart failure - AHF

Question 1

Define heart failure.

Answer 1

• syndrome, not a singular disease - a syndrome in which the patients should have the following features, symptoms of heart failure, typically breathlessness or fatigue, either at rest or during exertion, or peripheral oedema, and objective evidence of cardiac dysfunction at rest (i.e. pattern recognition, definition not very specific) - cardiac muscle fails to deliver sufficient circulation relative to the needs of the body

Question 2

Why is heart failure burden on the rise?

Answer 2

• age of communities increasing - HF treatment improving, so those with HF living longer

Question 3

Do all patients with heart failure have a reduced ejection fraction (a measure of LV systolic function)?

Answer 3

No, studies in USA, Denmark and Australia have shown that a large proportion of people with HF have a normal, or uncompromised, ejection fraction.

Question 4

Outline the clinical risk factors for heart failure.

Answer 4

• >60 years old - low physical activity - smoking - overweight - hypertension - hyperlipidaemia - diabetes - valvular heart disease - coronary artery disease - LV hypertrophy - FHx of cardiomyopathy - atrial fibrillation

Question 5

Explain the (clinical) stages of heart failure.

Answer 5

A Px progresses through the stages, one way: 1. Normal: no symptoms, normal exercise tolerance, normal LV function, but predisposing risk factors 2. Asymptomatic LV dysfunction: no symptoms, normal exercise tolerance, abnormal LV function 3. Compensated: no symptoms, reduced exercise tolerance, abnormal LV function 4. Decompensated: symptoms, significantly reduced exercise tolerance, abnormal LV function 5. Refractory: symptoms not controlled with treatment

Question 6

Explain the phases of heart failure.

Answer 6

A Px can move between the phases: 1. Diagnosis 2. Respond to treatment: physical function almost back to normal 3. Clinical instability: more symptoms present, physical function reduced 4. Poor response to treatment 5. End of life These phases are probably better than the stages, as they make you think about what sort of treatment should be discussed with the Px; e.g. if in phase 4 or 5, should be thinking about end of life/palliative care, not transplant.

Question 7

Explain the classes of heart failure.

Answer 7

assumes the Px has heart failure

a Px can move between the classes

Class I: asymptomatic

Class II: symptoms on moderate physical exertion

Class III: symptoms on minimal physical exertion

Class IV: symptoms at rest

Question 8

Outline the recommendations for a diagnostic investigation of heart failure.

Answer 8

• echocardiogram for all all Pxs with suspected HF
• coronary angiography for Pxs with Hx of exertional angina or suspected ischaemic LV dysfunction
• plasma BNP for Pxs presenting with recent-onset dyspnoea
• haemodynamic measurements for Pxs with refractory HF, diastolic HF, or in whom diagnosis of HF is in doubt
• endomyocardial biopsy for Pxs with cardiomyopathy with recent onset of symptoms, where congestive heart disease has been excluded by angiography, or where inflammatory or infiltrative processes suspected
• nuclear cardiology, stress echocardiography, positron emission tomography to assess reversibility of ischaemia and viability of myocardium in Pxs with HF who have myocardial dysfunction and congestive heart disease
• thyroid function tests for older Pxs without pre-existing congestive heart disease who develop atrial fibrillation, or in whom no other cause of HF evident

Question 9

What are the four types of heart failure that are surgically correctable (and hence better dealt with than treating medically)?

Answer 9

• coronary heart disease
• valvular heart disease
• congenital heart disease
• pericardial disease

Question 10

For patients that have been diagnosed with heart failure that is not surgically correctable, what discussion points are recommended?

Answer 10

• lifestyle (adopt a healthier lifestyle to address risk factors)
• personal issues (understand the effect of HF on energy levels, mood, depression, sleep disturbance, sexual function)
• medical issues (consider practical issues related to pregnancy, contraception, genetic predisposition)
• support (access to support services)

Question 11

Outline the recommendations for preventing heart failure and treating asymptomatic LV dysfunction.

Answer 11

• ACE-inhibitors indefinitely for all Pxs, unless intolerant
• antihypertensives for Pxs with elevated BP to prevent subsequent HF
• ACE-inhibitors for Pxs at high risk of ventricular dysfunction
• beta-blockers after MI, whether or not Px has systolic ventricular dysfunction
• statins to prevent ischaemic events and subsequent HF in Pxs who fulfill criteria for lipid-lowering

Question 12

When should biventricular pacing be considered?

Answer 12

Px has low ejection fraction, wide QRS complex, left bundle branch block, and symptoms still present despite medical therapy.