18 Investigations and Management of Heart Failure

Question 1

If a patient is admitted to the hospital with heart failure, what is their risk of readmission or death within 60 days?

Answer 1

30-50%

Question 2

How does NYHA (New York Heart Association) classify heart failure?

Answer 2

Class I- No symptomatic limitation of physical activity

Class II-

-Slight limitation of physical activity

– Ordinary physical activity results in symptoms

– No symptoms at rest

Class III-

– Marked limitation of physical activity

– Less than ordinary physical activity results in symptoms

– No symptoms at rest

Class IV-

– Inability to carry out any physical activity without symptoms

– May have symptoms at rest

– Discomfort increases with any degree of physical activity

Question 3

What immediate treatment might you give a patient with heart failure?

Answer 3

• Furosemide
• O₂ (if hypoxic)
• Respiratory support
• Nitrates/morphine
• Anticoagulants
• (beta blockers may worsen situation)

Question 4

What tests would you do on a patient with suspected heart failure?

Answer 4

• Blood tests (FBCs, NTpro-BNP etc)
• Blood pressure & heart rate
• O₂ levels
• ECG (may see tachycardia)
• CX-Ray (may show cardiomegaly, upper lobe diversion, pleural effusions)
• Transthoracic echocardiogram

Further tests:

Cardiac MRI-look for ischaemia/cardiomyopathy

Coronary angiography

Cardiomyopathy blood test screen-haemachromatosis

Genetics testing

Question 5

Why would a patient with heart failure be given Furosemide?

Answer 5

Venodilatory effect (immediate) (peak 60-90mins)

Higher doses required in renal failure

(need to be carefull with fluid balance)

Question 6

What blood tests should be done if a pateint has heart failure and what will they show?

Answer 6

1. FBC- test for anaemia- often with heart failure
2. U&Es- renal funtion deteriorates due to heart failure, Na/K levels for medications
3. LFTs (Liver Function Tests)- elevated if hepatic congestion
4. Clotting- important- considering anticoagulation
5. Thyroid function/ Vit D level- alternative explanation for symtoms
6. CRP- look for infection/ inflammation

Question 7

What is the most important test to do if a patient has suspected heart failure?

Answer 7

(NTpro-)BNP

= hormone released in response to atrial/venticular stretch due to fluid overload

-if negative= 97% accuracy

(Atrial fibrillation can triple BNP)

Question 8

How might the sympathetic nervous system respond to heart failure?

Answer 8

Attempt to improve cardiac output

• Increase contractility
• Vasoconstriction
• Tachycardia

Question 9

Why might the Sympathetic NS have negative effects on the body if a patient has heart failure?

Answer 9

Beta- adrenergic receptors=down-regulated/uncoupled

Noradrenaline

• induces cardiac hypertrophy/myocyte apoptosis
• induces up-regulation of RAAS

REDUCTION in HEART RATE VARIABILITY

Question 10

What physiological effects woould beta-blockers have on a patient with heart failure?

Answer 10

1. Reduce HR–> reduce myocardial oxygen demand
2. Reduce BP–> reduce myocardial oxygen demand
3. Reduce glycogen mobilisation

Question 11

How should beta-blockers be presccribed?

Answer 11

Initiate at low dose, titrate slowly

Question 12

Give some examples of management of patients following heart failure.

Answer 12

• Control BP
• Suregry eg : Valve replacement, Biventricular defibrillator
• Drugs