3. Chronic HF

Question 1

What are the two divisions of chronic HF?

Answer 1

Systolic and Diastolic

Systolic HF: Impaired LV contraction

Diastolic HF: Impaired LV relaxation

Question 2

6 symptoms of chronic HF

Answer 2

1. SOB worsened by exertion
2. Cough with frothy white/ pink sputum
3. PND: attacks of SOB/ cough that wakes from sleep and feels like can’t breathe
4. Swollen sacrum, legs and ankles
5. Orthopnea
6. Pleuritic chest pain

Question 3

3 causes of Paroxysmal Nocturnal Dyspnea

Answer 3

1. Fluid settles over larger lung surface area when asleep, so gas exchange is impaired
2. Respiratory centre of brain less sensitive to reduced oxygen saturation in sleep, so only responds when there is more signficant pulmonary cogestion and hypoxia
3. Less adrenalin circulating in sleep so myocardium more relaxed, cardiac output is less, worsening HF

Question 4

Causes of chronic heart failure?

Be aware triggers are different and include sepsis (via inflammatory end organ damage) arrythmia, iatrogenic and MI

Answer 4

1. Hypertension (more difficult for heart to pump)
2. Ischaemic heart disease (atherosclerosis imapirs blood supply to heart so it can’t pump effectively)
3. Valvular heart disease (e.g. aortic stenosis and mitral regurgitation makes it difficult to pump blood out of heart)
4. Arrythmia (e.g. atrial fibrillation makes it heart to co-ordinate blood flow out of heart). Be aware arrythmias are both a trigger and cause

Question 5

Which 3 tests are required before making a diagnosis of chronic HF?

Answer 5

BNP

ECHO - looking for ejection fraction under 50%

ECG (do to rule out arrythmia and ACS that can be treated to resolve HF)

Question 6

What is the most sensitive blood test for chronic HF and what are the thresholds for HF and specialist referral?

Answer 6

NT-proBNP greater than 300 ng/titre

If over 2000 ng/titre = urgent referral to specialist

Question 7

Lifestyle management of chronic heart failure (4 points)

Answer 7

Lifestyle management:
Smoking cessation
Exercise as tolerated
Optimise co-morbidity treatment
Yearly flu and pneumococcal vaccine

Question 8

What is a common side effect of ACEi and what is used instead and at what dose?

Answer 8

Cough

ARB

Candesartan titrated up to 32mg OD

Question 9

ACEi should be avoided in patients with this condition until advised by a specialist

Answer 9

Valvular heart disease

Question 10

What 2 conditions have to be met before aldosterone antagonists can be added to the medical management of chronic HF?

Answer 10

1. Symptoms not controlled by ACEi and BB

2. Have reduced ejection fraction

Question 11

Which 3 medications can cause electrolyte imbalances and how should they be monitored?

Answer 11

1. ACEi
2. Diuretics
3. Aldosterone antagonists

Monitor for electrolyte disturbance via regular U&Es

Question 12

Medical management of chronic heart failure

Answer 12

Medical management:
Information giving + written info
Refer to specialist + specialist nurse
ABAL
Acei (ramipril titrated as tolerated up to 10mg once daily)
Beta blocker (bisoprolol titrated as tolerated up to 10mg once daily)
Aldosterone antagonist (eplerenone/ spironolactone) if symptoms not controlled with A + B and if have reduced EF
Loop diuretics (furesomide 40mg once daily)

Question 13

Surgical management of chronic heart failure

Answer 13

Surgery in severe valve disease