3) Heart failure - diagnostic tools, differential diagnosis, management.

Question 1

what are the major complications of heart failure ?

Answer 1

pleural effusion

atrial fib
- promoting thrombus and embolus

fatal dysarrythmia - ventricular tachycardia -sudden cardiac death

hepatomegaly - cardiac cirrhosis

renal insufficiency - cardio renal syndrome
mostly acute decompensated heart failure

cardiac arrhythmia

cariogenic shock

stroke - esp with atrial fib increased risk of arterial thromboembolism

chronic kidney disease

Question 2

what are contraindicated drugs during heart failure ?

Answer 2

NSAIDS
reduce effect of diuretics and worsen renal perfusion

calcium channel blockers - verapamil and diltiazem
negative inotropic effect

thiazolidinediones
progression of chi increase

Question 3

what is the diagnostic approach to heart failure ?

Answer 3

BNP and NT pro BNP (better which is a precursor for BNP)

BNP =more than 400ng/L
NT- pro BNP = more than 450ng/L

elevated ANP and MR- pro ANP

complete blood count - anemia

serum electrolyte levels - hyponatremia = poor diagnosis

kidney function test - increased creatinine , decrease sodium

ECG

TRANSTHORACIC ECHOCARDIOGRAM - GOLDEN STANDARD

cardiac stress exercise testing ,

Question 4

in transthoracic echocardiogram what do we evaluate ?

Answer 4

atrial and ventricular size

intraventricular septal thickness more than 11mm = hypertrophy.

reduced ejection fraction 40 percent or less

Question 5

what lab values make cardiorenal syndrome with chi a bad prognosis

Answer 5

reduced GFR and high creatinine levels (> 3 mg/dL)

Question 6

what is the first management of heart failure ?

Answer 6

1) diuretics (furosemide, thiazides added for synergistic effect(hypokalaemia, hyponatremia ))
salt restriction less than 3g a day
fluid restriction
weight loss
pneumococcal vaccine and seasonal influenza vaccine

+

ACE (dry cough, angioedema ) / ARB = ( hyperkalemia)

(5) hydralazine nitrate
NYHA stage 3 and 4
EF less than 40 percent ) if ACE and ARB contrandicated

Question 7

what is the second step in management of first line heart failure

Answer 7

2) once stable on ACE

add beta blockers (particularly good for post myocardial infraction and hypertension)

Question 8

what is the third step in management of first line management of heart failure

Answer 8

still class NYHA 2-4

3) spironolactone or mineralcorticosteroid antagonist -IF LVEF is less than 40 percent

Question 9

what is the second line management of heart failure if still NYHA class 2-4 and the values that need to be ensured to start this treatment

Answer 9

4) LVEF 35 percent or lower - and sinus rhythm and resting heart rate over 70 bpm = ivabradine

Question 10

what is the second step of second line management of heart failure if still NYHA class 2-4 and the values that need to be ensured to start this treatment

Answer 10

all LVEF 35 percent or lower

QRS complex duration 0.12sec or more =
CRT-D ( cardiac resynchronisation therapy defib)
CRT-P (cardiac resynchronisation therapy ,pacemaker
indication - dilated cardiomyopathy
left bundle branch block

if QRS complex less than 0.12s
ICD = implantable cardioverter defibrillator

Question 11

if after a pacemaker and defib there is still NYHA class 2-4 ?

Answer 11

digoxin
or
H-ISDN = hydrasalazine and isosorbide denigrate

coronary revascularisation with PCTA

Question 12

what is the management in end stage heart failure ?

Answer 12

ef less than 20 percent cardiac transplantation

Question 13

what drug is given in acute decompensated heart failure ?

Answer 13

NESIRITIDE - BNP derivative =

Question 14

what is the emergency management of heart failure ?

Answer 14

upright position

nitrates