53. Oedema

Question 1

Causes oedema

Answer 1

Congestive cardiac failure (ischaemic, valvular, myopathic, copulmonale, hypertensive)

Hypoproteinaemia (liver disease, nephrotic syndrome, malnutrition)

Pre-eclampsia

Venous stasis (varicose veins, DVT, inferior vena cava obstruction)

Question 2

triggers acute left ventirucalr failure

Answer 2

Decompensated chronic heart failure
Iatrogenic eg aggressive IV fluids
MI
Arrhythmias
Sepsis
HTN emergency

Question 3

signs o/e acute left ventricualr fialure

Answer 3

Signs: type 1 resp failure, raised RR, reduced O2 sats, tachycardia, 3rd heart sound, bibasal crackles, hypotension in cardiogenic shock

If they also have right-sided heart failure, you could find:
Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck
Peripheral oedema of the ankles, legs and sacrum

Question 4

symptoms acute left ventricualr failure

Answer 4

Symptoms: acute SOB, feeling unwell, pink/white frothy sputum

Question 5

Approach to assessing acute left venticualr failure

Answer 5

ABCDE approach

A
B - o2, cxr, ABG. bloods fbc, u&e, lfts, troponin, tft, d-dimer, glucose, hba1c
C - ECG
D
E

Further: echo
BNP in GP

Question 6

Acute management left ventriucalr failure

Answer 6

S – Sit up
O – Oxygen
D – Diuretics (IV furosemide)
I – Intravenous fluids should be stopped
U – Underlying causes need to be identified and treated (e.g., myocardial infarction)
M – Monitor fluid balance

Specialist input
Hypotension: inotropes/vasopressors
Hypertension: GTN or IV nitrates

Question 7

xray findings congetsive hf

Answer 7

Alveolar oedema (bat wing opacities)
kerley B lines
Cardiomegaly (cardiothoracic ratio > 0.5)
upper lobe blood Diversion
pleural Effusions (bilateral blunting of costophrenic angles)
Fluid in the horizontal fissure

Question 8

causes chronic heart failure

Answer 8

Ischaemic heart disease
Valvular heart disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)
Cardiomyopathy

Question 9

what is ejection fraction?

Answer 9

The ejection fraction is the percentage of blood in the left ventricle squeezed out with each ventricular contraction. An ejection fraction above 50% is considered normal.

Question 10

pathophysiology hf with preserved ejection fraction

Answer 10

Heart failure with preserved ejection fraction is when someone has the clinical features of heart failure but an ejection fraction greater than 50%.

This is the result of diastolic dysfunction, where there is an issue with the left ventricle filling with blood during diastole (the ventricle relaxing).

Question 11

waking up at night, symptom called?

Answer 11

Paroxysmal nocturnal dyspnoea

Question 12

symptoms chronic heart failure

Answer 12

Breathlessness, worsened by exertion
Cough, which may produce frothy white/pink sputum
Orthopnoea, which is breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use)
Paroxysmal nocturnal dyspnoea (more detail below)
Peripheral oedema
Fatigue

Question 13

general/holistic management heart fialure

Answer 13

offer annual influenza vaccine
offer one-off pneumococcal vaccine

Consider antiplatelet for atherosclerotoc disease
Consider if statin therapy is indicated
Ensure that any causes, comorbidities, and precipitating factors are optimally managed.

Ensure drugs which may cause or worsen heart failure are reviewed and stopped if appropriate.

Screen for depression and anxiety

If suitable, ensure the person has been offered referral to a supervised exercise-based group rehabilitation programme for people with heart failure.

Question 14

who needs pneumococcal every 5 years

Answer 14

asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years

Question 15

Management of confirmed heart failure with preserved ejection fraction

Answer 15

1. Loop diuretic up to 80 mg furosemide
2. Refer for specialist management if no response to loop diuretic. SGLT-2 may be used for symptomatic w normal EF or mildly reduced ejection fraction eg dapagliflozin

Question 16

Management of confirmed heart failure with reduced ejection fraction

Answer 16

+ if fluid overload- loop diuretic
1. ACEi and BB
(Use clinical judgement to decide which drug to start first)
2. Mineralocorticoid receptor antagonist (MRA) eg spironolactone
3. Specialist advice

Question 17

when not to offer acei first for hf?

Answer 17

if there is clinical suspicion of hemodynamically significant valve disease, until the valve disease has been assessed by a specialist

Question 18

diabetes / fluid overload, first drug to start hf

Answer 18

ACEi

Question 19

Acronym for chronic heart fialure management

Answer 19

ABALS

ACE inhibitor or ARB
Beta blocker eg bisoprolol
Aldosterone antagonist (spironolactone, eplerenone)
Loop diuretic (furosemide)
Sodium-glucose co-transporter 2 (SGLT2) inhibitor
Specialist Drugs: Ivabradine, digoxin

Question 20

Causes of high output HF?

Answer 20

anaemia, thyrotoxicosis, pagets disease, arteriovenous malformations

Question 21

Explain the significance of the BNP/proBNP blood result?

Answer 21

high negative predictive value.
Normal = unlikely to be heart failure.

However isn’t diagnostic as other things can cause a high BNP such as ACS, myocarditis, PE,renal or liver impairment). low BNP can occur in end-stage HF, flash pulmonary oedema or right sided HF.

Question 22

ECG cor pulmonale?

Answer 22

Tall peaked p waves

Question 23

why check lfts heart dialure

Answer 23

often elevated due to reduced CO and increased venous congestion. abnormal liver tests are associated with worse prognosis

Question 24

why should you check ecg heart fialure

Answer 24

to look for life-threatening cause such as ACS

Question 25

when to refer probnp?

Answer 25

if levels are ‘high’ >400 arrange specialist assessment (including transthoracic echocardiography) within 2 weeks

if levels are ‘raised’ >100-400
arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks