9. Congestive Heart Failure

Question 1

What is chronic heart failure caused by and what does an impaired left ventricular function result in

Answer 1

either impaired left ventricular contraction (systolic heart failure) or left ventricular relaxation (diastolic heart failure)
a chronic back pressure of blood trying to flow into and through the left side of the heart

Question 2

Define Dyspnoea and what is it associated with

Answer 2

Difficult or laboured breathing

increase in the work of breathing which is associate d with reduced lung compliance (stiff lung) or increased RR

Question 3

Name some common causes of dysponea

Answer 3

asthma
heart failure
chronic obstructive pulmonary disease (COPD), interstitial lung disease
pneumonia
psychogenic problems that are usually linked to anxiety (can also occur with severe anaemia)

Question 4

Define orthopnoea

Answer 4

SOB when lying flat

Often a symptom of of left ventricular failure and/or pulmonary oedema

Question 5

Name some of the features that patients with chronic heart failure present with

Answer 5

Breathlessness worsened by exertion 
Cough- may produce frothy white/pink sputum 
Orthopnoea
Paroxysmal nocturnal dysponoea 
Peripheral oedema 
Loss of energy/tiredness

Question 6

What is Paroxysmal Nocturnal Dyspnoea (PND)

Answer 6

describes the experience that patients have of suddenly waking in the night with a severe attack SOB and cough

Question 7

Name the mechanism behind why people with heart failure suffer from Paroxysmal Nocturnal Dyspnoea (PND)

Answer 7

1. Fluid is settling across a large surface area of the lung when they sleep flat (so when sit up fluid sinks to the bottom)
2. During sleep the respiratory centres in the brain become less responsive so RR and effort don’t increase in response to reduced oxygen sats (develop significant pulmonary congestion and hypoxia before waking up)
3. There is less adrenalin circulating during sleep (means that myocardium is more relaxed which worsens cardiac output

Question 8

Why does the fact that during sleep the respiratory centres are less responsive and less circulating adrenalin factor into someone with cardiac failure suffer from Paroxysmal Nocturnal Dyspnoea (PND)

Answer 8

1. less responsive so RR increased and efforts don’t increase in response to reduced O2
2. less adrenalin means myocardium is more relaxed which worsens cardiac output

Question 9

Hear failure symptoms are defined by the new York heart association
What does NYHA 1-4 mean

Answer 9

NYHA 1: No symptoms and no limitation in ordinary physical activity

NYHA 2: Mild symptoms and slight limitation during ordinary activity

NYHA 3: Marked limitation in activity due to symptoms, even during less than ordinary activity (such as walking to the kitchen)

NYHA 4: Severe limitations, experiences symptoms even while at rest

Question 10

What are the clinical signs of heart failure (signs not symptoms)

Answer 10

Pulmonary oedema/pleural effusion 
Raised JVP
Pitting Oedema 
Ascites  (and hepatomegaly)
Tachycardia 
S3 gallop 
bibasal crepitations

Question 11

What 3 features are needed in order to be able to confidently diagnose heart failure

Answer 11

symptoms typical of heart failure
signs typical of heart failure
objective evidence of structural or function cardiac abnormality at rest

Question 12

Name some Objective evidence of structural or functional cardiac abnormality at rest

Answer 12

Cardiomegaly on CXR
S3 gallop
echocardiographic abnormality

Question 13

What specific blood test would you do if you suspect heart failure (describe what it is too)

Answer 13

BNP - brain natriuretic peptide
secreted by the ventricles in response to excessive stretching of heart muscle cells
normal levels would rule out heart failure

(they also use Nt-proBNP)

o BNP less than 100 ng/litre
o NT proBNP less than 300 ng/litre.

Question 14

What investigations would you carry out if you suspect heart failure

Answer 14

1. CXR
2. ECG
3. ABG
4. Bloods (FBC, U&E, Trop I, LFT, BNP )
5. Echocardiography

Question 15

Why would you order the following blood tests;

1. FBC
2. U&E
3. TFT
4. TROP I
5. LFT

Answer 15

1. FBC as anaemia can be a cause of heart failure as well as B12 deficiency
2. U&E as often patients also have impaired renal function
3. abnormal TFT can affect the heart
4. TROP I or T to rule out an MI
5. LFT as pulmonary congestive is associated with liver congestion

Question 16

What could you see on a CXR if someone is presenting with signs of heart failure

Answer 16

increased cardiac size
presence of pleural effusion or pulmonary odema
could also have heavy calcification of the pericardium or the valves

Question 17

What numerical value can be obtained from an echocardiogram

Answer 17

The ejection fraction which is a measurement % of how much blood the left ventricle pumps out with each contraction

Question 18

On an echocardiograph what would you see if someone has had a previous myocardial infarction

Answer 18

akinetic/hytpokinetic areas where the previous MI has thinned the wall

Question 19

What is the normal ejection fraction of the LV and what can patients with heart failure be subdivided into based on their ejection fraction %

Answer 19

approx 60%

heart failure with impaired systolic function (EF below 45%)
Heart failure with preserved LV function (greater than 45%)

Question 20

On an ECG what can left ventricular hypertrophy indicate

Answer 20

hypertension
aortic stenosis
HOCM - hypertrophic obstructive cardiomyopathy

Question 21

What are the main 4 causes of heart failure

Answer 21

Ischemic heart disease (accounts for 40% of all causes of heart failure in the UK eg coronary artery disease and acute MI)
valvular heart disease (commonly aortic stenosis)
hypertension
arrhhytmias (commonly AF)

Question 22

In the following categories of causes of heart failure, give some examples;

1. structural causes
2. congenital heart disease
3. Rate related causes
4. pulmonary causes

Answer 22

1. aortic regurgitation, aortic stenosis, mitral regurgitation, mitral stenosis
2. ASD, VSD, inherited cardiomyopathies
3. uncontrolled AF, thyrotoxicosis and anaemia (causing high output state), heart block (causing low output state)
4. COPD, pulmonary fibrosis, recurrent pulmonary emboli, primary pulmonary hypertension (can cause right sided heart failure)

Question 23

in the following categories of causes of heart failure, give some examples

1. ischemic causes
2. infective causes
3. toxins
4. other medical

Answer 23

1. coronary artery disease, AMI
2. chronic pericarditis (caused by TB, lupus and viruses), autoimmune such as amylooidosis and sarcoid, viral myocarditis
3. alcohol, certain drugs such as doxorubicin which is a cancer drug)
4. hyper tension, diabetes (due to CAD or diabetic cardiomyopathy), phaeochromocytoma (adrenal tumour)

Question 24

What non-pharmacological things would you do in the management of heart failure

Answer 24

yearly flu and pneumococcal vaccine
stop smoking
optimise treatment of co-morbidities
exercise at tolerated
Careful discussion and explanation of the condition
heart failure specialist nurse init for advice and support
refer to special if NT-proBNP is greater than 2000 ng/litre

Question 25

NICE guidelines question for stabilising a patient 1. What therapy would you give to someone with acute heart failure 2. What parameters do you need to measure when starting this treatment 3. What other medication are not used routinely but are an option in certain circumstances

Answer 25

1. IV diuretic therapy and if already on a diuretic then increase dose unless there is a concern with patients adherence 2. monitor renal function, weight and urine output 3. severe hypertension or aortic/mitral valve disease offer IV nitrates, reversible cariogenic shock offer sodium nitroprusside or inotropes or vasopressors (increase contractility and vasoconstriction

Question 26

What is the first line medical treatment for heart failure

Answer 26

ABAL ``` Ace inhibitor (eg ramipril titrated as tolerated up to 10mg once daily) Beta Blocker (eg bisoprolol titrated as tolerated up to 10mg once daily) Aldosterone antagonist when symptoms not controlled with A and B (spironolactone or eplerenone) Loop diuretics improves symptoms (eg furosemide 40mg once daily) ```

Question 27

what medicine can be prescribed if an ACEi is not tolerated and give an example

Answer 27

angiotensin receptor blocker (ARB) eg candesartan

Question 28

What medication should you avoid in patients with valvular heart disease until indicated by a specialist

Answer 28

ACE inhibitor

Question 29

under what circumstances should an aldosterone antagonist be used

Answer 29

when there is a reduced ejection fraction and symptoms are not controlled with ACEi and beta blocker

Question 30

which 3 medications cause electrolyte disturbances and so U&E need to be closely monitored

Answer 30

diuretics ACEi aldosterone antagonists

Question 31

NICE guideline question; | if a patient is already on a beta blocker then this should be continued unless .............

Answer 31

the HR is below 50 they are in 2nd/3rd degree heart block AV block or in shock

Question 32

Name some co-morbiites that need to be treated as the underlying cause in someone with heart failure with a preserved ejection fraction

Answer 32

``` rapid AF uncontrolled hypertension critical coronary artery disease significant valvular disease uncontrolled DM thyrotoxicosis ```

Question 33

What heart failure treatment inhibits left ventricular hypertrophy and remodelling of the heart

Answer 33

ACEi

Question 34

name some common ACEi

Answer 34

``` Ramipril Lisinopril Captopril Enalapril Perindopril Quinapril ```

Question 35

as well as inhibiting left ventricular hypertrophy and remodelling of the heart, what else do ACEi cause and why

Answer 35

decreased water and salt retention (stimulates ADH secretion)

Question 36

Name some common beta blockers and name the one that is NOT licenced to treat heart failure

Answer 36

Atenalol is NOT licensed Bisoprolol carvedilol Nebivolol metoprolol (MR)

Question 37

ARB auch as eplerenone and spironolactone are used in treatment of severe LV dysfunction which is defined as an EF of less than ____% and NYHA ___

Answer 37

35% NYHA II note that this drug also has anti-fibrotic effects

Question 38

under what circumstance would someone be fitted with a cardiac resynchronisation therapy device (CRT)

Answer 38

patients with HF that have significant electrical and mechanical desynchrony - ie the left and right ventricle may contract at slightly different times or - the left ventricle may contract in segments instead of as one unit

Question 39

Name the 3 leads that a CRT device has

Answer 39

Atrial lead RV lead LV lead which passes through the coronary sinus and into one of the vessels of the outside lateral wall of the heart

Question 40

in what circumstances with an implantable cardiac defibrillation (ICD) be used

Answer 40

patients with HF and EF of less than 35%

Question 41

what is the use of ICD devices

Answer 41

they can attempt to overdrive pace VT and deliver an electrical shock to cardiovert VT/VF

Question 42

what is cardio version

Answer 42

is a medical procedure by which an abnormally fast heart rate or other cardiac arrhythmia is converted to a normal rhythm using electricity or drugs

Question 43

name some clinical signs of right sided heart failure

Answer 43

bibasal crepitations

Question 44

name some clinical signs of left sided heart failure

Answer 44

ankle oedema, hepatomegaly and elevated JVP

Question 45

what risk factors should you ask about

Answer 45

Coronary artery disease including previous history of myocardial infarction, hypertension, atrial fibrillation, and diabetes mellitus. Drugs, including alcohol. Family history of heart failure or sudden cardiac death under the age of 40 years.

Question 46

apart from heart failure, what other conditions could cause ankle odema

Answer 46

Prolonged inactivity or venous insufficiency causing dependent oedema. Nephrotic syndrome. Drugs (for example dihydropyridine calcium-channel blockers, nonsteroidal anti-inflammatory drugs). Hypoalbuminaemia (from renal or hepatic disease). Pelvic tumour.

Question 47

what advise should you give in regards to driving and chronic heart failure

Answer 47

For group 1 entitlement (cars, motorcycles): driving may continue, provided there are no symptoms that may distract the driver's attention. The DVLA need not be notified. (different for lorries and buses)