Acute and Chronic Heart Failure

Question 1

Heart failure

-pathophysiology

Answer 1

Pathophysiology

• heart is unable to meet the demands of the body
  1. Reduced CO => SNS, RAAS activation
  2. Increased HR, contractility, VC, Na/fluid retention
  3. Faulty cardiac remodelling => vicious cycle

Question 2

Types of heart failure
- chronic subtypes
- acute

Answer 2

Chronic
Diastolic - HFPEF (40%+)
-stiff thick LV walls

Systolic - HFREF
- normal filling with weak contraction
- thin weak LV walls

Acute - sudden reduction in CO
-most commonly due to MI

Question 3

Presentation of acute HF

Answer 3

SOBOE, SOB
Edema
Fatigue
Chest pain
Pink white, foamy mucus

Cyanosis
High HR, JVP
Displaced apex beat
Bilateral crackles/wheeze
S3 HS

Question 4

Investigations

Diagnosis

Answer 4

Hx
Observations
Examinations
-cardiac, resp

Bedside
- ECG
- urine dip
- spirometry

Bloods
- FBC, U&E, LFT, CRP, Fe studies
- BNP (100+)

If BNP high => Transthoracic echo within 2wks
If BNP raised => Transthoracic echo in 6wks

Imaging
- CXR, CT
- Echo

Alveolar edema (batwings)
B lines (interstitial edema)
Cardiomegaly
Dilated upper vessels
Effusion

Question 5

Heart failure mimics

Answer 5

SOB
- COPD, asthma
- PE
- lung cancer
- anxiety

Peripheral edema
- nephrotic syndrome
- liver/kidney disease
- DHP CCB, NSAIDs

Question 6

Chronic heart failure

-management

Answer 6

AIM TO REDUCE CARDIAC REMODEELLLING
ACEi/ARB & Bb
2nd line - add spironolactone, consider SGLT2

3rd line to be initiated by specialist
-ivabradine - sinus rhythm 75+ and LVF U35%
-sacubatril-valsartan - LVF U35%, start in ACEi/ARB washout period
-hydralazine and nitrate - Afro-Caribbean
-digoxin - if AF

Flu/1 off pneumococcal vaccine
CV risk optimisation

CRT - if wide QRS complex (3small squares+)

Question 7

Acute heart failure
-key treatments

-management

Answer 7

Positioning - sit upright
Oxygen - CPAP in resp failure
Diuretics - loop 40mg

Continue regular medications for HF
-stop Bb if HR U50, 2nd/3rd degree HB, shock

Consider inotropes on HDU if
-reversible cardiogenic shock

=> same as chronic

Question 8

Medication, SE, CI
- ACEi, ARB
- Bb
- MRA

Answer 8

ACEi - venous, arterial VD => reduce prrload/afterload
SE - dry cough, hypotension, AKI, high K

ARB - block Ang2 action
SE - same as ACEi without cough

Bb - carvedilol/bisoprolol
SE - fatigue, hypoglycemia, cold peripheries, erectile dysfunction
CI - asthma

MRA - spironolactone
SE - gynecomastia, high K, AKI
CI - pregnancy

Question 9

Cardiorenal syndrome
- pathophysiology
- diagnosis
- management

Answer 9

Pathophysiology - coexistance of cardiac and renal injury
-reduce BP, perfusion => low renal perfusion

Diagnosis - CHF + high creatinine, low GFR

Management - close monitoring or renal and cardiac function

Question 10

Chronic heart failure presentation

Answer 10

SOB
Cough with prink frothy sputum
Orthopnea, PND
Wheeze
Weight loss
Bibasal crackles
RHF signs - high JVP, ankle edema, hepatomegaly