Acute Heart Failure

Question 1

Causes of acute heart failure.

Answer 1

Ischaemic Heart Disease

Valvular disease

MI

Sepsis

Arrhythmias

Cardiomyopathies

IV fluid overload

Question 2

Symptoms of acute heart failure.

Answer 2

Acute LVF typical presents as a rapid onset breathlessness. This is exacerbated by lying flat and improves on sitting up. Acute LVF causes a type 1 respiratory failure (low oxygen without an increase in carbon dioxide in the blood).

Shortness of breath

Looking and feeling unwell

Cough (frothy white/pink sputum)

Question 3

Signs of acute heart failure.

Answer 3

Increase respiratory rate

Reduced oxygen saturations

Tachycardia

3rd Heart Sound

Bilateral basal crackles (sounding “wet”) on auscultation

Hypotension in severe cases (cardiogenic shock)

Raised JVP if also Right Heart failure

Question 4

Tests done in acute heart failure.

Answer 4

History

Clinical Examination

ECG (to look for ischaemia and arrhythmias)

Arterial Blood Gas (ABG)

Chest Xray

Bloods (routine bloods for infection, kidney function, BNP and consider troponin if suspecting MI)

Question 5

Diagnosis of acute heart failure.

Answer 5

Made clinically + NT-proBNP and further more an ECHO.

Treatment should start before awaiting NT-proBNP results and doing an ECHO.

This is because the patient can deteriorate in the meantime whilst waiting.

BNP less than 100 ng/litre makes HF very unlikely

NT‑proBNP less than 300 ng/litre. makes HF very unlikely.

Question 6

CXR findings on acute HF.

Answer 6

Features of pulmonary oedema

Cardiomegaly

Kerley B lines

Fluid in the interlobar fissures

Bilateral pleural effusion.

Question 7

Management of acute heart failure.

Answer 7

Pour SOD for acute LVF:

Pour away (stop) their IV fluids

Sit up

Oxygen

Diuretics

Sit the patient upright. When lying flat the fluid in the lungs spreads to a larger area and when upright gravity takes it to the bases leaving the upper lungs clear for better gas exchange.

Oxygen if their oxygen saturations are falling (<95%). As always be cautious in patients with COPD.

Diuretics (e.g. IV furosemide 40mg stat). This reduces the circulating volume and means the heart is less overloaded allowing it to pump more effectively. This is like taking your backpack off when on a hike – it allows you to walk more easily.

Monitor fluid balance. Measuring fluid intake, urine output, U&E bloods and daily body weight is essential to balance their fluid input and output.

Question 8

Management algorithm of severe acute heart failure.

Answer 8

Do not routinely offer nitrates, isosorbide mononitrate, vasopressors, and morphine according to NICE

Question 9

Treatment after stabilisation.

Answer 9

Daily weight and make sure they are losing weight (in fluids)

Check obs

Repeat CXR

Change to oral diuretics

Consider thiazide

ACEi if LVEF <40%

Consider beta-blocker and spironolactone if LVEF <35%

Question 10

Non-pharmacological treatment after stabilisation.

Answer 10

Offer surgical aortic valve replacement to people with heart failure due to severe aortic stenosis assessed as suitable for surgery.

Consider transcatheter aortic valve implantation (TAVI) in selected people, with heart failure caused by severe aortic stenosis, who are assessed as unsuitable for surgical aortic valve replacement.

Coronary revascularisation

Consider surgical mitral valve repair or replacement for people with heart failure due to severe mitral regurgitation assessed as suitable for surgery.