Cardiac failure: Chronic Heart failure Flashcards
What are the features of pulmonary oedema on a chest x-ray?
Features may include interstitial oedema, bat’s wing appearance, upper lobe diversion, Kerley B lines, pleural effusion, and cardiomegaly if there is a cardiogenic cause.
What is interstitial oedema?
A feature of pulmonary oedema seen on a chest x-ray.
What does the bat’s wing appearance indicate?
A characteristic feature of pulmonary oedema on a chest x-ray.
What is upper lobe diversion?
Increased blood flow to the superior parts of the lung, indicating pulmonary oedema.
What are Kerley B lines?
Lines seen on a chest x-ray that indicate interstitial oedema.
What does pleural effusion indicate?
A possible feature of pulmonary oedema on a chest x-ray.
What is cardiomegaly?
Enlargement of the heart that may be seen on a chest x-ray if there is a cardiogenic cause of pulmonary oedema.
What is the first-line investigation for chronic heart failure diagnosis according to NICE 2018 guidelines?
All patients should have an N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test first-line.
What should be arranged if NT-proBNP levels are ‘high’?
Arrange specialist assessment (including transthoracic echocardiography) within 2 weeks.
What should be arranged if NT-proBNP levels are ‘raised’?
Arrange specialist assessment (including transthoracic echocardiography) within 6 weeks.
What is B-type natriuretic peptide (BNP)?
A hormone produced mainly by the left ventricular myocardium in response to strain.
What BNP level is considered high?
> 400 pg/ml (116 pmol/litre)
What NT-proBNP level is considered high?
> 2000 pg/ml (236 pmol/litre)
What BNP level is considered raised?
100-400 pg/ml (29-116 pmol/litre)
What NT-proBNP level is considered raised?
400-2000 pg/ml (47-236 pmol/litre)
What BNP level is considered normal?
< 100 pg/ml (29 pmol/litre)
What NT-proBNP level is considered normal?
< 400 pg/ml (47 pmol/litre)
What factors can increase BNP levels?
Left ventricular hypertrophy, Ischaemia, Tachycardia, Right ventricular overload, Hypoxaemia, GFR < 60 ml/min, Sepsis, COPD, Diabetes, Age > 70.
What factors can decrease BNP levels?
Obesity, Diuretics, ACE inhibitors, Beta-blockers, Angiotensin 2 receptor blockers, Aldosterone antagonists.
What is the significance of very high BNP levels?
Very high levels are associated with a poor prognosis.
What is the role of loop diuretics in chronic heart failure management?
Loop diuretics, such as furosemide, play an important role in managing fluid overload but have not demonstrated long-term reduction in mortality.
What is the first-line treatment for chronic heart failure?
The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker, generally starting one drug at a time.
Which beta-blockers are licensed to treat heart failure in the UK?
Beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.
Do ACE-inhibitors and beta-blockers affect mortality in heart failure with preserved ejection fraction?
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction.
What is the standard second-line treatment for chronic heart failure?
The standard second-line treatment is an aldosterone antagonist, also known as a mineralocorticoid receptor antagonist.
What are examples of aldosterone antagonists?
Examples of aldosterone antagonists include spironolactone and eplerenone.
What should be monitored when using ACE inhibitors and aldosterone antagonists?
Potassium levels should be monitored as both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia.
What is the role of SGLT-2 inhibitors in heart failure management?
SGLT-2 inhibitors reduce glucose reabsorption and increase urinary glucose excretion, with evidence showing they reduce hospitalisation and cardiovascular death.
What are examples of SGLT-2 inhibitors?
Examples of SGLT-2 inhibitors include canagliflozin, dapagliflozin, and empagliflozin.
What does NICE’s 2021 technology appraisal support regarding SGLT-2 inhibitors?
NICE’s 2021 technology appraisal supports the use of dapagliflozin as an add-on to optimised standard care.
What treatments are considered third-line for chronic heart failure?
Third-line treatments include ivabradine, sacubitril-valsartan, hydralazine with nitrate, digoxin, and cardiac resynchronisation therapy.
What are the criteria for using ivabradine?
Ivabradine is indicated for patients with sinus rhythm > 75/min and a left ventricular fraction < 35%.
What are the criteria for using sacubitril-valsartan?
Sacubitril-valsartan is considered for symptomatic patients with left ventricular fraction < 35% after an ACEi or ARB wash-out period.
What is the role of digoxin in chronic heart failure?
Digoxin has not been proven to reduce mortality but may improve symptoms due to its inotropic properties, especially if there is coexistent atrial fibrillation.
When is hydralazine in combination with nitrate indicated?
Hydralazine in combination with nitrate may be particularly indicated in Afro-Caribbean patients.
What are the indications for cardiac resynchronisation therapy?
Indications for cardiac resynchronisation therapy include a widened QRS complex (e.g., left bundle branch block) on ECG.
What vaccines should be offered to patients with chronic heart failure?
Patients should be offered an annual influenza vaccine and a one-off pneumococcal vaccine.
How often do adults with asplenia or chronic kidney disease need a pneumococcal vaccine booster?
Adults with asplenia, splenic dysfunction, or chronic kidney disease need a booster every 5 years.
What is cardiac resynchronisation therapy used for?
It is used for patients with heart failure and wide QRS to improve symptoms and reduce hospitalisation in NYHA class III patients.
What effect does exercise training have on heart failure patients?
Exercise training improves symptoms but does not affect hospitalisation or mortality.
What is the NYHA classification used for?
The NYHA classification is used to classify the severity of heart failure.
What are the characteristics of NYHA Class I?
No symptoms and no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations.
What are the characteristics of NYHA Class II?
Mild symptoms with slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea.
What are the characteristics of NYHA Class III?
Moderate symptoms with marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms.
What are the characteristics of NYHA Class IV?
Severe symptoms: unable to carry out any physical activity without discomfort; symptoms of heart failure are present even at rest with increased discomfort with any physical activity.
