Cardiac failure: Chronic Heart failure

Question 1

What are the features of pulmonary oedema on a chest x-ray?

Answer 1

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.

Question 2

What is interstitial oedema?

Answer 2

A feature of pulmonary oedema seen on a chest x-ray.

Question 3

What does the bat’s wing appearance indicate?

Answer 3

A characteristic feature of pulmonary oedema on a chest x-ray.

Question 4

What is upper lobe diversion?

Answer 4

Increased blood flow to the superior parts of the lung, indicating pulmonary oedema.

Question 5

What are Kerley B lines?

Answer 5

Lines seen on a chest x-ray that indicate interstitial oedema.

Question 6

What does pleural effusion indicate?

Answer 6

A possible feature of pulmonary oedema on a chest x-ray.

Question 7

What is cardiomegaly?

Answer 7

Enlargement of the heart that may be seen on a chest x-ray if there is a cardiogenic cause of pulmonary oedema.

Question 8

What is the first-line investigation for chronic heart failure diagnosis according to NICE 2018 guidelines?

Answer 8

All patients should have an N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test first-line.

Question 9

What should be arranged if NT-proBNP levels are ‘high’?

Answer 9

Arrange specialist assessment (including transthoracic echocardiography) within 2 weeks.

Question 10

What should be arranged if NT-proBNP levels are ‘raised’?

Answer 10

Arrange specialist assessment (including transthoracic echocardiography) within 6 weeks.

Question 11

What is B-type natriuretic peptide (BNP)?

Answer 11

A hormone produced mainly by the left ventricular myocardium in response to strain.

Question 12

What BNP level is considered high?

Answer 12

> 400 pg/ml (116 pmol/litre)

Question 13

What NT-proBNP level is considered high?

Answer 13

> 2000 pg/ml (236 pmol/litre)

Question 14

What BNP level is considered raised?

Answer 14

100-400 pg/ml (29-116 pmol/litre)

Question 15

What NT-proBNP level is considered raised?

Answer 15

400-2000 pg/ml (47-236 pmol/litre)

Question 16

What BNP level is considered normal?

Answer 16

< 100 pg/ml (29 pmol/litre)

Question 17

What NT-proBNP level is considered normal?

Answer 17

< 400 pg/ml (47 pmol/litre)

Question 18

What factors can increase BNP levels?

Answer 18

Left ventricular hypertrophy, Ischaemia, Tachycardia, Right ventricular overload, Hypoxaemia, GFR < 60 ml/min, Sepsis, COPD, Diabetes, Age > 70.

Question 19

What factors can decrease BNP levels?

Answer 19

Obesity, Diuretics, ACE inhibitors, Beta-blockers, Angiotensin 2 receptor blockers, Aldosterone antagonists.

Question 20

What is the significance of very high BNP levels?

Answer 20

Very high levels are associated with a poor prognosis.

Question 21

What is the role of loop diuretics in chronic heart failure management?

Answer 21

Loop diuretics, such as furosemide, play an important role in managing fluid overload but have not demonstrated long-term reduction in mortality.

Question 22

What is the first-line treatment for chronic heart failure?

Answer 22

The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker, generally starting one drug at a time.

Question 23

Which beta-blockers are licensed to treat heart failure in the UK?

Answer 23

Beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.

Question 24

Do ACE-inhibitors and beta-blockers affect mortality in heart failure with preserved ejection fraction?

Answer 24

ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction.

Question 25

What is the standard second-line treatment for chronic heart failure?

Answer 25

The standard second-line treatment is an aldosterone antagonist, also known as a mineralocorticoid receptor antagonist.

Question 26

What are examples of aldosterone antagonists?

Answer 26

Examples of aldosterone antagonists include spironolactone and eplerenone.

Question 27

What should be monitored when using ACE inhibitors and aldosterone antagonists?

Answer 27

Potassium levels should be monitored as both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia.

Question 28

What is the role of SGLT-2 inhibitors in heart failure management?

Answer 28

SGLT-2 inhibitors reduce glucose reabsorption and increase urinary glucose excretion, with evidence showing they reduce hospitalisation and cardiovascular death.

Question 29

What are examples of SGLT-2 inhibitors?

Answer 29

Examples of SGLT-2 inhibitors include canagliflozin, dapagliflozin, and empagliflozin.

Question 30

What does NICE's 2021 technology appraisal support regarding SGLT-2 inhibitors?

Answer 30

NICE's 2021 technology appraisal supports the use of dapagliflozin as an add-on to optimised standard care.

Question 31

What treatments are considered third-line for chronic heart failure?

Answer 31

Third-line treatments include ivabradine, sacubitril-valsartan, hydralazine with nitrate, digoxin, and cardiac resynchronisation therapy.

Question 32

What are the criteria for using ivabradine?

Answer 32

Ivabradine is indicated for patients with sinus rhythm > 75/min and a left ventricular fraction < 35%.

Question 33

What are the criteria for using sacubitril-valsartan?

Answer 33

Sacubitril-valsartan is considered for symptomatic patients with left ventricular fraction < 35% after an ACEi or ARB wash-out period.

Question 34

What is the role of digoxin in chronic heart failure?

Answer 34

Digoxin has not been proven to reduce mortality but may improve symptoms due to its inotropic properties, especially if there is coexistent atrial fibrillation.

Question 35

When is hydralazine in combination with nitrate indicated?

Answer 35

Hydralazine in combination with nitrate may be particularly indicated in Afro-Caribbean patients.

Question 36

What are the indications for cardiac resynchronisation therapy?

Answer 36

Indications for cardiac resynchronisation therapy include a widened QRS complex (e.g., left bundle branch block) on ECG.

Question 37

What vaccines should be offered to patients with chronic heart failure?

Answer 37

Patients should be offered an annual influenza vaccine and a one-off pneumococcal vaccine.

Question 38

How often do adults with asplenia or chronic kidney disease need a pneumococcal vaccine booster?

Answer 38

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

Question 39

What is cardiac resynchronisation therapy used for?

Answer 39

It is used for patients with heart failure and wide QRS to improve symptoms and reduce hospitalisation in NYHA class III patients.

Question 40

What effect does exercise training have on heart failure patients?

Answer 40

Exercise training improves symptoms but does not affect hospitalisation or mortality.

Question 41

What is the NYHA classification used for?

Answer 41

The NYHA classification is used to classify the severity of heart failure.

Question 42

What are the characteristics of NYHA Class I?

Answer 42

No symptoms and no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations.

Question 43

What are the characteristics of NYHA Class II?

Answer 43

Mild symptoms with slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea.

Question 44

What are the characteristics of NYHA Class III?

Answer 44

Moderate symptoms with marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms.

Question 45

What are the characteristics of NYHA Class IV?

Answer 45

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.