Cardiovascular: Congestive Cardiac Failure (Heart failure)

Question 1

what is the most common underlying cause of congestive cardiac failure?

Answer 1

coronary artery disease

Question 2

heart failure is classified into which two main categories?

Answer 2

reduced (HF-REF) or preserved ejection fraction (HF-PEF)

Question 3

The New York Heart Association (NYHA) has a functional classification of heart failure based on severity of symptoms and limitation of physical activity, what does class I indicate?

Answer 3

no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness, or palpitations.

Question 4

The New York Heart Association (NYHA) has a functional classification of heart failure based on severity of symptoms and limitation of physical activity, what does class II indicate?

Answer 4

slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Question 5

The New York Heart Association (NYHA) has a functional classification of heart failure based on severity of symptoms and limitation of physical activity, what does class III indicate?

Answer 5

marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Question 6

The New York Heart Association (NYHA) has a functional classification of heart failure based on severity of symptoms and limitation of physical activity, what does class IV indicate?

Answer 6

unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken discomfort is increased

Question 7

what are some risk factors for congestive cardiac failure?

Answer 7

Ischaemic Heart Disease
Valvular Heart Disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)

• congenital heart disease
• High output states; Anaemia, Thyrotoxicosis, Phaeochromocytoma, Septicaemia, Liver failure, Arteriovenous shunts, Paget’s disease, Thiamine (vitamin B1) deficiency.
• obesity
• drugs
• diabetes

Question 8

what are some clinical features of congestive cardiac failure?

Answer 8

Breathlessness worsened by exertion
Cough.

They may produce frothy white/pink sputum.

Orthopnoea (the sensation of shortness of breathing when lying flat, relieves by sitting or standing). Ask them how many pillows they use at night.

Paroxysmal Nocturnal Dyspnoea (see below)

Peripheral oedema (swollen ankles)

Question 9

what investigations would you conduct to confirm a diagnosis of congestive cardiac failure?

Answer 9

BNP blood test (specifically “N-terminal pro-B-type natriuretic peptide” – NT‑proBNP)

Echocardiogram

ECG

Question 10

what is the treatment for congestive cardiac failure?

Answer 10

“ABAL”

• ACE inhibitor (e.g. ramipril titrated as tolerated up to 10mg once daily)
• Beta Blocker (e.g. 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 (e.g. furosemide 40mg once daily)

NB: a ARB (Angiotensin Receptor Blocker (ARB) can be used instead of an ACE inhibitor if ACE inhibitors are not tolerated) - Avoid ACE inhibitors in patients with valvular heart disease until indicated by a specialist.

Aldosterone antagonists are used when there is a reduced ejection fraction and symptoms are not controlled with an ACEi and beta blocker.

Patients should have their U&Es monitored closely whilst on diuretics, ACE inhibitors and aldosterone antagonists as all three medications can cause electrolyte disturbances.

Question 11

what are some complications of congestive cardiac failure?

Answer 11

• arrhythmias
• depression
• cachexia.
• CKD
• sexual dysfunction ( This may be related to cardiovascular disease, fatigue, weakness, the use of drugs (such as beta-blockers), or depression and anxiety)
• sudden cardiac death

Question 12

what is prognosis of congestive cardiac failure?

Answer 12

50% of people with heart failure die within 5 years of diagnosis.

Question 13

what signs on examination may you find with a patient with congestive cardiac failure?

Answer 13

Irregular heart beat, peripheral oedema, rapid weight gain from fluid retention, tachycardia, tachypnoea, pleural effusion, raised JVP, hepatomegaly.

Question 14

what is chronic heart failure?

Answer 14

Impaired left ventricular contraction (“systolic heart failure”) or left ventricular relaxation (“diastolic heart failure”).

This impaired left ventricular function results in a chronic back-pressure of blood trying to flow into and through the left side of the heart.

Question 15

what is Paroxysmal Nocturnal Dyspnoea (PND)?

Answer 15

a term used to describe the experience that patients have of suddenly waking at night with a severe attack of shortness of breath and cough.

this is caused by:

• fluid settling across a large surface area of their lungs as they sleep lying flat
• resp rate is low when asleep and does not respond to de-saturating
• less adrenaline when they sleep; means the myocardium is more relaxed and this worsens reduces the cardiac output.