Case 2 - Heart failure

Question 1

Features of HF on CXR

Answer 1

• Alveolar shadowing
• Kerley B lines
• Consolidation - bat wing and Cardiomegaly
• Dilation of upper lobe vessels
• Effusions

Question 2

Common causes of heart failure

Answer 2

• Ischaemic heart disease
• Hypertension
• Valvular disease
• Cardiomyopathy
• Arrhytmias

Question 3

Why do patients develop ankle oedema in HF?

Answer 3

• Right ventricle failure
• = increased RA pressure
• = increased vena cava pressure
• = increased systemic venous pressure
• = no pressure gradient for fluid to be reabsorbed at venule end of capillary beds
• = fluid stays intersitium
• = oedema

Question 4

Management of acute heart failure?

Answer 4

• IV diuretics - bolus (higher dose if already on)
• Monitor U&Es, weight and urine output
• Consider inotropes/vasopressors if cardiogenic shock which is reversible
• O2 if needed
• Consider NIV if acidaemia annd severe dyspnoea

Question 5

Management of chronic heart failure - all

Answer 5

• Diuretics for congestive symptoms and fluid retention
• Personalised exercise based cardiac rehabilitation program unless unstable

Question 6

Management HF with reduced EF

Answer 6

• ACEi
• Beta blocker
• Add spironolactone/eplerenone if symptoms persist
• SGLT2 inhibitors also now used in HF

Question 7

Managemeent HF pEF

Answer 7

• Manage co-morbidities eg
• HTN
• AF
• IHD
• Diabetes

Question 8

When to get specialist advice?

Answer 8

In HFrEF if symptoms persist despite ACEi, BB and MRA

Question 9

3rd line medications (after ACEi and BB and spironolactone) for HF

Answer 9

• Ivabradine - need to have HR above 75 to initiate (causes BRADycardia)
• Hydralazine and nitrate - use in Afro-carribean patients
• Sacubitril-valsartan - EF needs to be less than 35%, need to stop ACEi/ARB before initiating
• Digoxin - used if co-existent AF
• Cardiac resyndrocnisation - if prolonged QRS complexes

Question 10

Vaccines for HF

Answer 10

• Pneumococcal (one off, every 5 yrs if asplenia, splenic dysfunction or CKD)
• Annual influenza