Chronic Heart Failure

Question 1

Two main types of chronic heart failure?

Answer 1

1) Heart failure due to impaired ventricular contraction (systolic HF)
2) Heart failure due to impaired ventricular relaxation (diastolic HF)

Impaired ventricular contraction causes chronic back pressure in the left side of the heart, leading to blood backing up into the lungs, resulting in Sx associated with CHF.

Question 2

How do patients with chronic heart failure present?

Answer 2

• Breathlessness that is worse on exertion.
• Cough –> frothy white/pink sputum
• Breathlessness that is worse when lying flat –> ask how many pillows they sleep with at night and if they prop up their pillows.
• Paroxysmal nocturnal dyspnea –> waking up at night gasping for breath, and coughing and wheezing.
• Peripheral oedema –> swollen legs/ankles

Question 3

What is paroxysmal nocturnal dyspnea? Why do patients present such a symptom?

Answer 3

Waking up at night gasping for air, coughing and wheezing.

May feel like they are suffocating or drowning.

Patients typically sit on the side of their bed or stand up or go to their windows to take in as much fresh air as possible. Symptoms typically last for a few minutes.

Mechanisms

• When lying flat, fluid covers a large area of the lungs making it difficult to breathe. When sitting/standing up, gravity takes over and pulls fluid to the base of the lungs. This clears the upper segments of the lungs from fluid for proper ventilation to take place.
• Respiratory centre in the brain is less sensitive during sleep, therefore respiratory rate and effort does not increase as much when the patient ‘;s oxygen saturation levels are decreasing.
• When sleeping, noradrenaline levels in the body are lower, therefore inotropic effect of the heart is reduced. The reduction in the contractility of the heart exacerbates the patients condition as more blood is likely to pool in the heart and cause back pressure to the lungs.

Question 4

How do you diagnose chronic heart failure?

Answer 4

• Clinical assessment
  > History
  > Clinical examination
  > Bibasal crackles on auscultation to indicate pulmonary oedema
  > Peripheral oedema such as swollen ankles/legs/sacrum.
• BNP (NT-pro BNP) levels
  
  • > 2000ng/L –> refer urgently to cardiac specialist. Less than 2000ng/L, refer routinely.
• ECG
• Echocardiogram

Question 5

Causes of chronic heart failure?

Answer 5

VAHI

V- valvular disorders e.g. aortic dissection, mitral valve regurgitation.

A - arrhythmia e.g. AF

H - hypertension

I - ischaemic heart disease

Question 6

How do you manage patients with chronic heart failure?

Answer 6

1) Check patient’s BNP levels –> if greater than 2000 ng/L, then refer urgently to cardiac specialist. If not, then refer routinely.
2) Explain to the patient why they are having their symptoms.
3) Medical Management (ABAL)
4) Surgical management if there is valvular cause for chronic heart failure e.g. aortic stenosis, mitral valve regurgitation.
5) Heart failure specialist nurse to give advice and support for patients with chronic heart failure.

Additional Management

• Advice on stopping smoking
• Advice on exercising as much as they can tolerate
• Yearly flu and one-time pneumococcal vaccine
• Optimising treatment for other co-morbidities

Medical Management (ABAL)

• Ace inhibitors e.g. ramipril (titrated to 10mg/day max)
• Beta blocker e.g. bisoprosol (titrated to 10mg/day max)
• Aldosterone antagonist e.g. spironolactine or eplerenone
• Loop diuretics e..g furesomide (titrated to 40mg/day) or Bumetanide (e.g. 1mg/OD)

Things to consider for medical management

• if ACEi are not tolerated first line, then you can use aldosterone receptor antagonist e.g. Candesartan (32mg/OD).
• Avoid ACEi in patients with valvular heart disease, until cardiac specialist says its ok to do so.
• Make sure to check U&Es closely because ACEi, beta blockers and loop diuretics all affect electrolyte levels and may cause electrolyte disturbance if not monitored very well.