chronic heart failure

Question 1

what is heart failure

Answer 1

when structural or functional abnormalities of the heart cause reduced cardiac output. It is a progressive disease.

Heart failure can either have a reduced or preserved ejection fraction

Question 2

what are the symptoms of heart failure

Answer 2

• shortness of breath
• persistent coughing and wheezing
• ankle swelling
• reduced exercise tolerance
• fatigue

these symptoms may be accompanied with signs such as:
elevated jugular venous pressure (abnormal right heart dynamics), pulmonary crackles (sounds made when pt inhales), and pulmonary oedema (excess fluid in lungs)

Question 3

which patient groups have a higher risk of heart failure

Answer 3

• men
• smokers
• diabetics
• risk increases with age
• afro/caribbean patients with hypertension

Question 4

what is the most common cause of heart failure

Answer 4

coronary heart disease (also known as ischaemic heart disease).

It is when atherosclerotic plaques block/reduce blood flow coronary arteries

Question 5

name some of the complications that can occur from heart failure

Answer 5

• chronic kidney disease
• atrial fibrillation
• depression
• sudden cardiac death
• sexual dysfunction
• cachexia (weakness/ wasting away of the body due to chronic illness)

Question 6

what is heart failure with REDUCED ejection fraction

Answer 6

when the left ventricle loses its ability to CONTRACT normally (leading to reduced cardiac output). The patient has an ejection fraction of less than 40%

Question 7

what is heart failure with PRESERVED ejection fraction

Answer 7

when the left ventricle loses its ability to RELAX normally. The ejection fraction is normal or only mildly reduced

Question 8

which type of heart failure leads to an ejection fraction of less than 40%

Answer 8

heart failure with REDUCED ejection fraction

Question 9

what is the New York Heart Association (NYHA) functional classification tool used for

Answer 9

to define how heart failure is progressing based on the severity of symptoms and limitation to physical activity

Question 10

name some non-drug treatments (lifestyle changes) that can reduce the progression of heart failure

Answer 10

• smoking cessation
• reducing alcohol consumption
• increase exercise if appropriate (150 mins moderate exercise per week. 75 mins if vigorous)
• dietary changes (increase fruit + veg, reduce saturated fat intake)
• max 6g of salt per day

Question 11

how often should patients with heart failure weigh themselves

Answer 11

weigh themselves everyday at a set time of the day. They should report any weight gain of more than 1.5-2kg in 2 days to their GP or heart failure specialist

Question 12

when should patients with heart failure report weight gain

Answer 12

if they gain more than 1.5-2 kg in days they should report this to their GP or heart failure specialist

Question 13

TRUE OR FALSE

patients with heart failure should always reduce/restrict fluid and salt intake

Answer 13

false

fluid and salt intake should only be restricted if they are high

Question 14

which salt substitutes should be avoided in patients with heart failure

Answer 14

salt substitutes containing potassium to reduce the risk of hyperkalemia

Question 15

which vaccines are recommended in patients with heart failure

Answer 15

• pneumococcal disease

- annual flu vaccine

Question 16

which CCBs should be avoided in patients with heart failure

why should they be avoided

Answer 16

all CCB (except amlodipine)

• rate limiting CCB (verapamil + diltazem)
• short acting dihydropyridines CCB (nifedipine + nicardipine)

these should be avoided because they reduce cardiac contractility and exacerbate symptoms

Question 17

TRUE OR FALSE:

patients with heart failure (with reduced ejection fraction) and angina can safely be treated with amlodipine

Answer 17

True

note: although amlodipine is a dihydropyridine CCB, it is not short acting so can be used. it is the only CCB that can be used in heart failure + angina

Question 18

why are diuretics be used in patients with heart failure

what is the first-line choice of diuretics

Answer 18

diuretics used to relieve breathlessness + oedema in patients with fluid retention.

first line choice: loop diuretics such as furosemide, bumetanide, torasemide

Question 19

what the first line treatment for patients with heart failure + reduced ejection fraction

Answer 19

• ACE inhibitor (e.g rampiril, lisinopril, enalapril)

AND

• Beta-blocker (e.g bisoprolol, carvedilol, nebivolol)
• note: you can start either the ACE inhibitor, or BETA blocker first. only start the second addition once the patient has been stable on first drug. start at low dose and titrate up*

Question 20

what is the next step if a patient with heart failure + reduced ejection fraction still has symptoms despite being on optimal first line treatment

Answer 20

speak to specialist, consider adding:

• an aldosterone antagonist such as spironolactone or eplerenone
• hydralazine
• digoxin

Question 21

when might digoxin be used in patients with heart failure + reduced ejection fraction

Answer 21

as add-on therapy in worsening or severe heart failure in patients with sinus rhythm.

note: digoxin does not reduce mortality due to heart failure. it only decreases symptoms + decreases hospitalisations due to acute exacerbations

Question 22

what monitoring should occur when a patient with heart failure + reduced ejection fraction is treated with:

• ACE inhibitors
• ARB
• Aldosterone antagonists
• beta blockers

Answer 22

• serum potassium and sodium
• renal function
• blood pressure
• heart rate
• symptom control

should be checked prior to starting treatment, 1-2 weeks after starting treatment, and at each dose increment. once max dose tolerated, monitor every month for first 3 months, then every 6 months after

Question 23

what is the treatment for patients with heart failure and preserved ejection fraction

Answer 23

should be treated under care of heart failure specialist