Chronic heart failure

Question 1

Chronic heart failure mechanism

Answer 1

Impaired left ventricular contraction - systolic heart failure
Impaired left ventricular relaxation - diastolic heart failure
Results in chronic back-pressure of blood trying to flow through left side of heart

Question 2

Chronic heart failure presentation

Answer 2

Breathlessness worse with exertion
Cough - frothy white/pink sputum
Orthopnoea - how many pillows
Paroxysmal nocturnal dyspnoea
Peripheral oedema

Question 3

PND mechanism

Answer 3

Fluid settling across large surface area when flat - stand and fluid sinks - upper lungs can be used

Sleep - respiratory centre less responsive - respiratory rate and effort not increasing in response to reduced O2 sats - more pulmonary congestion and hypoxia

Less adrenalin circulating during sleep - myocardium more relaxed - worsens cardiac output

Question 4

CCF diagnosis

Answer 4

Clinical presentation
BNP blood test (NT-proBNP) (N-terminal pro B-type natriuretic peptide)
Echo
ECG

Question 5

CCF diagnosis

Answer 5

Clinical presentation
BNP blood test (NT-proBNP) (N-terminal pro B-type natriuretic peptide)
Echo
ECG

Question 6

CCF causes

Answer 6

Ischaemic heart disease
Valvular heart disease esp aortic stenosis
HTN
Arrhythmias esp AF

Question 7

CCF general management

Answer 7

Refer to specialist (BNP>2000 - urgent)
Medical management
Surgical if severe AS/MR
HF specialist nurse input
Yearly flu and pneumococcal vaccine
Stop smoking
Optimise treatment of co-morbidities
Exercise as tolerated

Question 8

CCF medical management

Answer 8

ABAL
A - ace inhibitor (ramipril 10mg OD) - avoid if valvular heart disease /ARB (candesartan 32mg OD)
B - beta blocker (bisoprolol 10mg OD)
A - aldosterone antagonist if symptoms not controlled / reduced ejection fraction (spironolactone / eplerenone)
L - loop diuretics improves symptoms (furosemide 40mg OD)

Monitor U&Es when on diuretics, ACEi and aldosterone antagonists