Chronic Heart Failure Flashcards
What is chronic heart failure?
Clinical features of impaired heart function, specifically the function of the left ventricle to pump blood out of the heart and around the body.
What does impaired left ventricular function cause?
Chronic back flow of blood
The left atrium, pulmonary veins and lungs experience an increased volume and pressure of blood.
They start to leak fluid and cannot reabsorb excess fluid from the surrounding tissues, resulting in pulmonary oedema.
What causes heart failure?
Ischaemic heart disease
Valvular heart disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)
Cardiomyopathy
Symptoms
Breathlessness, worsened by exertion
Cough, which may produce frothy white/pink sputum
Orthopnoea, which is breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use)
Paroxysmal nocturnal dyspnoea (more detail below)
Peripheral oedema
Fatigue
Signs on examination
Tachycardia (raised heart rate)
Tachypnoea (raised respiratory rate)
Hypertension
Murmurs on auscultation
3rd heart sound on auscultation
Bilateral basal crackles on auscultation of the lungs, indicating pulmonary oedema
Raised jugular venous pressure (JVP)
Peripheral oedema of the ankles, legs and sacrum
Diagnosis involves:
Clinical assessment (history and examination)
N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test
ECG
Echocardiogram
New York Heart Association Classification
Class I: No limitation on activity
Class II: Comfortable at rest but symptomatic with ordinary activities
Class III: Comfortable at rest but symptomatic with any activity
Class IV: Symptomatic at rest
Management
R – Refer to cardiology
A – Advise them about the condition
M – Medical treatment
P – Procedural or surgical interventions
S – Specialist heart failure MDT input, such as the heart failure specialist nurses, for advice and support
What does the urgency of the referral depend on?
The urgency of the referral and specialist assessment depends on the NT-proBNP result.
According to the NICE guidelines:
From 400 – 2000 ng/litre should be seen and have an echocardiogram within 6 weeks
Above 2000 ng/litre should be seen and have an echocardiogram within 2 weeks
Medical management in heart failure
ABAL
A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated
B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated
A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone)
L – Loop diuretics (e.g., furosemide or bumetanide)
Additional management
Flu, covid and pneumococcal vaccines
Stop smoking
Optimise treatment of co-morbidities
Written care plan
Cardiac rehabilitation (a personalised exercise programme)
Chest Xray findings
A: Alveolar oedema (with ‘batwing’ perihilar shadowing)
B: Kerley B lines (caused by interstitial oedema)
C: Cardiomegaly (cardiothoracic ratio >0.5)
D: upper lobe blood diversion
E: Pleural effusions (typically bilateral transudates)
F: Fluid in the horizontal fissure
When should beta blockers not be given?
HR < 50 BPM
Medical treatment when ejection fraction <40%
ACE inhibitor -
Aldosterone antagonist - spironolactone
P wave corresponds to
4th heart sound
