Chronic Heart Failure

Question 1

Definition of heart failure

Answer 1

Heart failure occurs when the heart is unable to maintain sufficient cardiac output to meet the blood supply damands of the body during rest and activity.

Question 2

Describe the progression of dyspnoea in CHF

Answer 2

Exertional dyspnoea -> dyspnoea at rest -> orthopnoea (begin sleeping on multiple pillows) -> PND

Question 3

Key Sx of CHF

Answer 3

SOB
Irritating cough (esp nocturnal)
Lethargy / Fatigue
Ankle Odema
Weight changes: loss or gain
Pre-syncope / Syncope
Palpitations

Question 4

Key examination findings in LHF

Answer 4

May be no signs initially

Tachycardia
Low volume pulse
Tachypnoea
Laterally displaced apex beat (LV hypertrophy)
Bilateral basal crackles (pulmonary odema)
Gallop rhythm (3rd heart sound)
Pleural effusion
Poor peripheral perfusion

*Always look for underlying valvular disease

Question 5

Key examination findings in RHF

Answer 5

Elevated JVP
Right ventricular heave
Peripheral / ankle odema
Hepatomegaly
Ascites

*Always look for underlying valvular disease

Question 6

Difference between systolic and diastolic heart failure?

Answer 6

Systolic - impaired LV ejection fraction (<40%) - dilated LV contracts poorly

Diastolic - impaired relaxation of LV resulting in reduced LV filling

**Can have simultaneous systolic and diastolic HF

Question 7

When to suspect specifically left diastolic heart failure?

Answer 7

Suspect in elderly with HTN and normal heart size on CXR, presenting with SOB and /or pulmonary odema

Question 8

Key investigations idirected at diagnosing CHF?

Answer 8

Echocardiography:
Differentiates between systolic and diastolic HF
Measures ventricular function
Also provides information on valves, any congenital defects and pericardial disease

ECG: Look for evidence of ischemia, conduction abnormalities, arrhythmias and LV hypertrophy

CXR: 
Cardiomegaly and interstitial odema
Small basal pleural effusions
Fluid in fissures
Prominent vascular markings

Spirometry / Resp Function: To detect any associated airways dysfunction

B type natriuretic peptide - hormone secreted from ventricular myocardium, is indicator of severity and prognosis of CHF

Question 9

Peripheral Investigations that may be useful in CHF?

Answer 9

FBC and ESR: Anemia can occur with CHF, and severe anemia can cause CHF

Serum electrolytes: Usually normal in CHF, but important to monitor them as part of management

Kidney function tests (UCEs): Monitor for drug therapy

LFTs: Congestive hepatomegaly (RHF) gives abnormal LFTs

Urinalysis

TFTs - especially in atrial fibrillation

Viral studies - in suspected viral myocarditis

Question 10

Specialized cardiac investigations - specialists - in CHF

Answer 10

Coronary Angiography - for suspected and/or known ischemia

Hemodynamic testing

Endomyocardial biopsy

Nuclear cardiology

Question 11

What are the aims associated with treating HF?

Answer 11

1. Determine and treat the cause of the HF
2. Remove any precipitating factors
3. Apropriate patient education
4. Both non-pharmacological measures and pharmacological treatment

Question 12

HF Prevention?

Answer 12

Dietary: healthy weight, optimal nutrition
Discourage excessive alcohol and smoking
Control HTN
Control other cardiac risk factors - e.g. hypercholesterolemia
Early detection and control of DM

Early intervention in MI to preserve myocardial function - i.e. thrombolysis, stenting
Appropriate secondary prevention of MI, post-MI - BBs, ACEI, low dose aspirin

Appropriate timing of surgery / angioplasty for ischemic or valvular heart disease

Question 13

What are the key ‘precipitating factors’ in HF that can be treated / prevented?

Answer 13

1. Arrhythmias
2. Electrolyte imbalances
3. Anemia
4. MI
5. Dietary - Excess Na+, malnutrition
6. Excessive alcohol consumption
7. Adverse drug reactions - e.g. fluid retention with NSAIDs and Cox-2 agents
8. Infections
9. Hypo- or hyper-thyroidism
10. Lack of therapy compliance
11. Fluid overload

Question 14

Drugs that can aggravate CHF?

Answer 14

NSAIDs and Cox-2 inhibitors (fluid retention)
Corticosteroids
TCAntidepressants
CCB - diltiazem, verapamil
Some anti-arrhythmics - quinidine
Macrolide Abx
Type 1 antihistamines
H2-receptor antagonists (ranitidine)
Glitazones
TNF-alpha inhibitors

Question 15

First-line therapy for HF?

Answer 15

1. ACEI - start with 1/4 or 1/2 of lowest recommended therapeutic dose, and adjust gradually to reach a maintenance or maximum dose
2. • Diuretic (if congestion)
     Loop diuretics preferred
3. • Aldosterone Antagonist Diuretic (only if still not controlled)

Question 16

Treatment for HF unresponsive to first-line therapy?

Answer 16

ACEI + Frusemide + Selective BB + Digoxin + Spironolactone

Severe heart failure - seek specialist advice

Consider vasodilators

Consider transplant

Question 17

Emergency management of acute cardiogenic pulmonary odema in HF?

Answer 17

1. Prop patient up
2. Administer O2
3. GTN sublingual
4. Insert large bore cannula
5. Frusemide 40mg IV, increase to 80mg IV as needed
6. Morphine + Metoclopramide
7. CPAP for unresponsive cases
8. Venesection if desperate

*Give Digoxin if in rapid atrial fibrillation, and not already taking it

Keep in mind underlying cause:

• MI –> silent?
• Arrhythmia
• Cardiomyopathy
• Anemia