Chronic Heart Failure

Question 1

Define chronic cardiac failure.

Answer 1

A complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. The term “congestive heart failure” (CHF) is reserved for patients with breathlessness and abnormal sodium and water retention resulting in oedema.

Question 2

Explain the aetiology/risk factors of chronic cardiac failure.

Answer 2

Coronary artery disease
Hypertension
Valvular disease
Myocarditis

Question 3

Summarise the epidemiology of chronic cardiac failure.

Answer 3

The prevalence of CHF in the western world has been estimated at 1% to 2%, and the incidence is thought to approach 5 to 10 per 1000 people per year.

Question 4

Recognise the presenting symptoms of chronic cardiac failure.

Answer 4

Tachycardia (heart rate >120 beats per minute)
Chest discomfort
Ankle oedema
Night cough
Fatigue, muscle weakness, or tiredness

Question 5

Recognise the signs of chronic cardiac failure on physical examination.

Answer 5

Dyspnoea
Neck vein distension
S3 gallop
Cardiomegaly
Hepatojugular reflux
Rales
Hepatomegaly

Question 6

Identify appropriate investigations for chronic cardiac failure and interpret the results.

Answer 6

ECG
Echocardiogram
CXR
B-type natriuretic peptide (BNP)/N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels
FBC
Serum electrolytes (including calcium and magnesium)
Serum creatinine, blood urea nitrogen
BM
LFT
Thyroid function tests (especially thyroid-stimulating hormone [TSH])
Blood lipids
Serum ferritin
Transferrin saturation

Question 7

Generate a management plan for chronic cardiac failure.

Answer 7

In newly diagnosed patients with CHF, congestion and volume overload should be promptly treated with diuretics, which may be given intravenously in the initial phase. Loop diuretics used for the treatment of heart failure and congestion include furosemide, bumetanide, and torasemide.

In patients with low left ventricular ejection fraction (LVEF), in addition to diuretics, ACE inhibitors, beta-blockers, and aldosterone antagonists (e.g. spironolactone, eplerenone) should be added.

In unstable patients, beta-blockers should be initiated only after stabilisation, optimisation of volume status, and discontinuation of inotropes. Beta-blockers should be initiated at a low dose.

In patients with CHF and reduced LVEF who are hospitalised with exacerbation of heart failure, unless there is evidence of low cardiac output or haemodynamic instability or contraindication, both ACE-inhibitors and beta-blockers should be continued.

Question 8

Identify the possible complications of chronic cardiac failure and its management.

Answer 8

Pleural effusion
Chronic renal insufficiency
Anaemia
Acute decompensation of chronic heart failure
Acute renal failure
Sudden cardiac death

Question 9

Summarise the prognosis for patients with chronic cardiac failure.

Answer 9

The evaluation of a patient would be incomplete without an initial and periodic assessment of short- and long-term prognosis. However, the likelihood of survival can be determined reliably only in populations and not in individual patients.
Haemoglobin A1c was also found to be an independent progressive risk factor for cardiovascular death, hospitalisation, and mortality, even in non-diabetic patients.