Chronic Heart Failure

Question 1

Causes of chronic heart failure.

Answer 1

Ischaemic Heart Disease

Valvular Heart Disease (commonly aortic stenosis)

Hypertension

Arrhythmias (commonly atrial fibrillation)

Cardiomyopathies

Question 2

Clinical presentation of chronic heart failure.

Answer 2

Breathlessness worsened by exertion

Cough. They may produce frothy white/pink sputum.

Orthopnoea (the sensation of shortness of breathing when lying flat, relieves by sitting or standing). Ask them how many pillows they use at night.

Paroxysmal Nocturnal Dyspnoea (see below)

Peripheral oedema (swollen ankles)

Question 3

Diagnosis of chronic heart failure.

Answer 3

Question 4

Management of chronic heart failure

Answer 4

Question 5

ACEi therapy in chronic HF

Answer 5

Do not offer ACE inhibitor therapy if there is a clinical suspicion of haemodynamically significant valve disease until the valve disease has been assessed by a specialist

Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached

Measure serum sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increment

Measure blood pressure before and after each dose increment of an ACE inhibitor.

Once the target or maximum tolerated dose of an ACE inhibitor is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell

Question 6

NYHA heart failure classifications

Answer 6

I

No symptoms

Asymptomatic

II

Symptoms with ordinary activity

Mild symptoms

III

Symptoms with less than ordinary activity

Moderate symptoms

IV

Symptoms at rest or with any minimal activity

Severe symptoms

Question 7

Beta blockers in chronic HF.

Answer 7

Do not withhold treatment with a beta-blocker solely because of age or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease or chronic obstructive pulmonary disease

Introduce beta-blockers in a ‘start low, go slow’ manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta‑blocker

Switch people whose condition is stable and who are already taking a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart failure with reduced ejection fraction, to a beta-blocker licensed for heart failure.

Question 8

Ivabradine in chronic HF.

Answer 8

Ivabradine is recommended as an option for treating chronic heart failure for people:

with NYHA class II to IV stable chronic heart failure with systolic dysfunction and

who are in sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and

who are given ivabradine in combination with standard therapy including beta-blocker therapy, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists, or when beta‑blocker therapy is contraindicated or not tolerated and

with a left ventricular ejection fraction of 35% or less

Question 9

Sacubitril valsartan in chronic HF.

Answer 9

Sacubitril valsartan (ARNI) is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people:

with NYHA class II to IV symptoms and

with a left ventricular ejection fraction of 35% or less and

who are already taking a stable dose of ACE inhibitors or ARBs.