Chronic - Heart failure

Question 1

Name 5 causes of left heart failure.

Answer 1

• Ischaemic heart disease
• Valvular heart disease (commonly aortic stenosis)
• Hypertension
• Arrhythmias
• Cardiomyopathy

Question 2

Name 2 causes of right sided heart failure.

Answer 2

• Left-sided heart failure
• Cor pulmonale - respiratory disease causes pulmonary hypertension

Question 3

What is the Frank-Starling Law?

Answer 3

The Frank-Starling Law states that the stroke volume of the left ventricle will increase as the left ventricular volume increases (preload) due to the myocyte stretch causing a more forceful systolic contraction.

Question 4

List 5 symptoms of chronic heart failure.

Answer 4

• SOB - worsened by exertion
• Orthopnoea - SOB when lying flat, relieves by sitting/standing (ask how many pillows they use at night)
• Paroxysmal nocturnal dyspnoea - suddenly waking at night with a severe attach of SOB and cough
• Cough - frothy white/pink sputum
• Peripheral oedema - swollen ankles
• Fatigue
• Nocturia
• Poor exercise tolerance

Question 5

What causes paroxysmal nocturnal dyspnoea?

Answer 5

• Gravity
  
  • Fluid settles across a large surface area of the lungs as they sleep lying flat
  • As they stand up the fluid sinks to the lung bases and their upper lungs clear and can be used more effectively
• Pulmonary congestion and hypoxia
  
  • During sleep the respiratory centre in the brain becomes less responsive so their respiratory rate and effort does not increase in response to reduced oxygen saturation like it normally would when awake

Question 6

How is chronic heart failure diagnosed?

Answer 6

• NT-proBNP - first-line
  
  • If positive - thoracic echocardiography
    
    • ​If high within 2 weeks
    • If raised within 6 weeks
• ECG - can show arrhythmias/evidence of ischaemic changes which led to the heart failure or signs of LV/RV hypertrophy

Question 7

How is chronic heart failure managed?

Answer 7

• Referral to specialist
• Explanation of condition - it is a progressive disease that cannot be cured
• Medical management
  
  • 1st-line - ACE-inhibitor (ramipril) and a Beta-blocker (bisoprolol)
  • 2nd-line - aldosterone antagonist (spironolactone or eplerenone)
  • 3rd line - ivarbradine, hydralazine+nitrate, digoxin, cardiac resynchronisation therapy (initiated by a specialist)
• General management
  
  • Smoking cessation and optimise co-morbidities
  • Cardiac rehabilitation programme
  • Annual flu vaccine
  • One-off pneumococcal vaccine

Question 8

Should ramipril or bisoprolol be started first in the management of chronic heart failure?

Answer 8

Generally, one drug should be started at a time

NICE advise to use clinical judgement to determine which to start first

(do not start ACEi without specialist advice in valvular heart disease)

Question 9

What should be monitored when taking spironolactone or eplerenone?

Answer 9

Potassium-sparing drugs

Monitor U&Es - in particular potassium

Question 10

What are the indications for cardiac resynchronisation therapy in chronic heart failure?

What is CRT?

Answer 10

Widened QRS on ECG e.g. LBBB

CRT - while functioning like a normal pacemaker to treat slow heart rhythms, a CRT device also delivers small electrical impulses to the left and right ventricles to help them contract at the same time

CRT-D - the defibrillator can treat VT or VF if they arise

Question 11

What can be used for symptomatic relief of heart failure e.g. peripheral oedema?

Answer 11

Loop diuretics e.g. furosemide

Question 12

What is the New York Heart Association Classification of Heart Failure?

Answer 12

Question 13

What can cause Cor Pulmonale?

Answer 13

Cor pulmonale is right sided heart failure caused by respiratory disease.

• COPD is the most common cause
• Pulmonary Embolism
• Interstitial Lung Disease
• Cystic Fibrosis
• Primary Pulmonary Hypertension

Question 14

What are the signs of cor-pulmonale?

Answer 14

• Hypoxia
• Cyanosis
• Raised JVP (due to a back-log of blood in the jugular veins)
• Peripheral oedema
• Third heart sound
• Murmurs (e.g. pan-systolic in tricuspid regurgitation)
• Hepatomegaly due to back pressure in the hepatic vein (pulsatile in tricuspid regurgitation)

Question 15

Name 4 pieces of advice you would provide someone with heart failure in primary care.

Answer 15

• Advise the person to monitor their weight at home to detect fluid retention of worsening heart failure
• Lifestyle advice - avoid excessive salt, exercise, smoking cessation
• Maintain fluid balance - 1.5L-2L per day, do not restrict
• If acutely unwell with diarrhoea&vomiting - stop ACEi + aldosterone antagonist, risk of AKI, seek medical advice

Question 16

What safety netting advice would you give someone with heart failure at GP?

Answer 16

Worsening heart failure – seek urgent medical attention:

• Increasing breathlessness
• Increasing fatigue
• Worse ankle/abdominal swelling
• Rapid weight gain

Question 17

What preventative measures can be taken in heart failure?

Answer 17

Offer annual influenza vaccine and once-only pneumococcal vaccination