Congestive heart failure

Question 1

What is heart 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.
Heart failure is when the heart is unable to generate a CO sufficient to meet the demands of the body without increasing diastolic pressure.

Question 2

What is congestive heart failure?

Answer 2

This term is reserved for patients with dyspnoea and abnormal sodium and water retention resulting in oedema.

Question 3

How is heart failure classified?

Answer 3

It is classified based on left ventricle ejection fraction (LVEF):
HFrEF: LVEF <40%
HFmrEF: LVEF between 40-49%
HFpEF: LVEF >50%
Ejection fraction is the amount of blood being pumped out of the heart with each contraction.
A normal EF is 50-70%.

Question 4

What are the causes of heart failure?

Answer 4

Coronary heart disease and HTN are the most common causes of HF in the UK.
Other causes of HF include:
Structural causes - valvular disease
Congenital heart disease- inherited cardiomyopathies, ASD, VSD.
Rate-related cause- uncontrolled AF, thyrotoxicosis, anaemia (high CO), heart block
Pulmonary causes- COPD, pulmonary fibrosis, recurrent PE, primary pulmonary HTN.
Alcohol and drugs
Pericardial disease- chronic pericarditis (caused by TB, lupus, viruses)
Autoimmune disease- amyloidosis and sarcoid

Question 5

Signs and symptoms of heart failure

Answer 5

Dyspnoea 
Neck vein distension 
S3 gallop 
Cardiomegaly 
Hepatojugular reflux
Rales 
Orthopnoea 
PND 
Nocturia 
Tachycardia 
Chest discomfort
Hepatomegaly 
Ankle oedema 
Night cough 
Signs of pleural effusion 
Fatigue 
Confusion

Question 6

Risk factors for heart failure

Answer 6

MI 
DM 
Dyslipidaemia 
Old age 
Male 
HTN 
Left ventricular dysfunction 
Cocaine abuse 
Exposure to cardiotoxic agents 
LVH 
Renal insufficiency 
Valvular heart disease 
Sleep apnoea 
Elevated homocysteine 
CRP 
IGF-1
Dilation of the LV 
FHx of the HF 
AF 
Anaemia 
Thyroid disorders 
Obesity

Question 7

Diagnosis of heart failure

Answer 7

Take a careful and detailed history, and perform a clinical examination and tests to confirm the presence of heart failure.
Perform an ECG and consider the following tests to evaluate possible aggravating factors and/or alternative diagnoses:
chest X-ray
blood tests:
renal function profile (important in relation to the treatment required)
thyroid function profile
liver function profile (pulmonary congestion-associated liver congestion)
lipid profile
glycosylated haemoglobin (HbA1c)
full blood count
urinalysis
peak flow or spirometry.
Try to exclude other disorders that may present in a similar manner.
Measure NT-proBNP in people with suspected heart failure.
Perform transthoracic echocardiography to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts.

Question 8

NT-proBNP in the diagnosis of heart failure

Answer 8

This is used to confirm the diagnosis of HF- raised(higher levels indicates prognosis)
Because very high levels of NT-proBNP carry a poor prognosis, refer people with suspected heart failure and an NT-proBNP level above 2,000 ng/litre (236 pmol/litre) urgently, to have a specialist assessment and transthoracic echocardiography within 2 weeks.
Refer people with suspected heart failure and an NT-proBNP level between 400 and 2,000 ng/litre (47 to 236 pmol/litre) to have specialist assessment and echocardiography within 6 weeks.

Question 9

Clinical problems with NT-proBNP

Answer 9

Be aware that:
obesity, African or African–Caribbean family origin, or treatment with diuretics, ACE inhibitors, beta-blockers, ARBs or MRAs can reduce levels of serum natriuretic peptides
high levels of serum natriuretic peptides can have causes other than heart failure (for example, age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [eGFR less than 60 ml/minute/1.73 m2], sepsis, chronic obstructive pulmonary disease, diabetes, or cirrhosis of the liver).
Be aware that:
an NT-proBNP level less than 400 ng/litre (47 pmol/litre) in an untreated person makes a diagnosis of heart failure less likely
the level of serum natriuretic peptide does not differentiate between heart failure with reduced ejection fraction and heart failure with preserved ejection fraction.
Review alternative causes for symptoms of heart failure in people with NT-proBNP levels below 400 ng/litre. If there is still concern that the symptoms might be related to heart failure, discuss with a physician with subspecialty training in heart failure.

Question 10

What does CXR show in heart failure?

Answer 10

Looking for evidence of pulmonary oedema and/or consolidation.
Perihilar ‘bat-wing’ appearance shows pulmonary oedema.
Cardiomegaly: heart >50% of the thorax
Dilated upper lobe veins
Kerley B lines
Pleural effusion (blunted costophrenic angles)
Thickened bronchial walls (fluid in fissures)

Question 11

Differentials of heart failure

Answer 11

Ageing/physical activity
COPD- dyspnoea will be episodic
Pneumonia- patients present with fever, cough and productive sputum
PE- sudden onset of chest pain, dyspnoea
Cirrhosis- jaundice
Nephrotic syndrome- loss of appetite, peripheral oedema, fatigue and dyspnoea
Deep venous thrombosis

Question 12

Complications of HF

Answer 12

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

Question 13

Management of chronic HF

Answer 13

Make a care plan. 
Lifestyle advice: 
-Salt and fluid restriction
-Smoking and alcohol
-Vaccinations
-Contraception and pregnancy
-Drug treatment for all types of heart failure
-Monitor and review 
-Cardiac rehabilitation 
-Palliative care

Question 14

Lifestyle advise of HF

Answer 14

-Salt and fluid restriction-
Do not routinely advise people with heart failure to restrict their sodium or fluid consumption.
Ask about salt and fluid consumption and, if needed, advise as follows:
restricting fluids for people with dilutional hyponatraemia
reducing intake for people with high levels of salt and/or fluid consumption.
Continue to review the need to restrict salt or fluid.
Advise people with heart failure to avoid salt substitutes that contain potassium.

Question 15

Vaccinations for HF

Answer 15

Offer people with heart failure an annual vaccination against influenza.

Offer people with heart failure vaccination against pneumococcal disease (only required once).

Question 16

Contraception and pregnancy in HF

Answer 16

In women of childbearing potential who have heart failure, contraception and pregnancy should be discussed.
If pregnancy is being considered or occurs, specialist advice should be sought.
Subsequently, specialist care should be shared between the cardiologist and obstetrician.

Question 17

Drug treatment in HF

Answer 17

Diuretics
Calcium-channel blockers
Amiodarone
Anticoagulants

Question 18

How do you treat heart failure with preserved ejection fraction?

Answer 18

People who have heart failure with preserved ejection fraction should usually be offered a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day).
People whose heart failure does not respond to this treatment will need further specialist advice.
People who have heart failure with preserved ejection fraction should usually be offered a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day).
People whose heart failure does not respond to this treatment will need further specialist advice.

Question 19

Treating hyperkalaemia in patients with HF

Answer 19

Sodium zirconium cyclosilicate is recommended as an option for treating hyperkalaemia in adults only if used:
in emergency care for acute life-threatening hyperkalaemia alongside standard care or
in outpatient care for people with persistent hyperkalaemia and chronic kidney disease stage 3b to 5 or heart failure, if they:
have a confirmed serum potassium level of at least 6.0 mmol/litre,
are not taking an optimised dosage of RAAS inhibitor because of hyperkalaemia, and
are not on dialysis.

Question 20

Treating chronic heart failure with a reduced ejection fraction

Answer 20

Offer an ACE inhibitor and a beta-blocker licensed for heart failure to people who have heart failure with reduced ejection fraction.
Use clinical judgement when deciding which drug to start first.
-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 bpm or more and
who are given ivabradine in combination with standard therapy including beta-blocker therapy, 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.
-Implantable cardioverter defibrillators (ICDs), cardiac resynchronisation therapy (CRT) with defibrillator (CRT-D) or CRT with pacing (CRT-P) are recommended as treatment options for people with heart failure who have left ventricular dysfunction with a left ventricular ejection fraction of 35% or less as specified below.

Question 21

Palliative care in HF

Answer 21

Do not offer long-term home oxygen therapy for advanced heart failure.
Be aware that long-term home oxygen therapy may be offered for comorbidities, such as for some people with chronic obstructive pulmonary disease.

Question 22

Management of acute heart failure

Answer 22

Offer intravenous diuretic therapy to people with acute heart failure.
Start treatment using either a bolus or infusion strategy.
Do not routinely use non-invasive ventilation (continuous positive airways pressure or non-invasive positive pressure ventilation) in people with acute heart failure and cardiogenic pulmonary oedema.
If a person has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting non-invasive ventilation without delay:
-at acute presentation or
-as an adjunct to medical therapy if the person’s condition has failed to respond.
Offer beta-blockers if there is heart failure
Offer an angiotensin-converting enzyme inhibitor (or angiotensin receptor blocker if there are intolerable side effects) and an aldosterone antagonist during hospital admission to people with acute heart failure and reduced left ventricular ejection fraction.
Offer surgical aortic valve replacement to people with heart failure due to severe aortic stenosis assessed as suitable for surgery.

Question 23

NYHA classification of HF

Answer 23

NYHA Classification - The Stages of Heart Failure:
Class I - No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
Class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
Class III - Marked limitation inactivity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20—100 m). Comfortable only at rest.
Class IV - Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
No NYHA class listed or unable to determine.

Question 24

Cardinal symptoms of HF?

Answer 24

The combined presence of dyspnoea, oedema, elevated JVP, basal crepitations and an enlarged liver.
Note: Ankle oedema, hepatomegaly and elevated JVP suggest right heart failure and bibasal crepitations suggest left heart failure.

Question 25

What is dyspnoea?

Answer 25

This refers to a state where the subject is uncomfortably aware of his/her breathing. It is usually associated with either the increase in the work of breathing - associated with reduced lung compliance (stiff lungs) or increased respiratory rate.
It is, therefore, a non-specific symptom and may occur in diseases pertaining to the cardiovascular, respiratory systems or in the presence of severe anaemia.

Question 26

What is orthopnoea?

Answer 26

Shortness of breath that occurs when lying flat causing the person to have to sleep propped up in bed or sitting in a chair.
It is often a symptom of left ventricular failure and/or pulmonary oedema.

Question 27

Why does orthopnoea occur?

Answer 27

Orthopnoea occurs because the normal pooling of blood in the lungs in the supine position is added to a chronically congested pulmonary vasculature; the increased venous return cannot be compensated for by the left ventricle.

Question 28

The intensity of murmur and grades

Answer 28

Based on the intensity of a murmur it may be classified into the four following grades:
Grade 1: The murmur is heard only on listening intently for some time.
Grade 2: A faint murmur that is heard immediately on auscultation.
Grade 3: A loud murmur with no palpable thrill.
Grade 4: A loud murmur with a palpable thrill.

Question 29

What is the Frank-Starling curve?

Answer 29

The Frank-Starling curve describes the relationship between the volume of blood in the heart at the end of diastole (known as the pre-load or end-diastolic volume) and the force of contraction of the ventricle.
In the normal heart, if myocardial fibres are stretched by an increased volume of blood, there will be an increase in the force and velocity of the contraction.

Question 30

What are the changes to the “Frank-Starling curve” in a failing heart?

Answer 30

A failing heart has reduced contractility. This increases the end-diastolic volume. Initially, the heart will try to respond by increasing the force of contraction.
However, a greater end-diastolic volume is required to give the same force of contraction. The graph is shifted to the right.
Eventually, a critical point will be reached where the heart can no longer respond to increasing end-diastolic volumes and it will decompensate- stroke volume will decrease with further increases in end-diastolic volume.
The increased venous pressure causes fluid to leak out of the blood into the alveolar interstitial fluid resulting in pulmonary oedema.