FN: Chronic Heart Failure

Question 1

Diagnosis of CCF

Answer 1

Famingham Criteria

2 major criteria or 1 major + 2 minor

Question 2

Major criteria

Answer 2

PND
\+ve abdominojugular reflux
Neck vein distension
S3
Basal creps
Cardiomegaly
Acute pulmonary oedema
Increase CVP (>16cm h20)
Wt. oss >4.5 kg in 5d secondary to treatment

Question 3

Minor criteria

Answer 3

Bila ankle oedema
SOBOE
Increased HR >120
Nocturnal cough
Hepatomegaly
Pleural effusion
30% reduced vital capacity

Question 4

Investigations

Answer 4

Bloods
CXR
ECG
Echo

Question 5

Bloods included

Answer 5

FBC
U ad E
TFTs
Glucose lipids
BNP or NTproBNP

Question 6

CXR

Answer 6

ABCDE
A - alveolar shadowing
Kerly B lines
Cardiomegaly (cardiothoracic ratio >50%)
Upper lobe Diversion
Effusions
Fluid in the fissures

Question 7

ECG

Answer 7

Ischaemia
Hypertrophy
AF

Question 8

Echo

Answer 8

The key investigation

1. Global systolic and diastolic function - ejection fraction normally - 60%
2. Focal/global hypokinesia
3. Hypertrophy
4. Valve lesions
5. Intracardiac shunts

Question 9

B-ype Natriuretic Peptide: BNP or NtproBNP secreted from

Answer 9

Ventricles in response to
Increase pressure - stretch
Tachycardia
Glucocorticoids
Thyroid hormones

Question 10

B-ype Natriuretic Peptide: Actions

Answer 10

1. Increase GFR and reduced renal Na reabsorption

2. Redcued preload by relaxing smooth muscle

Question 11

BNP is a biomaker of

Answer 11

Heart Failure

Question 12

BNP markers

Answer 12

Increased BNP (>100) better than any other variable and clinical judgement in diagnosing heart failure

Question 13

BNP correlates with

Answer 13

LV dysfunction
i.e. increase most in decompensated heart failure
Increased BNP = increased mortality

Question 14

BP <100 exlcudes

Answer 14

heart failure (96% NPV)

Question 15

BNP also increases in

Answer 15

RHF: cor pulmonale, PE

Question 16

New york Heart Association Classification

Answer 16

1. No limitation of activity
2. Comfortable @ rest, dyspnoea on ordinary activity
3. Marked limitation of ordinary activity
4. Dyspnoea @ rest, all activity - discomfort

Question 17

General Management

Answer 17

Primary/Secondary Cardiovascular risk
1. Stop smoking
2. REduced salt intake
3. Optimise wt:: increase or decrease - dietician
Supervised group exercised based rehab programme
4. Aspirin
5. Statins

Question 18

Treatment percipitants/Causes

Answer 18

Underlying cause:

1. Valve disease
2. Arrhythmias
3. Ischaemia

Exacerbating factors

1. Anaemia
2. Infection
3. Increase BP

Question 19

Specific Management

Answer 19

ACEi
Beta blocker
Diuretics
Spironolactone
Digoxin
Vasodilators

Question 20

ACEi/ARB:

Answer 20

e.g. lisinorpil or candesartan (if there is a cough

Question 21

If patient intolerant to CE-i and ARBs (vasodilators)

Answer 21

Hydralazine + ISDN - also reduces mortality when added to standard therapy (including ACE-i) in Black patients with heart Failure.

Question 22

Beta blockers

Answer 22

Carvedilol (3.125 mg/12h) or bisoprolol (start low and go slow)
Switch stable pts taking a beta blockers for a comorbidity to a beta blocker licensed for heart failure

Question 23

Loop diuretic

Answer 23

Frusemide (40 mg) or bumetanide

Question 24

Spiromolactone/eplerenone

Answer 24

Watch K carefully (on ACEi too)

Question 25

1st line

Answer 25

ACEi/ARB
beta blocker
Loop diuretic

Question 26

2nd line

Answer 26

Spiroolactone/eplerenone
ACEi + ARB
Vasodilators

Question 27

3rd line

Answer 27

Digoxin

Cardiac resynchronisation therapy ± ICD

Question 28

Other considerations

Answer 28

Monitoring:

1. BP: may be very low
2. Renal function
3. Plasma K
4. Daily wt

Use amlodipine for comorbid HTN or angina
Avoid verapamil, diltiazem and nifedipine (short acting)

Question 29

Invasive therapies

Answer 29

Cardiac resynchronisation ± ICD
Intra-aortic balloon counterpulsation
LVAD
Heart transplant (70% 5 yrs)