Heart Failure

Question 1

Causes of high-output failure? (4)

Answer 1

Anaemia
Paget’s disease
Hyperthyroidism
AV malformations

Question 2

Causes of low-output failure? (3)

Answer 2

Increased preload e.g. fluid overload, mitral regurgitation
Pump failure e.g. IHD, inadequate heart rate, arrythmia, negatively inotropic drugs
Chronic excessive afterload e.g. hypertension, aortic stenosis

Question 3

Classification of heart failure? (2)

Answer 3

Heart failure with reduced ejection fraction

Heart failure with preserved ejection fraction (HFPEF)

Question 4

NICE guidelines- referral thresholds for natriuretic peptide levels? (3)

Answer 4

> 2000- urgent 2-week referral for echo + specialist assessment

400-2000- 6 week referral for echo + specialist assessment

<400- less likely to be heart failure- refer if remaining clinical suspicion

Question 5

Causes of a falsely low BNP? (3)

Answer 5

Obesity
Drugs- ACE inhibitors, ARBs, beta blockers, aldosterone antagonists
Afro-Caribbean ethnic origin

Question 6

NYHA classifications (4)

Answer 6

I- no limitation

II- slight limitation of physical activity, comfortable at rest

III- marked limitation of physical activity of less than ordinary intensity; comfortable at rest

IV- unable to carry out any physical activity without discomfort; symptoms present at rest

Question 7

Non-drug management? (3)

Answer 7

Low salt diet
May need fluid restriction
Vaccination- pneumococcal and annual influenza

Question 8

Relief of congestive symptoms in heart failure?

Answer 8

Titrated loop diuretic e.g. furosemide, bumatenide with possible addition of a thiazide if needed

Question 9

First-line management for LVSD?

Answer 9

ACE inhibitor + beta blocker

Question 10

How should ACE inhibitors and beta blockers be initiated and titrated?

Answer 10

One at a time according to clinical judgement (e.g. if patient has concurrent angina, start the beta blocker first). Titrate to maximum tolerated dose and introduce the second drug

Question 11

Alternative if

a) ACE not tolerated
b) ACE/ARB not tolerated

Answer 11

a) ARB

b) hydralazine + nitrate- specialist supervision

Question 12

If symptoms persist/worsen despite first-line treatment?

Answer 12

Consider addition of aldosterone antagonist e.g. spironolactone, eplerenone

Question 13

Specialist treatments for heart failure?

Answer 13

Amiodarone (if associated arrythmia)
Digoxin
Sacubitril + valsartan (Entresto)
Dapagliflozin

Question 14

Management of HFPEF?

Answer 14

Loop diuretic
Optimal management of other co-morbidities
Cardiology referral

Question 15

Options for low potassium with loop/thiazide diuretics?

Answer 15

Combination with amiloride, a potassium sparing diuretic (e.g. co-amilofruse)

Question 16

Other drugs to consider? (3)

Answer 16

Anticoagulants if concurrent AF, recurrent VTE
Aspirin if IHD
Statin if high CVD risk

Question 17

Drugs to avoid in heart failure?

Answer 17

Rate-limiting calcium blockers e.g. verapamil, diltiazem
Short-acting dihydropyridines e.g. nifedipine
Corticosteroids + NSAIDs (promote fluid retention)

Question 18

Pathophysiology of heart failure?

Answer 18

Reduced cardiac output –> reduced renal plasma flow –> activation of RAAS –> fluid and sodium retention –> cardiomyocyte stretching and cardiac remodelling

Question 19

Interventional treatments for heart failure? (3)

Answer 19

Cardiac resynchronization
Implantable defibrillator
Heart transplantation