Heart Failure

Question 1

List HF Complications

What is the Prognosis?

Answer 1

Depression, CKD, Cachexia, Sexual dysfunction, Sudden cardiac death

• 50% die within 1 yr
• 40% hospitalised re-admitted within 1yr

Question 2

Outline the NYHA Classification of HF

Classes 1+2: Mild, Classes 3+4: Severe/ Advanced

Answer 2

1;

• No symptoms from ordinary activity
• No activity limitations

2;

• Fine at rest, symptoms from ordinary activity.
• Slight activity limitations

3;

• Fine at rest, symptoms from less than ordinary activity
• Marked limitation

4;

• Symptoms at rest, discomfort with any activity
• Unable to do activity without symptoms

Question 3

List HF symptoms according to NYHA Classification

List 4 non-classified symptoms

Answer 3

1: None
2: Palpitations, Fatigue, SoB
3: Pain, Fatiue, SoB
4: Persistent cough, Swelling, Cognitive change, PND

Other: Dizziness, Fainting, Appetite loss, Confusion

Question 4

What does Pink Frothy Sputum signify?

Answer 4

Pulmonary oedema

Question 5

List some investigations in a pt with HF

Answer 5

• ECG. Consider CXR, FBC, PEFR/ Spirometery, Urinalysis

Serum Natriuretic Peptide

Question 6

Outline the use of Serum Natriuretic Peptide in diagnosing HF

If Serum Natriuretic Peptide is abnormal, what’s the next step?

Answer 6

• HF unlikely if normal
• Nt-proBNP >2000ng/litre: Refer for Specialist assessment + Transthoracic Echo within 2wks
• Nt-proBNP 400-2000ng/ litre: Refer for Specialist assessment + Transthoracic Echo within 6wks

Question 7

Outline the general treatment for HF

Specific treatment depends if EF is Reduced or Preserved

Answer 7

• In all people: Loop diuretic whilst waiting for assessment
• Consider Antiplatelet and Statin, screen for MH
• Advice on Contraception + Pregnancy, Nutrition
• Supervised exercise-based rehab program

Question 8

If symptoms persist, despite HF treatment, referral to specialist must be made for advice on which 3 medications

Answer 8

• Amiodarone
• Digoxin
• Ivabradine

Question 9

Outline treatment of Hf with Reduced EF

Which medications are avoided and why? What can be used instead?

Answer 9

• (Loop over Thiazide) Diuretic.
• ACEi/ARB + B-blocker 1 at a time, if existing treatment stable
• Avoid rate-limiting CCBs (Verapamil, Diltiazem) and Short-acting Dihydropines (Nifedpine) as they reduce contractility. Amlodipine is safe to use.

Question 10

Outline treatment of HF with Preserved EF

What is a common symptom, which associated treatment is not usually recommended?

Answer 10

Should be managed by HF specialist.
Low-Medium dose Diuretic for fluid retention

SoB is common in Advanced HF, but LTOT is not routinely recommended

Question 11

Describe the follow-up and monitoring of a patient being treated for HF

(Regarding ACEi/ARB, Aldosterone antagonists and B-blockers)

Answer 11

Starting ACEi, ARBs, Aldosterone antagonists; Check Serum K + Na, Renal function, BP;

• Before treatment, 1-2wks after starting treatment, At each dose increment
• Once on target/ max. tolerated dose, monitor monthly for 3mths then every 6mths

Starting B-blockers: Check HR + BP at start of treatment and at each dose change