Heart failure

Question 1

An independent 72 year old male presents with dyspnoea on exertion at 200m on flat surface, orthopnoea and lower limb swelling. He has no angina. He had coronary bypass surgery 17 years prior. His only medications are aspirin and rosuvastatin. How would you manage him?

Answer 1

Impression
Given past Cardiac history, current SOBOE, swelling and orthopnea, I am concerned about an exacerbation of this mans likely heart failure with subsequent APO.

Important differentials to consider;

• ACS,
• renal failure/AKI
• respiratory: infective, malignancy, COPD

Goals

• initial assessment to rule out HD instability and red flag differentials
• cardiac consult, likely hospital admission for managing fluid overload and investigation as to HFrEF or HFpEF, and optimising medications regimen according to underlying pathology. otherwise ongoing CVD risk factor mitigation.

Question 2

Heart failure - Assessment

Answer 2

Assessment
Given significant exertional dyspnoea and signs of heart failure, would assess for HD compromise in order to assess need for emergent management.

Question 3

Heart failure - History

Answer 3

History

• Characterise SOBOE, what is baseline? cough, productive? time frame of sx, characterise degree of function
• RISKS: smoking, HTN, obesity, diabetes, alcohol, sedentary, poor diet, etc
• REDS: haemoptysis, chest pain, LOC, unintentional weight loss, weight gain,
• meds: non-compliance?
• previous investigations: ECHO, see cardiologist?

Question 4

Heart failure - Examination

Answer 4

Examination

• General appearance + vitals
• Cardioresp exam: Murmurs, S3/4, creps at lung bases, characterise peripheral oedema (to what level), changes to breath sounds, hepatosplenomegaly, elevated JVP, thrills/heaves, displaced apex beat, cool extremities. Distinguish R vs L heart failure (or mixed picture), ascites

Question 5

Heart failure - Investigations

Answer 5

Investigations

• Bedside: ECG (ACS), urinalysis (renal)
• Labs: FBC (anaemia), trops (ACS), UEC (eGFR), LFT (hepatomegaly), BNP (HF), Lipids/BSL/HbA1C
• Imaging: ECHO (ejection fraction calculation), CXR (ABCDE signs of heart failure/APO), consider coronary angiogram if indicated

Question 6

Heart failure - Management

Answer 6

Management

• call for senior help
• immediate disposition is CCU vs ICU depending on condition, involve cardio early for review, manage any HD instability utilising AtoE assessment and management approach.

Acute (POND)

• positioning
• O2, BiPAP or CPAP to drive fluid off lungs (increase alveolar recruitment)
• Nitrates
• diuretics (Furosemide)

Pharmacological
Mx ultimately depends on type of Heart failure.
HFpEF: no evidence based disease modifying drugs, symptomatic and risk factor control is mainstay.

HFrEF (medications that can be utilised)
Aim for max doses of medications
- B Blocker
- ACEi/ARB
- MRA (aldactone, spironolactone): need to K and creatinine monitor 1 week after starting
- ARNI: sacubitril-valsartan
Requires management from cardiologist 

Non-pharmacological

• Lifestyle changes: smoking, alcohol, etc.
• salt and fluid restriction
• cardiac rehabilitation
• avoid exacerbating medications (NSAIDs)