Heart Failure

Question 1

Definition of heart failure

Answer 1

clinical syndrome where the heart is unable to pump enough blood to meet the metabolic needs of the body

Question 2

What are the types of heart failure?

Answer 2

1. Heart failure with reduced ejection fraction (HF-rEF): LVEF is <35%. Typically systolic dysfunction (impaired myocardial contraction dyring systole).
2. HF-preserved EF: diastolic dysfunction (impaired ventricular filling during diastole).
3. Acute vs chronic HF
4. Right-sided HF: caused by increased right ventricular afterload (pulomary hypertension) or right ventricular preload (tricuspid regurgitation)
5. More common is left-sided HF: Increased left ventricular afterload (arterial HTN, aortic stenosis) or increased left ventricular preload (aortic regurgitation with backflow).
6. High-output HF: ‘normal’ heart is still unable to pump enough blood to meet metabolic needs of body - anaemia, Paget’s, pregnancy, arteriovenous malformation, thyrotoxicosis, thiamine-deficiency

Question 3

What are the differences in signs and symptoms fom LVHF and RVHF?

Answer 3

LVHF - backlog acculumates in lungs –> pulmonary oedeoma + dyspnoea, orthopnoea, bibasal fine crackles

RVHF: backlog accumulates in body –> peipheral oedeoma, raised JVP, hepatomegaly, weight gain (due to fluid retention)/cardiac cachexia (loss of body fat)

Question 4

Most common precipitating causes of acute HF

Answer 4

ACS, hypertensive crisis, acute arrhythmia, valvular disease

Question 5

Signs and symptoms of acute HF

Answer 5

Sx:
- breathlessness
- reduced exercise tolerance
- oedema
- fatigue

Signs:
- cyanosis
- tachycardia
- elevated JVP
- displaces apex beat
- bibasal crackles
- S3 heart sound

Question 6

Ix for acute HF

Answer 6

1. Blood tests (looks for underlying abnormality included anaemia, electrolyte abnormalities, infection)
2. Echocardiogram
3. B-type natriuretic peptide (>100mg/litre)

Question 7

Tx for acute HF

Answer 7

1. Loop diuretics (furosemdie, bumetanide)
2. Oxygen if sats <94%
3. Vasodilator (nitrates) if MI, severe HTN and/or aortic/mitral valve disease
4. CPAP if patient has respiratory failure
5. Continue regular medications like ACE-I and BB
6. Give inotropic agent (eg. dobutamine) if pt has cardiogeneic shock and hypotension

Question 8

When would you stop a HF patient’s BB?

Answer 8

HR < 50, heart block or shock

Question 9

What are the features of chronic HF

Answer 9

dyspnoea
cough: may be worse at night and associated with pink/frothy sputum
orthopnoea
weight loss (‘cardiac cachexia’): occurs in up to 15% of patients. Remember this may be hidden by weight gained secondary to oedema
bibasal crackles on examination
signs of right-sided heart failure: raised JVP, ankle oedema and hepatomegaly

Question 10

How to dx chronic HF?

Answer 10

1st line: N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test

• if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
• if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks

Question 11

Tx regimen for patients with chronic HF

Answer 11

1st line: ACEI or BB (bisoprolol)

2. aldosterone antagonist (spironolactone and eplerenone)
3. SGLT-2 inhibitors like dapagliflozin
4. Third-line tx must be started by a specialist: ivabradine,digoxin, hydralazine, cardiac resynchronisation therapy

Question 12

When is cardiac resynchronisation therapy indicated for Pts with chronic HF

Answer 12

Widened QRS complex (LBBB)

Question 13

In addition to the usual drug regimen for chronic HF, what else is offered to Pts?

Answer 13

1. annual influenza vaccine
2. One-off pneumococcal vaccine