Heart Failure

Question 1

Heart failure ejection fractions

Answer 1

HFrEF <= 40%
HRmrEF 41-49%
HF-PEF >=50%

Question 2

New York Heart Association (NYHA) classification of heart failure

Answer 2

I - no limitation on physical activity.
II - slight limitation on physical activity, symptoms on ordinary physical activity.
III - symptoms on less than ordinary physical activity, marked limitation
IV (end-stage) - cannot do any physical activity without symptoms or symptoms at rest

Question 3

Incidence of heart failure in the UK

Answer 3

1 in 35 65-74y
1 in 15 75-84y
1 in 7 >= 85y

Question 4

Prognosis in heart failure

Answer 4

50% die within 5y
30-40% of deaths are sudden cardiac death
End-stage - 6-12 months

Question 5

NT Pro-BNP values and referral for assessment + Echo

Answer 5

> 2000 - seen within 2 weeks
400-2000 - seen within 6 weeks
< 400 - HF unlikely

Question 6

What can raise NT Pro-BNP values?

What can reduce NT Pro-BNP values?

Answer 6

Raise: > 70y, LVH, MI, tachycardia, hypoxia, pulmonary HTN, PE, eGFR < 60, sepsis, COPD, DM, liver cirrhosis

Reduce: BMI > 35, ACEi/ARB, BB, spironolactone, Afro-Caribbean origin

Question 7

Investigations for HF

Answer 7

1) NT Pro-BNP

2) ECG

3) Bloods: FBC, iron studies, LFT, U&E, TFT, HbA1c, lipids

Question 8

Blood test indicators of a poor outcome in HF patients

Answer 8

Low Hb, raised PLT:lymophocyte, low lymphocytes

Question 9

Medical management of HRrEF or HFmrEF

Answer 9

1) Loop diuretic if fluid overload

2) ACEi/ARB + BB
- start ACEi first if DM or fluid overload as BB can worsen symptoms
- do not start ACEi if suspect valve disease
- If K > 5 - specalist advice before starting ACEi
- can take a few weeks-months for improvement

Question 10

If HFrEF or HFmrEF not well controlled on ACEi + BB, what medication can be added?

Answer 10

Spironolactone

Question 11

If HFeEF or HFmrEF not well controlled on ACEI + BB + spironolactone what are the next steps?

Answer 11

Get advice and consider:
1) Replacing ACEi with socubitril valsartan if EF < 35%
2) SGLT-2 inhibitor (gliflozin)
3) Ivabradine if sinus rhythm + HR > 75 + EF < 35%
4) Hydralazine + nitrate if Afro-Caribbean
5) Digoxin if sedentary / AF
6) 6) cardiac resynchronisation therapy if wide QRS/BBB

Question 12

Non-medical management of HF

Answer 12

1) Structured exercise rehabilitation programme (unless uncontrolled HTN/high energy pacing)

2) Annual flu and single pneumococcal vaccine

3) Dietician if BMI < 18.5 or weight loss advice if BMI > 30

Question 13

Advice for HF patients

Answer 13

1) Monitor weight - if increases icy 2kg in 3 days for review

2) Aim for < 5g salt/day and do not use salt substitutes which can raise K (as may be on ACEi/MRA)

3) Follow mediterranean or DASH diet.

4) If NYHA III/IV do not exercise in water

Question 14

Driving advice in HF

Answer 14

G1: continue if no distracting symptoms.

G2: disqualified if symptomatic - consider re-licensing if LVEF > 40%

Question 15

Which HF patients should be referred to cardiology?

Answer 15

1) NYHA III/IV
2) LVEF <=35%
3) NT Pro-BNP > 2000 (2 weeks) or 400-2000 (6 weeks)
4) Valve disease

Question 16

Diuretics: dosing, monitoring & what do if creatinine rises

Answer 16

Furosemide 20-40mg to 120mg max/day

Bumetanide 0.1-1mg to 5mg max/day

Monitoring:
1) Before starting check U&E + BP
2) Re-check at 1-2 weeks & at every dose increase

Creatinine rises by > 20%/eGFR falls by > 15% - recheck U&E in 2 weeks.

Creatinine rises by 30-50%/eGFR > 30 - recheck U&E in 1 week

Creatinine rises by > 50%/eGFR < 25 - stop

Question 17

What vaccinations should be offered?

Answer 17

Annual flu

Pneumococcal:
- once
- every 5 years if asplenia, splenic dysfunction or CKD

Question 18

Suspected HF with previous MI

Answer 18

Do not do BNP

Urgent referral, echo and specialist assessment due to poor prognosis

Question 19

Which BBs to offer in HF?

Answer 19

Carvedilol or bisoprolol - reduce mortality