HEART FAILURE

Question 1

What is heart failure?

Answer 1

The heart is unable to produce adequate cardiac output to meet the body’s metabolic requirements

Question 2

NYHA classification of heart failure

Answer 2

Class I- No limitation of activity
Class II- Slight limitation of activity
Class III-Marked limitation of activity
Class IV- Unable to carry out any physical activity without discomfort, symptoms at rest

Question 3

Causes of heart failure

Answer 3

Hypertension
Pulmonary hypertension
Rheumatic heart disease
Ischaemic heart disease
Congenital heart disease
Cardiomyopathies
Cardiac arrhythmia
Severe anaemia
Thyrotoxicosis

Question 4

Symptoms of left heart failure

Answer 4

1. Breathlessness
   On exertion
   On lying flat (orthopnoea)
   At night (paroxysmal nocturnal dyspnoea)
2. Easy fatiguability
3. Cough
4. Wheezing

Question 5

Nature of sputum in heart failure

Answer 5

frothy blood-stained sputum

Question 6

Symptoms of right heart failure include

Answer 6

Swelling of the feet and lower extremities
Abdominal swelling
Right hypochondrial pain from an enlarging liver

Question 7

Which symptom of heart failure may be absent in children below six months of age

Answer 7

Pitting pedal edema

Question 8

Signs of left heart failure

Answer 8

Tachypnoea
Tachycardia
Basal crepitations
Gallop rhythm
Displaced apex beat
Cardiac murmur
Rhonchi

Question 9

Signs of right heart failure

Answer 9

Tachycardia
Pitting pedal oedema
Ascites
Tender, smooth, soft hepatomegaly
Raised jugular venous pressure
Gallop rhythm
Cardiac murmur

Question 10

Signs present in both left and right heart failure

Answer 10

Gallop rhythm
Tachycardia
Cardiac murmur

Question 11

Signs of heart failure in children

Answer 11

Failure to thrive
Difficulty in feeding

Question 12

Investigations in heart failure

Answer 12

FBC
BUE/Cr
ECG
Echocardiography
Chest X-ray
LFT
Fasting blood sugar
Fasting lipid profile
TFT
Cardiac enzymes
Coronary angiography

Question 13

When is cardiac enzyme test needed in heart failure

Answer 13

When there is suspicion of myocardial infarction

Question 14

Treatment objectives in heart failure

Answer 14

To relieve symptoms and improve quality of life
To treat the precipitating cause
To treat complications
To prevent recurrence of symptoms
To reduce need for hospital re-admissions
To reduce mortality

Question 15

Non-pharmacological treatment of heart failure

Answer 15

Reduce salt intake
Weight reduction
Avoid alcohol
Avoid or quit smoking
Encourage moderate exercise
Bed rest
Prop in bed

Question 16

When is bed rest needed in heart failure patient

Answer 16

acute heart failure or exacerbations of chronic heart
failure

Question 17

Initial treatment of acute heart failure

Answer 17

Oxygen if SpO2 < 90%

And

Furosemide, IV,
Adults
40-80 mg, repeat after 30 minutes if necessary
Children
12-18 years; 20-40 mg repeated 8 hourly as necessary
1 month-12 years; 0.5-1 mg/kg repeated 8 hourly (max 4 mg/
kg/dose)

Question 18

Maintenace treatment of acute heart failure patients after treatment

Answer 18

Furosemide, IV,

Adults
40-80 mg 12 hourly

Children
12-18 years; 20-40 mg repeated 8 hourly as necessary
1 month-12 years; 0.5-1 mg/kg repeated 8 hourly (max 4 mg/
kg/dose)

Question 19

Dose of furosemide for initial treatment of acute heart failure

Answer 19

Furosemide, IV,
Adults
40-80 mg, repeat after 30 minutes if necessary
Children
12-18 years; 20-40 mg repeated 8 hourly as necessary
1 month-12 years; 0.5-1 mg/kg repeated 8 hourly (max 4 mg/kg/dose)

Question 20

Next step in treatment if patient is not improving after initial treatment

Answer 20

Furosemide
and
IV Morphine
and
IV Metoclopramide

Question 21

Morphine can be used for heart failure in children T/F

Answer 21

False

Question 22

Treatment of acute heart failure patients who are improving after initial treatment

Answer 22

Furosemide, oral,
Adults
40-80 mg 12 hourly
Children
0.5-2 mg/kg 8-12 hourly

Question 23

Treatment of acute heart failure with fast atrial fibrillation or in sinus rhythm with systolic dysfunction

Answer 23

Digoxin oral
Elderly
125 micrograms 12 hourly for 24-48 hours
Adults
250 micrograms 12 hourly for 24-48 hours
Then
250 micrograms daily
Then
125 micrograms daily

Question 24

Treatment of acute heart failure in patients in cardiogenic shock (adult systolic blood pressure <85 mmHg) with hypotension and or hypoperfusion

Answer 24

Dobutamine, IV infusion,
Adults
2.5-10 micrograms/kg per minute

Question 25

Why should ECG be monitored for patients being given inotropic agents

Answer 25

Risk of arrhythmias and myocardial ischemia

Question 26

Treatment of symptomatic heart failure

Answer 26

Furosemide
and
Lisinopril or Ramipril
and
Carvedilol or Bisoprolol or Metoprolol

Question 27

Alternatives if ACEi is not tolerated

Answer 27

Losartan, oral,
Adults
25-50 mg daily
Or
Candesartan, oral,
Adults
4-16 mg daily

Question 28

Ramipril dose in heart failure

Answer 28

2.5 to 10 mg

Question 28

Lisinopril dose in heart failure

Answer 28

2.5 to 20mg daily

Question 29

Carvedilol dose in heart failure

Answer 29

3.125mg to 12.5mg 12 hourly, max. of 25mg 12 hourly

Question 30

Maintenance dose of furosemide in heart failure

Answer 30

40 to 80mg daily in adults
1-2mg/kg in children

Question 31

Dose of bisoprolol in heart failure

Answer 31

1.25 to 10mg daily

Question 32

Dose of metoprolol in heart failure

Answer 32

25 to 100mg daily

Question 33

Maintenace dose of digoxin in heart failure patients with fast atrial fibrillation or in sinus rhythm with systolic
dysfunction

Answer 33

Digoxin, oral,
Elderly
125 micrograms 12 hourly for 24-48 hours,
Then
125 micrograms 24 hourly
Adults
250 micrograms 12 hourly for 24-48 hours,
Then
250 micrograms once daily
Children
5 micrograms/kg 12 hourly

Question 34

Spironolactone dose for symptomatic heart failure

Answer 34

25 to 50mg daily