Heart Failure

Question 1

10% of those over 70 have HF. Define Heart failure

Answer 1

Heart failure is a clinical syndrome characterised by structural/functional cardiac abnormalities leading to reduced cardiac output and increased intracardiac pressure (=> dilatation)

Question 2

What method is used to determine the ejection fraction on an ECHO?

Answer 2

Simpson’s Biplane method

Question 3

Is an ECHO performed at the bedside or in the radiology lab?

Answer 3

It can be performed in both settings
Bedside for acute cases
Radiology lab for more accurate figures

Question 4

The ejection fraction is calculated from which part of the heart?

Answer 4

Left ventricle => LVEF

Question 5

HF can be classified into 3 types. What are they and what is used to obtain this classification?

What are the criteria necessary for this

Answer 5

ECHOcardiogram is used to calculate the ejection fraction, Hypertrophy, enlargement, and diastolic dysfunction (below)
HFreducedEF: LVEF <40%
+ Signs and Sx of HF

HFmoderately-reducedEF: LVEF 40-49%
+ Elevated BNP
+1 of the additional criteria on ECHO
a) LV hypertrophy/LA enlargement
b) Diastolic dysfunction

HFpreservedEF: LVEF 50+%
+ Elevated BNP + Both additional criteria

Question 6

The epidemiology of HFrEF is that of young males whereas the epidemiology of HFpEF is more of older women. What is meant by diastolic dysfunction when trying to meet the criteria in this classification? Honours if you can go into detail
What investigation is used to determine this?

Answer 6

ECHO is used to determine diastolic dysfunction
It assesses the ability of the ventricle to relax and fill during diastole (which is more difficult with hypertrophy)

Honours:
It uses the following:
E/A ratio (early/late ventricular filling velocities)
E/e’ ratio (early diastolic filling velocity/early diastolic mitral annular velocity)

Question 7

List the causes of HF

Answer 7

1) Diseased myocardium:
a) Ischaemic heart disease - previous MI, CAD
b) Toxic Damage - Alcohol, chemotherapy agents, thiamine deficiencies, hypothyroidism
c) Infiltrative Disease - Amyloid, sarcoidosis, haemochromatosis
d) Genetic Abnormalities - Hypertrophic and Diastolic cardiomyopathy

2) Abnormal loading:
a) HTN
b) AVSD
c) Valvular disease
d) Fluid overload (renal failure/insufficiency, iatrogenic)

3) Arrhythmias - Atrial/ventricular tachyarrhythmia and bradyarrhythmias

4) Cocaine Use

5) Diabetes is also a RF

Question 8

Describe the typical cough in HF

Answer 8

Productive cough with Pink frothy sputum (pulm oedema)

Question 9

What are the symptoms of HF?

Answer 9

SOB
Orthopnoea
PND
Cough with pink frothy sputum (oedema)
Chest pain
Weight gain/Increased shoe size, tighter trousers/jeans

Question 10

What tool is used to grade the severity of symptoms and exercise intolerance in HF?

Answer 10

NYHA - New York Heart Association Classification

Question 11

What is the NYHA classification used for?

Get into it

Answer 11

Used to determine the severity of the symptoms and exercise intolerance

Class I: No limitation in normal physical activity
Class II: Comfortable at rest, mild sx with normal activity
Class III: Comfortable at rest, marked sx with normal activity
Class IV: symptomatic at rest, increased discomfort with any physical activity

Question 12

You are performing a cardiovascular exam on a patient presenting to the ED. You note a midline sternotomy scar. What should you then look for?

Answer 12

Look for a GSV or LSV harvesting scar on leg

Question 13

You are asked to perform an examination on a patient giving a hx of HF. Go through the examination stating the findings you are looking for.

Answer 13

General Inspection: Dyspnoea, trouble lying flat/extra pillows

Closer inspection: Peripheral cyanosis, raised JVP, Scars (midline sternotomy -> check legs)

Palpation: Displaced apex beat (LVH), Parasternal heave

Auscultation:
Heart: S3 heart sound/ Gallop rhythm/tricuspid regurg.
Lungs: Reduced breath sounds, bibasal coarse crackles

Special/offer: Ankle oedema, sacral oedema

Question 14

What is required for the diagnosis of HF?

Answer 14

BNP >500
ECHO - ejection fraction via Simpson’s Biplane method for type

Question 15

What is the full role of the ECHO as an investigation for HF?
I am asking for the specific findings for HF as well as other things it looks at

Answer 15

Must include:
1) Determining EF for type of HF based on Simpson Biplane method
2) LV hypertrophy/LA enlargement (also part of criteria for typing)
3) Diastolic dysfunction
4) !!Dilated inferior vena cava
Others: Atrial, ventricular size, Valvular disease, LV hypertrophy/LA enlargement, Pericardial disease, RV systolic pressure

Question 16

What findings on ECG are consistent with Left atrial enlargement and LV hypertrophy?

Answer 16

Tall R waves in I
Prolonged P wave in II
Left axis deviation

Question 17

What is a quick way to determine the cardiac axis at a glance?

Answer 17

Quick Method:
Check Lead I:
Positive QRS: The axis is either normal or deviated to the left.
Negative QRS: The axis is deviated to the right.

Check Lead aVF:
Positive QRS: The axis is either normal or deviated to the right.
Negative QRS: The axis is deviated to the left.

Question 18

What is the full list of investigations you would like to perform for a patient with HF? Give your rationale for each

Answer 18

Bedside:
ABG - Respiratory failure
ECG - LV hypertrophy/LA enlargement (Tall R waves in I, Prolonged P wave in II, + left axis deviation) Previous MI, rule out MI, Arrhythmias as cause
Vitals
ECHO in acute case

Bloods:
FBC - Anaemia, WCC for infectious exacerbation
CRP - raised in infection/infl.
BNP - >500 diagnostic
Troponin to rule out MI + CKMB for re-infarction
U&E - Renal disease (cause/rf) + monitor medications of HF
LFTs - Raised AST/ALT from hepatic congestion
Lipid profile & HbA1c (RFs)
Iron studies (Haemochromatosis)

Imaging:
CXR -> ABCDE for HF + Rule out pneumonia, pneumothorax, aortic dissection
ECHO - EF,
+Atrial, ventricular size
Valvular disease
LV hypertrophy/LA enlargement
Pericardial disease
RV systolic pressure
Cardiac MRI -> may be considered

Question 19

What does ARNI stand for?
What are they?
What benefits does it provide over ACEi and ARBs?
What is the preferred ARNI used in the tx of HF

Answer 19

Angiotensin receptor - Neprilysin inhibitor
They are a combination of an ARB + Neprilysin inhibitor which add the benefit of vasodilation, natriuesis (sodium excretion), and diuresis

Sacubitril/Valsartan

Question 20

What beta blocker should not be used in acute HF?

What is another contraindication to this drug?

Answer 20

Bisoprolol

Contraindicated in acute HF and severe bronchospasm (or asthma)

Question 21

What are the 4 pillars of management for HF
Is it used for both HFrEF and HFpEF?

Answer 21

1) ACEi/ARBs/ARNI - Ramipril/ Losartan/ Sacubitril/Valsartan
2) Beta blockers - Atenolol or Metoprolol (ensure patient not on CCB)
3) MRA - Mineralocorticoid receptor antagonist - Spironolactone
4) SGLT2i - Empagliflozin or Dapagliflozin

It is recommended for use in HFrEF. For HFpEF the only one of the above that is recommended to improve disease outcomes is SGLT2i however the others may still be used for example if they have HTN -> ACEi and if they also have A.fib -> Beta blockers
+ along with Furosemide.
Note that this is decided on based on the Multidisciplinary DMP (Disease management program)

Question 22

What does SGLT2i stand for?

What are the main SE?

Answer 22

Sodium glucose co-transporter 2

Excretes glucose in urine => Genital and UT infections => advise
Dehydration/hypotension
Weight loss

Question 23

What is the full acute management of HF?

Answer 23

1) ABCDE + Call for help (2x wide bore cannulas, !!!!Insert urinary catheter)
2) Quick Ix: Send out ABG, BNP, Cardiac biomarkers, CXR
3) IV loop diuretics - Furosemide
4) GTN infusion - Ensuring to check with cardiology to ensure no hypotension or aortic stenosis
5) Analgesia
6) Monitor fluid balance - if hypotensive, cautious administration of 250ml - ICU referral for inotropes
7) O2 (non-rebreather, HFNC, CPAP)

Question 24

For any disease requiring smoking cessation as part of their management, what can you do to support these patients?

Answer 24

Patient education
Quit.ie
NRT - Patches, gum, lozenges
Medications: Varenicline and Bupropion

Note: Both of these medications should be started 1-2 weeks before the panned quit date and continued for up to 12 weeks

Question 25

How does Disulfiram work?
Although disulfiram doesnt reduce dependence, what medication can?

Answer 25

Acetaldehyde dehydrogenase inhibitor leading to buildup of acetaldehyde responsible for hangover symptoms like sweating, N+V, palpitations, headaches…

Acamprosate (GABA and glutamate modulation)

Question 26

What are the surgical management options for HF? When are these indicated?

Answer 26

Surgical management is indicated for NYHA IV who fail therapy and recurrent admissions requiring inotropes

1) LVAD - Left ventricular assist device !Used as a bridge to
2) Cardiac transplant

Question 27

The management of HF is based on 3 factors which are
1) HFrEF vs HFpEF
2) NYHA (asymptomatic vs symptomatic)
3) Multidisciplinary MDP recommendations

What is the full long term management plan for symptomatic heart failure?

Answer 27

Even if asked for definitive management, still say the whole thing

First, seek advice from Multidisciplinary DMP (Disease management programme)

Prevention/lifestyle:
Referral to dietician for weight loss, reduced cholesterol and salt intake for HTN
Smoking cessation: Quit.ie, Patient education, NRT, Varenicline and Bupropion
Reduce alcohol intake to 14U, education, patient support groups (AA), Disulfiram, Acamprosate
Physiotherapy for exercise and rehabilitation
Strict BP and glycaemic control

HFrEF - 4 pillars:
1) ACEi/ARBs/ARNI - Ramipril/ Losartan/ Sacubitril/Valsartan
2) Beta blockers - Atenolol, metoprolol (ensure patient not on CCB)
3) MRA - Mineralocorticoid receptor antagonist - Spironolactone
4) SGLT2i - Empagliflozin or Dapagliflozin

HFpEF - Diuretics - Furosemide + SGLT2i + Multidisciplinary DMP

Surgical management is indicated for NYHA IV who fail therapy and recurrent admissions requiring inotropes

1) LVAD - Left ventricular assist device !Used as a bridge to
2) Cardiac transplant

Followup with regular GP/OPD appointments including ECHO

Question 28

What is the multidisciplinary DMP

Answer 28

Comprehensive approach to the management of HF with a team of healthcare professionals optimizing personalized treatment to improve outcomes

Question 29

What EF is considered severely reduced?

How would you manage this patient?

Answer 29

EF<30%

Lifestyle management + ICD (not LVAD)

Question 30

The management of HF is based on 3 factors which are
1) HFrEF vs HFpEF
2) NYHA (asymptomatic vs symptomatic)
3) Multidisciplinary MDP recommendations

What is the full long term management plan for asymptomatic heart failure?

Answer 30

Prevention/lifestyle:
Referral to dietician for weight loss, reduced cholesterol and salt intake for HTN
Smoking cessation: Quit.ie, Patient education, NRT, Varenicline and Bupropion
Reduce alcohol intake to 14U, education, patient support groups (AA), Disulfiram, Acamprosate
Strict BP and glycaemic control

HFrEF:
If previous hx of MI: ACEi + Beta blockers
If EF <30% -> ICD defibrilator device

HFpEF: Only close monitoring

Followup with regular GP/OPD appointments including ECHO