Heart failure

Question 1

three main underlying causes of heart failure

Answer 1

coronary artery disease
diabetes mellitus
hypertension

Question 2

heart failure may also be called

Answer 2

congestive heart failure CHF
congestive cardiac failure CCF

Question 3

pathogenesis of heart failure

Answer 3

pressure or volume overload increases the work on the myocardium
this is initially compensated by cardiac hypertrophy
chronic overload leads to decompensation where the cardiomyocytes lose their contractility
stroke volume and output is reduced

Question 4

classification by ejection fraction

Answer 4

HFrEF (reduced): <40%, (previously called systolic failure)
HFmrEF (mildly reduced): 40-49%
FHpEF(preserved): >50%, ( previously called diastolic failure)

Question 5

symptoms at presentaton

Answer 5

dyspnoea
cough
fatigue
poor exercise tolerance
ankle swelling

Question 6

signs at presentation

Answer 6

tachycardia
additional heart sounds/murmurs
elevated jugular venous pressure
tachypnoea
bilateral lung base crackles
enlarged liver
peripheral oedema

Question 7

ECG might show

Answer 7

acute or previous ischaemia, arrhythmia and other abnormalities that may suggest causative or exacerbating aetiologies such as IHD

Question 8

laboritory tests

Answer 8

FBC, UECs, LFTs, troponin, BSL
consider serum BNP or NT-proBNP when diagnosis unclear

Question 9

imaging

Answer 9

CXR - classic findings include alveolar oedema, Kerley B lines, cardiomegaly, upper lobe diversion and pleural effusion
echocardiography - can differentiate between HFrEF and HFpEF, s well s highlight other abnormalities or causative factors
may also consider stress testing or cardiac MRI

Question 10

differential diagnosis

Answer 10

for shortness of breath:
- COPD, sleep apnoea
for peripheral oedema:
- venous insufficiency, thrombosis
- CKD and/or nephrotic syndrome
- cirrhosis
- calcium-channel blockers

Question 11

specific treatments for underlying causes

Answer 11

lower blood pressure
revascularisation or drug therapy for coronary artery disease
manage diabetes
arrythmias
excess alcohol intake
use of recreational stimulant drugs
cardaic amyloidosis, haemochromatosis, thalassaemia, chemotherapy toxicity)
valvular heart ddisease
hyperthyroidism
chronic lung disease
pulmonary embolism
pericardial effusion

Question 12

drug therapy for HFrEF

Answer 12

all patients with HfrEF should be started on
ACEI/ARB
beta blocker
aldosterone antagonist
SGLT2
Loop diuretic can be dded to therapy at any stage to control symptoms of congestion

Question 13

when should you add the bet blocker

Answer 13

once the patient is euvolaemic

Question 14

first line choices for ACEI/ARB

Answer 14

either an ACE or sacubitril+valsartan (non-pbs)
ARBs are second line

Question 15

starting the patient on a beta blocker

Answer 15

can initially worsen the symptoms
do not start during acute decompensation or if the patient has congestion
start with low dose and increase gradually
monitor symptoms and measure weight daily

Question 16

beta blocker examples

Answer 16

bisoprolol
nebivolol
metoprolol succinate

Question 17

starting aldosterone antgonist

Answer 17

eg. eplerenone or spironolactone

Question 18

hyperkalaemia risk

Answer 18

in patients with kidney impairment
the combnation of aldosterone antagonist and renin-angiotensin system inhibitor cn cause life threatening hyperkalaemia
a small rise in serum potassium (within normal range) may occur and may be transient

Question 19

starting an SGLT2

Answer 19

eg. dapagliflozin or empagliflozin

Question 20

when to start a loop diuretic

Answer 20

can be used in patients with heart failure to reduce signs and symptoms of congestion
eg. furosemide or bumetanide

Question 21

how to treat patients with HFpEF

Answer 21

SGLT2 inhibitor eg. empagliflozin and dapagliflozin
this is the only routine drug that should be prescribed for all patients with HFrEF

Question 22

what else might you prescribe for someone with HFpEF

Answer 22

drugs for their comorbidities/underlying causes
eg. blood pressure reducing medication, beta blockers for afib or fast resting ventricualr rate or coexisting coronary artery disease

Question 23

lifestyle advice for HF

Answer 23

drug management to support adherance
fluid management advice
sodium restriction advice
- no added salt diet, excessive salt intake can precipitate or worsen heart failure
regular assessment for depression
- depression is a common comorbidity
obesity management advice
dietitian input
physical activity support

Question 24

drug management advice to support adherance might include

Answer 24

• when and why dose adjustments are needed
• adverse events
• regurlalry updated drug list should be supplied to care team
• do not use NSAIDs or pseudoephidrine

Question 25

fluid mangement advice might include

Answer 25

• use daily weight charts as an indictor of fluid retention
• use fluid management program
• limit fluid intake to 1.5L per day
• manage night time symptoms with recliner or extra pillows