Heart failure (3.4)

Question 1

What drug can be given in an emergency situation to help clear fluid on the lungs in heart failure (stabilisation)?

Answer 1

Diuretic e.g. Furosemide 40mg IV

Question 2

What investigations would you do on a patient presents with suspected heart failure? (9)

Answer 2

Chest x ray (pulmonary oedema, pneumonia)
BNP/ Pro-BNP

Bloods:
ABG (hypoxia, CO2 retention, acid-base balance, lactate)
FBC (anaemia, WCC increase in pneumonia)
CRP (infection or inflammation)
U+E (history o CKD, potassium)
LFT
Serum glucose (hypo or hyper with diabetes)
Troponin I (MI)

ECG (ACS, arrythmias, LVH)
Echo

Question 3

What levels of BNP would rule out acute heart failure?

Answer 3

<100 ng/litre

Question 4

What can commonly cause heart failure (aetiology)? (10)

Answer 4

Ischaemic (CAD, AMI)
Hypertension
Diabetes
Valvular (AS, MR)
Tachycardia induced (uncontrolled AF)
Drugs (alcohol, doxorubicin)
Infective (viral myocarditis)
Endocrine (Thyrotoxicosis, phaeochromocytoma)
Dilated cardiomyopathy
Genetic (HCM)

Question 5

Potential reported symptoms of heart failure?

Answer 5

Breathlessness at rest
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue

Question 6

Potential signs on examination for heart failure?

Answer 6

Pulmonary oedema/pleural effusion
Raised JVP
Pitting oedema
Ascites
Tachycardia
S3 gallop

Question 7

What three elements contribute to a clinical diagnosis of heart failure syndrome?

Answer 7

Typical symptoms
Typical signs
Objective evidence of structural or functional abnormality at rest (cardiomegaly, S3, ECG abnormality)

Question 8

What is a normal LV ejection fraction?

Answer 8

> 55%

Question 9

How do we classify heart failure patients based on LV ejection fraction?

Answer 9

Preserved LV function: EF>45%
LV systolic dysfunction: EF<45%

Question 10

What drug(s) should be prescribed for an acute heart failure in patients with impaired systolic function?

Answer 10

Beta blocker (48h after)
ACE inhibitor (or ARB)
Aldosterone antagonist

Question 11

When should beta blockers be stopped in acute heart failure?

Answer 11

HR<50
2nd/3rd degree AVN block
Shock

Question 12

When should CRT devices be in planted in patients with heart failure?

Answer 12

Electrical and mechanical desynchrony (15%)

Question 13

What is a CRT device?

Answer 13

Cardiac resynchronisation therapy:
Consists of 3 leads: atrial, RV, LV (coronary sinus to outside of lateral wall)
Improves the synchronisation of the ventricles

Question 14

What is an ICD?

Answer 14

Implantable cardiac defibrillators:
Detect and treat ventricular arrhythmias
Override VT (provide shock)

Question 15

Which patients with heart failure should we offer an ICD to?

Answer 15

EF<35%

Question 16

What’s the ABCDE of heart failure findings on CXR?

Answer 16

A - Alveolar oedema (bat winging)
B - Kerley B lines
C - Cardiomegaly
D - Dilated upper lobe vessels
E - Pleural Effusion (often bilateral)

Question 17

Where can pleural effusion be seen on a CXR?

Answer 17

Opacity in the fissures of the lungs (right horizontal)
Blurred costophrenic angles

Question 18

What is the NYHA (New York heart association) grading system for heart failure symptoms?

Answer 18

1 - No symptoms or limitation in ordinary physical activity
2 - Mild symptoms and slight limitation in ordinary activity
3 - Marked limitation even in less-than-ordinary activity
4-Severe symptoms even at rest

Question 19

How does the heart increase cardiac output in heart failure?

Answer 19

Increase preload
Fluid retention
Increasing force of contraction up until a critical point where the heart cannot respond to an increase in end diastolic volume

Question 20

What is a negative consequence of increased fluid retention (to up cardiac output) during heart failure?

Answer 20

Raised pulmonary venous and pulmonary capillary wedge pressure (left ventricular diastolic)