Heart failure

Question 1

What is heart failure?

Answer 1

A complex syndrome that can occur from any structural or functional cardiac disorder that impairs the ability of the heart to fill with and eject blood and therefore to function efficiently as a pump to support physiological circulation.

Question 2

What is the most common form of HF?

Answer 2

Left ventricular systolic dsyfunction (LVSD) - heart failure due to reduced ejection fraction.

Question 3

What are the signs and symptoms of HF?

Answer 3

Symptoms - fatigue, breathlessness, decreased exercise tolerance, paroxysmal nocturnal dysponea.

Signs - fluid retention (oedema) usually starts in the ankles, raised venous blood pressure (patient may have a raised jugular venous pressure which can be seen in teh neck), abnormal heart sounds?

Question 4

What is paroxysmal nocturnal dysponea?

Answer 4

Patients wake up in the night breathing very heavily to try and get rid of excess CO2.

Question 5

How is heart failure classified?

Answer 5

NYHA classification

Question 6

What is the most commonly used diagnostic test in HF?

Answer 6

Doppler 2D echocardiogram - looks at the ejection fraction % at rest

<30% (60% is normal) indicates severe dysgfunction.

Question 7

If a patient remains symptomatic despite optimal treatment with an ACEi and a B blocker, what second lne treatments could be considered?

Answer 7

Consider adding:

• Aldosterone antagonist
• ARB
• Hydralazine in combination with nitrate (especially if the patient is of african or carribean descent)

Question 8

How should ACEi therapy be initiated and titrated?

Answer 8

Start at a low dose and titrate upwards at short intervals (e.g. every two weeks) until optimal tolerated or target dose is achieved.

Measure serum urea, creatinine, electrolytes and eGFR when starting and after each dose increment.

Question 9

How should BB therapy be initiated and titrated in HF?

Answer 9

Start low and go slow

assess HR, BP and clinical status after each titration

Question 10

How can we treat the congestive symptoms of HF?

Answer 10

Diuretics

Question 11

what advice should patients with HF we given regarding salt restriction/

Answer 11

Advise to stick to the recomended intake of 6g. Importantly, patients should be advised to avoid salt substitutes due to risk of hyperkalemia.

Question 12

What signs and symptoms might indicate worsening HF that patients should be counselled on?

Answer 12

Increased SOB and decrease in exercise tolerance
Weight gain of more than 2kg in two days
Paroxysmal nocturnal dyspnoea
Development or worsening of peripheral oedema or ascites.

Question 13

Name five common drugs that should be avoided in HF

Answer 13

NSAIDs
corticosteroids (use lowest dose, for shortest time)
Antacids with high Na content
Soluble analgesics with high sodium content.
CCB (is essential amlodipine or felodipine can be used)

Question 14

What are the three aims of management of CHF?

Answer 14

Reduce mortality
Delay disease progression
Control symptoms and improve QoL

Question 15

What monitoring do patients taking diuretics need to do?

Answer 15

Patients are advised to monitor their own fluid levels by weighing themselves daily - and many can be taught to tailor the dose they take according to weight fluctuations.

Question 16

In addition to monitoring weight, what other monitoring is required for diuretics?

Answer 16

Renal function, U&Es and BP.

Hypokalemia can occur with loop diurectics (and thiazie)

Question 17

ACEI can cause hyperkalemia, at what point should therapy be stopped?

Answer 17

Stopping therapy should only be considered if serum potassium rises to over 6mmol/L

Question 18

What vaccinations should be advised in patients with HF?

Answer 18

Pateints with heart failure should be considered for immunisation because:

pulmonary infection is more common in patients with heart failure
pulmonary infection can make heart failure worse
If appropriate, patients should receive immunisation against:

influenza - annually
pneumococcus – a single immunisation

Question 19

what other co-morbidity are patients with HF more likely to have?

Answer 19

Depression - chronic illness is associated with increased risk so we need to monitor this.

Question 20

What is the first line treatment for patients with HF?

Answer 20

ACEi
BB
Diuretic

Question 21

Should you start the ACEI or BB first? or at the same time?

Answer 21

Traditionally the ACEi is started first - if the patient is hemodynamically stable then we could start them together. Need to consider the individual patient’s BP, renal function etc.

Question 22

What diuretic is first line in HF?

Answer 22

Loop diuretic e.g. furosemide

Question 23

When should patients take diuretic therapy?

Answer 23

In the morning

Question 24

When is digoxin used in HF?

Answer 24

3rd line treatment. Reserved for patients with worsening or severe heart failure.

Question 25

How would hypertension be managed alongside HF?

Answer 25

Patient is already taking BB and ACEi for HF so would optimise these doses before adding in any other drugs.