Heart Failure

Question 1

Why do people retain fluid in congestive cardiac failure (CCF)?

Answer 1

Kidney is underperfused so retains salt and water.

Question 2

What are the signs and symptoms of cardiac failure mainly due to?

Answer 2

Fluid retention.

Question 3

What are the causes of left heart failure?

Answer 3

Ischaemic heart disease, previous MIs, cardiomyopathy, valvular disease.

Question 4

What are the causes of right heart failure?

Answer 4

Secondary to left heart failure, cor pulmonale (any severe lung disease puts a strain on right side of heart), congenital heart disease.

Question 5

What are the symptoms of left heart failure?

Answer 5

Dyspnoea on exertion/rest, orthopnoea, paroxysmal nocturnal dyspnoea (people often run to open a window), pulmonary oedema.

Question 6

What are the signs of left heart failure?

Answer 6

Tachycardia, fine crepitations, pleural effusion, 3rd heart sound (caused by sudden deceleration of blood entering left ventricle), gallop rhythm (3rd heart sound and tachycardia).

Question 7

What will you see on a CXR for left heart failure?

Answer 7

Cardiomegaly, bats wing shadows esp lower zones, interstitial fluid.

Question 8

What are the signs, symptoms and CXR findings of right heart failure?

Answer 8

Symptoms: peripheral oedema.
Signs: peripheral oedema, elevated JVP, hepatomegaly, ascites (fluid in abdomen).
CXR: normal.

Question 9

What treatment would you give for previous MIs/cardiomyopathies, cor pulmonale, valvular disease and fast AF?

Answer 9

MIs/cardiomyopathies: standard treatment. Cor pulmonale: diuretics and oxygen only. Valvular disease: surgery ideally. Fast AF: digoxin or DC shock.

Question 10

What is the first line treatment for CCF?

Answer 10

Diuretics, ACIEs, beta blockers (start low go slow), spironolactone (severe cases only).

Question 11

What is the second line treatment for CCF?

Answer 11

Digoxin (positive inotrope and antiarrhythmic).
Other vasodilators (nitrates, hydralazine).

Question 12

What is the 3rd line treatment for CCF?

Answer 12

Implantable cardiac defib, cardiac resynchronisation therapy, tranplantation.

Question 13

What type of diuretic is commoner in heart failure?

Answer 13

Loop diuretics e.g. furosemide.

Question 14

What is a side effect of diuretics but why is this not a big problem in heart failure?

Answer 14

Can lose potassium, coincidental drugs (ACEIs, spironolactone) help retain and normalise K.

Question 15

Give 3 examples of ACEIs.

Answer 15

Captopril, enalapril, lisinopril.

Question 16

What are the side effects of ACEIs?

Answer 16

Angioneurotic oedema, first dose hypertension esp if serum Na is low, renal impairment (U/Es must be monitored after ACEI begun).

Question 17

What are the initial risks of beta-blockers?

Answer 17

Hypotension, worsening dyspnoea.

Question 18

Give 2 examples of beta blockers.

Answer 18

Bisoprolol (beta1 selective). Carvedilol (non-selective plus alpha blocker).

Question 19

What class of drug is spironolactone?

Answer 19

Aldosterone receptor antagonist.

Question 20

When is spironolactone used?

Answer 20

In moderate/severe CCF.

Question 21

What are the side effects of spironolactone?

Answer 21

Hyperkalaemia, renal dysfunction, gynaecomastia (anti-male sex hormone activity can cause breast growth in men.

Question 22

What does ivabradine do and when should you use it?

Answer 22

Slows heart rate, only use if HR fast despite beta blockers.

Question 23

What is the name of the drug that is a combination of an ARB and Neprilysin inhibitor?

Answer 23

Sacubitril-valsartan.

Question 24

What do neprilysin inhibitors do?

Answer 24

Block natriuretic peptide breakdown and boosts natriuretic peptide (BNP) levels.

Question 25

What will sacubitril-valsartan likely replace in the future and what can it cause?

Answer 25

ACEIs, angioneurotic oedema so must not use alongside ACEI.

Question 26

When would you use cardiac resynchronisation therapy (CRT)?

Answer 26

For prolonged QRS (bundle branch block).

Question 27

What is cardiac resynchronisation therapy?

Answer 27

3 pacemakers inserted to force LV and RV to contract together.

Question 28

What is the use of digoxin?

Answer 28

Excellent therapy for AP, mediocre therapy for CCF in sinus rhythm.

Question 29

What is acute LVF therapy?

Answer 29

Sit up, oxygen (careful in COPD), IV furosemide, IV diamorphine (not in COPD), IV nitrates.