Heart failure

Question 1

How common is it?

Answer 1

1/35 people 65-74yr. 75-84yr 1/15. 1/7 >85 yr.

Question 2

What causes it?

Answer 2

Main causes: Ischaemic heart disease, cardiomyopathy (dilated), hypertension

Other causes: Cardiomyopathy (hypertrophic, restrictive), valvar heart disease (mitral, aortic, tricuspid). Congenital heart disease (atrial septa defect, ventricular septal defect). Alcohol and chemotherapy. Hyperdynamic circulation (anaemia, thyrotoxicosis, Paget’s disease).

Right heart failure: (RV infarct, pulmonary hypertension, pulmonary embolism, cor pulmonale, (COPD)). Severe bradycardia or tachycardia. Pericardial disease (constrictive

Question 3

What risk factors are there?

Answer 3

Any risk factors for the things listed in ‘causes’. Also AF, diabetes, family history of heart failure or sudden cardiac death.

Question 4

How does it present?

Answer 4

Breathlessness- on exertion, at rest, on lying flat (orthopnoea), nocturnal cough, or waking from sleep (paroxysmal nocturnal dyspnoea)

Fluid retention (ankle swelling, bloated feeling, abdominal swelling, or weight gain)

Fatigue, decreased exercise tolerance, or increased recovery time after exercise

Light headedness or history of syncope

Question 5

Signs on examination?

Answer 5

Tachycardia (rate over 100).

A laterally displaced apex beat, heart murmurs, and third and fourth heart sounds (gallop rhythm).

Hypertension.

Raised JVP.

Enlarged liver (due to engorgement),

respiratory signs such as tachypnoea, basal crepitation’s, and pleural effusions. Dependent oedema, ascites. Obesity.

Question 6

Investigations?

Answer 6

Echocardiography

If the person has not had a previous MI, measure their naturitic peptide level

Arrange a 12 lead ECG

Consider other tests to evaluate for possible aggravating factors and to exclude other conditions eg: CXR, urine dipstick for blood and protein, lung function tests. Blood tests such as urea and electrolytes, eGFR, FBC, thyroid function, LFTs. HbA1c, and fasting lipids

Question 7

Treatment

Answer 7

Confirmed heart failure with reduced ejection fraction (systolic): Loop diuretic. Prescribe both an ACEi and β-blocker licensed to treat heart failure but only start one drug at a time.

Confirmed heart failure with preserved ejection fraction (diastolic): Loop diuretic. Consider an antiplatelet drug and statin. Lifestyle

Question 8

Conditions that would present similarly

Answer 8

Conditions causing dyspnoea: COPD, asthma, PE, lung cancer, anxiety.

Conditions causing peripheral oedema: Dependent oedema, for example prolonged inactivity or venous insufficiency, nephrotic syndrome, drugs (e.g. dihydropyridine calcium-channel blockers, NSAIDs). Hypoalbuminemia, pelvic tumour.

Other conditions: Obesity, severe asthma or thyroid disease, bilateral renal artery stenosis.