heart failure

Question 1

1st line treatment for HF

Answer 1

ACEi
beta blocker
loop diuretic - congestion + fluid retention
antiplatelet + statin if indicated (eg atherosclerosis)
annual flu jab + one-off pneumococcal

conservative:
lifestyle
manage comorbidities
exercise-based group rehab
screen for depression + anxiety

?dont start ace and bb at same time?

Question 2

2nd line treatment for HF

Answer 2

one of:
aldosterone antagonist - spironolactone
A2RB - candesartan, losartan (don’t use w ACEi)
hydralazine with nitrate - esp in afrocaribbeans

hydralazine:
smooth muscle relaxant + arterial dilator
→ increased CO + SV
→ decreased vascular resistance

Question 3

3rd line treatment for HF

Answer 3

CRT
digoxin - esp if AF. inotrope.
ivabradine in some cases - slows HR

Question 4

what is CRT? how does it differ from a pacemaker?

Answer 4

in HF, ventricles oft uncoordinated → decreased efficiency
CRT - leads inserted to left ventricle (and right heart) to enable both sides to beat together - resynchronisation
→ better pump function + reduced symptoms (breathlessness, fatigue)

normal pacemaker - only has leads in right heart

Question 5

HF on CXR

Answer 5

Alveolar oedema (bat's wings)
B - Kerley B lines (interstitial oedema)
Cardiomegaly
Dilated prominent upper lobe vessels
Effusion - pleural

Question 6

HF - investigations

Answer 6

BNP/echo:
hx MI - echo in 2 weeks
no hx MI - measure BNP:
if high - echo in 2 weeks
if raised - echo in 6 weeks

obs incl - urinalysis - renal failure
ECG
FBC, U+Es, LFTs, 
TFTs, lipid profile
CXR, spirometry + peak flow

Question 7

NYHA classification

Answer 7

I - no limitation of physical activity. no sx on ordinary activity
II - slight limitation of physical activity. sx on ordinary physical activity
III - marked limitation of physical activity. sx on less than ordinary activity
IV - unable to carry on any physical activity without discomfort. sx at rest