Heart Failure

Question 1

What are some causes of acute heart failure?

Answer 1

Can occur with MI

Valvular collapse

Question 2

What are some causes of chronic heart failure?

Answer 2

More gradual onset so things like:

mitral stenosis, raised pulmonary pressure causing Right heart failure, chronic ischaemia

Question 3

What symptoms/signs are seen with left heart failure?

Answer 3

Exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea

Question 4

What symptoms/signs are seen with right heart failure?

Answer 4

Hepatomegaly, splenomegaly, ascites, peripheral oedema

Question 5

What is seen in congestive cardiac failure?

Answer 5

Signs of hypervolaemia such as peripheral oedema

Question 6

Briefly describe the pathophysiology behind low output heart failure.

Answer 6

Cardiac output is reduced and fails to increase on exertion. This can be due to pump failure, reduced heart rate (i.e. from beta-blockers), excessive preload (mitral regurg), fluid overload, excessive afterload (i.e. from aortic stenosis or hypertension)

Question 7

What is sort of cough is characteristic of someone with heart failure?

Answer 7

Nocturnal cough +/- pink frothy sputum

Question 8

What are the symptoms of heart failure?

Answer 8

Exertional breathlessness, orthopnoea, PND, fatigue, nocturnal cough +/- pink frothy sputum, weight loss +/- muscle wasting, cold peripheries, nocturia

Question 9

What are some signs of heart failure?

Answer 9

Cardiomegaly, 3rd and 4th heart sounds, elevated JVP, tachycardia, hyper/hypotension, bi-basal crackles, pleural effusion, ankle oedema, ascites.

Question 10

In which sided heart failure would you expect to see more systemic symptoms due to a back pressure in the venous system?

Answer 10

Right sided heart failure

Question 11

In which sided heart failure would you expect to see more chest symptoms due to insufficient pumping of blood to the body?

Answer 11

Left sided heart failure

Question 12

What classification system exists for severity of heart failure and how many classes are there

Answer 12

New York Heart Association Classification of Heart Failure. 4 classes.
Class I (no limitation) to Class IV (symptoms at rest)

Question 13

What is blood test is key to order in suspected heart failure?

Answer 13

N-terminal pro-B-type natriuretic peptide (NT-proBNP)

Normal BNP < 100. If BNP > 400, heart failure is very likely and an urgent referral to cardiology should be made

Question 14

What investigations should be ordered if heart failure is suspected?

Answer 14

ECG, CXR, BNP.

If abnormal results, do an Echocardiogram.

Question 15

What changes might be seen on a CXR of someone with heart failure?

Answer 15

A - Alveolar bat wings
B - Kerley B lines (interstitial oedema)
C - Cardiomegaly
D - Dilated prominent upper lobe vessels
E - Plueral effusions, pulm. cogestion, loss of costophrenic angles

Question 16

What is the first line management for someone with heart failure?

Answer 16

Lifestyle advice

ACE-inhibitor (or ARB if intolerant) PLUS beta-blocker

Question 17

What are some adjuncts that may be used in certain patient groups for the management of heart failure?

Answer 17

Diuretics (e.g. furosemide)
Aldosterone antagonsists (e.g. spironolactone)
Hydralazine and isosorbide nitrate
Digoxin
Ivabradine
Vasopressin antagonist (e.g. Tolvaptan)

Question 18

Which calcium channel blocker can be used in HF and which ones should be avoided?

Answer 18

Can be used - Amlodipine

Avoid - diltiazem, verapamil

Question 19

Which patient group might benefit from the addition of loop diuretics in the management of their HF?

Answer 19

All patients with evidence of fluid retention

Question 20

Which patient group might benefit from the addition of an aldosterone antagonist (e.g. spironolactone) in the management of their HF?

Answer 20

Patients with New York Heart Association class II to IV heart failure who have left ventricular ejection fraction (LVEF) < 35%

Question 21

Which patient group might benefit from the addition of digoxin in the management of their HF?

Answer 21

Patients with reduced LVEF, especially those with Atrial Fibrillation.

Question 22

What things should be assessed/covered during each 6-monthly review for patients with HF?

Answer 22

Assess fluid status, functional capacity, cardiac rhythm, cognitive status, nutritional status.
Review medication and side effects.
Monitor renal function (U+Es, creatinine, eGFR).
Annually - pneumococcal and influenza vaccine, depression screening.