Heart Failure

Question 1

What are the main subtypes of HF?

Answer 1

HF with Left Ventricular systolic dysfunction - i.e. ejection fraction of <40%

HF with preserved ejection fraction - i.e. normal or >40%

Question 2

Investigations for HF, WITHOUT previous MI?

Answer 2

Measure serum natriuretic peptides - these are released in high CO states

If levels High or raised - specialist assessment and doppler transthoracic echocardiography within 2 and 6 weeks respectively

Question 3

Investigations for HF, WITH previous MI?

Answer 3

Proceed straight to transthoracic echocardiography

Question 4

What are the levels for serum natriuretic peptides?

Answer 4

High = BNP >400pg/mL , NTproBNP >2000pg/mL

Raised = BNP 100-400, NTproBNP 400-2000

Normal = BNP <100, NTproBNP <400

Question 5

What happens after transthoracic echocardiography?

Answer 5

If abnormality present - assess severity, aetiology and RF - classify into HFLVF or HFPVF

If no clear abnormality - measure natriuretic peptides - THEN either HFPEF or HF unlikely

Question 6

First line therapies in Heart failure with preserved ejection fraction?

Answer 6

Manage comorbidities - HTN, IHD, DM etc in line with NICE guidance

Question 7

First line therapies in heart failure with Left ventricular dysfunction?

Answer 7

Offer both ACE-I or beta-blockers as 1st line
Ramipril, Bisoprolol (ACE-i if DM, Beta-blockers if angina)
Furosemide to relieve fluid overload

Offer ARB if intolerant of ACE-I
Consider hydralazine + nitrate if intolerant of ACEi and ARBs

Consider starting antiplatelet - Aspirin 75-150mg for patients with atherosclerotic disease
Statin if indicated by QRISK

Question 8

Which CCBs should be avoided in heart failure?

Answer 8

Non-dihydropyridine agents - Verapamil, diltiazem - as can cause dangerous bradycardia

Question 9

2nd line therapies for HFLVEF

Answer 9

Aldosterone antagonist
ARB
Hydralazine + nitrate
Loop diuretics if fluid retention/pulmonary oedema - Furosemide

Question 10

What else should be offered to HF patients?

Answer 10

Vaccination - offer annual flu vaccine + one off vaccine against pneumococcal disease

Depression and anxiety screen
Patient education

Question 11

Classification of heart failure symptoms?

Answer 11

Class I - no symptoms on ordinary activity
Class II - slight limitation of physical activity by SoB, fatigue, palpitations
Class III - breathless at slight activity
Class IV - breathless at rest

Question 12

features of heart failure on CXR?

Answer 12

^^cardiothoracic ratio
alveolar oedema - Bat wing opacities
Pleural effusion
dilated upper lobe vessels - cephalisation
kerley B lines at lung peripheries

Question 13

Follow-up schedule for HF?

Answer 13

6 monthly review of functional capacity, fluid status, rhythm, nutritional status
Drug treatment and SEs
Serum U&E, creatinine, eGFR

Monitor at ~2 weeks if condition/drug treatment changes
Assess anxiety and depression