Heart failure

Question 1

What are the causes of HF?

Answer 1

IHD
Cardiomyopathy
HTN

Question 2

What are the sx of chronic HF;

Answer 2

dyspnoea
malaise
cold peripheries
leg swelling 
ankle oedema
cough - frothy pink sputum 
Exertional dyspnoea
orthopnoea
paroxysmal nocturnal dyspnoea 
cardiac wheeze

Question 3

What are the signs of chronic HF?

Answer 3

• Tachycardia
• Displaced apex beat
• Elevated JVP
• Cardiomegaly
• 3rd and 4th HS
• Bibasal crackles
• Pleural effusion
• Peripheral ankle oedema

Question 4

Explain the NYHA classification of HF

Answer 4

Class I - no sx, no limitation of ordinary physical activity
II - mild, slight limitation during ordinary activity
III - marked limitation on activity due to sx, some at rest (dyspnoea, fatigue, palpitations)
IV - severe limitation, sx at rest, mostly bed bound

Question 5

What are the ix for hf, give results you’d find in HF

Answer 5

FBC 
U&Es - renal function
NT-proBNP
ECG
Echo 
XR - cardiomegaly, Kerley B lines, pulmonary congestion

Question 6

What is the management of suspected HF w a prev MI?

Answer 6

echo in 2 weeks

Question 7

What is the management of suspected HF w no prev MI?

Answer 7

measure BNP

Question 8

What is NT-proBNP

Answer 8

Hormone produced by LV myocardium in response to strain

Question 9

What is the management of NT-proBNP <400ng/L

Answer 9

unlikely HF, review for alternative causes

Question 10

What is the management of NT-proBNP of 400-2000ng/l

Answer 10

specialist assessment and echo in 6 weeks

Question 11

What is the management of NT-proBNP of >2000ng/l

Answer 11

assessment and echo in 2 weeks

Question 12

What are the other causes of raised NT-proBNP?

Answer 12

>70yrs
LV hypertrophy
RV overload
Ischaemia
Hypoxaemia 
Tachycardia
Sepsis
COPD
DM
Cirrhosis
Renal dysfunction <60 egfr

Question 13

What are the causes of reduced NT-proBNP?

Answer 13

obesity
african Caribbean 
Diuretics
ACEi
BB
ARBs 
aldosterone antagonists

Question 14

What is the 1st line pharmacological management of HF w a reduced ejection fraction

Answer 14

ACEi - ramipril

BB - atenolol

Question 15

What is given if ACEi aren’t tolerated?

Answer 15

ARB - losartan

Question 16

What needs to be monitored when giving ARBs

Answer 16

Na
K
Renal function

Question 17

What can be added to first line treatment of HF if sx persist>

Answer 17

Mineralocorticoid receptor antagonists (spironolactone)
Ivabradine 
Sacubitril valsartan
Hydralazine + nitrate
Digoxin (AF)

Question 18

what are the conditions for giving Ivabradine and sacubitril valsartan?

Answer 18

class II-IV NYHA
Sinus rhythm >75bpm
LV ejection fraction <35%

Question 19

What are medications given to all HFs?

Answer 19

diuretics - loop - furosemide for relief of congestive sx and fluid retention
CCB -amlodipine
Amiodarone - LFTs, TFTs
Anticoagulants - HF and AF

Question 20

What are the surgical options for rx of HF?

Answer 20

Cardiac transplant if severe refractory sx, refractory cardiogenic shock

Question 21

What is acute HF?

Answer 21

Sudden onset or worsening of sx of HF

Question 22

What age does acute HF usually present?

Answer 22

> 65

Question 23

What are precipitating causes of acute hF?

Answer 23

acute coronary syndrome
hypertensive crisis
acute arrhythmia
valvular disease

Question 24

What are the features of acute HF?

Answer 24

Fluid congestion signs
weight gain
orthopnoea
dyspnoea
cyanosis
increased HR, JVP
Displaced apex beat 
S3 HS

Question 25

What are the investigations in acute HF and why?

Answer 25

bloods - look for underlying abnormality e.g. anaemia, inf
CXR - pulmonary venous congestion, interstitial oedema, cardiomegaly
Echo - pericardial effusion, cardiac tamponade
BNP - >100mg/l - myocardial damage

Question 26

What is the management of acute HF?

Answer 26

Initial: Diuretics, closely monitor renal function, weight and UO during diuretics
Do not routinely offer: Opiates, nitrates, inotropes or vasopressors, sodium nitroprusside
After stabilising: If already on BBs, continue unless HR <50bpm, 2nd/3rd degree AV block or shock, offer ACEi and aldosterone antagonist