heart failure

Question 1

what are the causes of heart failure?

Answer 1

• Ischaemic heart disease
• hypertension
• valvular heart disease
• atrial fibrillation
• chronic lung disease
• cardiomyopathy
• previous cancer chemo drugs
• HIV

Question 2

how do patients with Heart failure present?

Answer 2

• 50% of patients will have systolic heart failure of heart failure with reduced ejection reaction (HFREF)
• Heart failure normal ejection fraction (HFNEF) patients have a similar clinical course and outcome as those with LV systolic dysfunction
• HFNEF are elderly, overweight, have hypertension and AF.

Question 3

what patients have an especially poor prognosis?

Answer 3

• severe fluid overload
• high NT-proBNP levels
• severe renal impairment
• advanced age
• multi morbidity
• frequent admissions with heart failure

Question 4

what blood tests would you do for heart failure?

Answer 4

• renal function (baseline and diuretic effect)
• FBC (anaemia as a consequence of bone marrow issues)
• LFT hepatic congestion
• TFTs thyroid disease
• ferritin and transferrin
• Brain natriuretic peptide (NT-proBNP) identifies patients with LV dysfunction. Levels less than 100ng/L rule out acute heart failure
• NTproBNP should be measured only where there is doubt about diagnosis. A level above normal range doesn’t equal heart failure as any stimulus which causes increased cardiac chamber stress can elevate these peptides e.g AF or RV strain.

Question 5

what features will a CXR of heart failure show?

Answer 5

• cardiomegaly
• pleural effusions?
• perihilar shadowing/consolidation
• alveolar oedema
• air bronchograms
• increased width of vascular pedicle

Question 6

what investigations are done into left ventricular function?

Answer 6

• echocardiography = the key investigation. May find dilated, poorly contracting LV (systolic dysfunction); stiff, poor relaxing, small diameter LV (dysastolic dysfunction); valvularr heart disease, atrial myxoma, pericardial disease
• cardiac MRI: may elaborate cause for heart failure as echo may miss right ventricle.

Question 7

what lifestyle modifications can be done to manage heart failure?

Answer 7

1) smoking cessation
2) reduce alcohol consumption
3) salt restriction
4) fluid restriction may be indicated in presence of hyponatraemia. Daily weight monitoring to identify fluid accumulation early.

Question 8

how can heart failure be managed medically?

Answer 8

1) diuretics are first line. effective symptomatic treatment. Loop Diuretics e.g furosemide. Bumetanide is better absorbed orally. Monitor urine input and output and do daily weighing to asses response to treatment. thiazide diuretics can be useful when employed with a loop. if hypokalaemia persists, consider spironolactone.
2) ACE inhibitors if hypertensive. improves exercise tolerance and slows disease progression.
3) ARBs - valsartan and candesartan.
4) Angiotensin receptor Neprilysin inhibitor (ARNI) - sacubitril/valsartan. For HFREF.
5) Beta blockers - start low and go slow. Systolic BP should be >100 and resting HR >60 and no AV block.

Question 9

what vasodilators can be used in heart failure?

Answer 9

• hydralazine
• isosorbide mononitrate

especially beneficial for patients of African or Caribbean origin. use if patient can’t take ACEI or ARBs.

Question 10

what is used if patients can’t tolerate B blockers?

Answer 10

Ivabradine

good if can’t take B blockers of if RHR is >75 with beta blockers.

Question 11

what is the use of nitrates in heart failure?

Answer 11

• nitrates reduce preload, reduce pulmonary oedema and reduce ventricular size.
• IV use when acute, good if theres underlying ischaemia, hypertension or regurgitant aortac mitral valve disease
• in chronic heart failure, can be useful for release of orthopnea and exertion dyspnoea

Question 12

what is the use of a Cardiac resynchronisation pacemaker (CRT pacemaker) as a complex device therapy?

Answer 12

where medical therapy fails, a special pacemaker device can be used where there is a LBBB (QRS duration is broad and depolarisation of electricity is delayed from the septum to the lateral wall resulting in mechanical reduction).

if there two points are paced QRS duration can be altered and narrow for normal muscle pumping.

this is a CRT or Cardiac resynchronisation pacemaker.

Question 13

what is the use of an implantable cardiac defibrillator (ICD) as a complex device therapy?

Answer 13

purpose is to prevent sudden cardiac death associated with heart failure by detecting cardioverting VT/VF.

Achieve this by delivering an electric shock. Used for secondary prevention in survivors of sudden cardiac arrest or for primary prevention

Question 14

can implantable cardiac defibrillators (ICD) co exist with a cardiac resynchronisation pacemaker (CRT)?

Answer 14

yes