Heart Failure

Question 1

Clinical Features

Answer 1

Dyspnoea

cough: may be worse at night and associated with pink/frothy sputum

Orthopnoea

Paroxysmal nocturnal dyspnoea

Wheeze (‘cardiac wheeze’)

Weight loss (‘cardiac cachexia’): occurs in up to 15% of patients. Remember this may be hidden by weight gained secondary to oedema

Bibasal crackles on examination

Signs of right-sided heart failure: raised JVP, ankle oedema and hepatomegaly

Question 2

What is a way classifying heart failure?

Answer 2

New York Heart Association (NYHA) classification

Question 3

NYHA I

Answer 3

No symptoms

No limit on physical activity

Question 4

NYHA II

Answer 4

Mild symptoms

Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea

Question 5

NYHA III

Answer 5

Moderate symptoms

Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms(<50% day is immobile)

Question 6

NYHA IV

Answer 6

Severe symptoms

Unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

Question 7

Acute Management

Answer 7

oxygen
loop diuretics
opiates
vasodilators
inotropic agents
CPAP
ultrafiltration
mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices

Question 8

Drugs that improve mortality

Answer 8

1st: Beta Blocker and ACE inhibitor
2nd: Spironolactone
3rd: Cardiac resynchronisation therapy or digoxin

Question 9

Other chronic management

Answer 9

Offer annual influenza vaccine

Offer one-off pneumococcal vaccine

Question 10

Chest X ray findings

Answer 10

[ABCDEF]

Alveolar oedema (bat wing) 
kerley. B lines (interstitial oedema laterally) 
Cardiomegaly 
blood reDistribution towards upper lobes
pleural Effusions 
Fluid in the horizontal Fissure