Heart Failure

Question 1

Heart failure definition

Answer 1

CO inadequate for body requirements

Question 2

HF classification

Answer 2

NY classification
I - Heart disease but not dyspnoea from ordinary activity
II - Comfortable at rest, dyspnoea during ordinary activity
III - Less than ordinary activity causes dyspnoea (limiting)
IV - Dyspnoea at rest

Question 3

Types of HF

Answer 3

Systolic failure (EF<40%)
Diastolic failure (can be HFpEF with EF>50%)

LV failure
RV failure
(LV + RV = CCF)

Acute HF
Chronic HF

Low-output HF
High-output HF (rare, due to inc demand for CO e.g. anaemia, pregnancy)

Question 4

HFpEF causes

Answer 4

Constrictive pericarditis
Tamponade
Restrictive cardiomyopathy

Obesity
Ventricular hypertrophy

Question 5

Acute HF features

Answer 5

New onset with pulmonary/peripheral oedema but no peripheral hypoperfusion

Question 6

Chronic HF features

Answer 6

Develops slowly
Venous congestion common
Arterial pressure maintained until very late stage

Question 7

Low-output HF causes

Answer 7

Excessive preload (causes ventricular dilatation so exacerbates pump failure)
Pump failure
Chronic excessive afterload (ventricular hypertrophy so diastolic dysfunction)

Question 8

HF diagnosis

Answer 8

Symptoms of failure
Objective evidence of cardiac dysfunction at rest
Framingham criteria for CCF

Question 9

HF signs

Answer 9

Oedema
Dyspnoea
Dec BP
Narrow pulse pressure
RV heave due to pulmonary hypertension

Question 10

HF investigations

Answer 10

ECG or BNP >100ng/L, then echo

ECG or echo may indicate cause

Question 11

HF prognosis

Answer 11

25-50% die within 5yrs of diagnosis
5yr mortality if admitted ~75yrs
Higher BNP greater likelihood of sudden death

Question 12

LV failure CXR signs

Answer 12

Alveolar oedema (hilar bat's wing sign)
Kerley B lines
Cardiomegaly
Dilated prominent upper lobe veins
Effusions (pleural)

Question 13

Acute HF management

Answer 13

Sit pt upright
High flow O2 if low SpO2
IV access, monitor ECG, treat arrythmias

Diamorphine 1.25mg-5mg IV slowly
Furosemide 40-80mg IV slowly (larger dose in renal failure)

GTN 2 puffs SL or 2x0.3mg tablets SL (if sBP>90)
Systolic BP >100 then isosorbide dinitrate 2-10mg/h (keep BP>90)

If worsening: further 40-80mg furosemide, CPAP, nitrate infusion

If systolic BP <100, treat as cardiogenic shock

Question 14

Chronic HF lifestyle treatment

Answer 14

Stop smoking
Stop alcohol
Eat less salt
Optimise weight + nutrition

Question 15

Chronic HF drugs

Answer 15

ACE-i + bisoprolol/carvedilol

Spironolactone, ARB or Hydralazine + isosorbide dinitrate (in afro-caribbean especially)

Cardiac resync or Digoxin/ivabradine if symptoms persist

Diuretics for fluid overload (symptomatic not prognostic treatment)

Question 16

Intractable HF management

Answer 16

Furosemide 200mg -> 5mg bumetanide
Fluid restriction
Metolazone added to furosemide

Question 17

HF palliative care

Answer 17

Treat comorbidities
Good nutrition
Symptomatic relief e.g. opiates for pain + dyspnoea, O2 may help

Question 18

LVAD usage

Answer 18

Bridging therapies for those awaiting heart transplant

Question 19

HF monitoring

Answer 19

Daily weight monitoring

Question 20

HF prognostic indicator

Answer 20

Hyponatraemia