Heart Failure

Question 1

Q1) DY is a 78 year old male with a history of a large anterior myocardial infarction three years ago.

He presents with a three week history of fatigue, ankle swelling, decreased exercise capacity and shortness of breath.

On examination there was pitting oedema, cardiomegaly, raised jugular venous pressure and crackles at the lung bases.

ECG showed sinus rhythm and echocardiography revealed severe left ventricular systolic dysfunction with ejection fraction of 26%

Answer 1

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Question 2

Q1a) What is the pathophysiological significance of the raised jugular venous pressure and crackles at the lung bases?

Answer 2

• The raised JVP indicates systemic venous congestion, which suggests Right Heart Failure is present
• The crackles indicate pulmonary congestion, which suggests Left Heart Failure is also present
• Hence, the patient has biventricular cardiac failure with pulmonary oedema

Question 3

Q1b) Which class of diuretic would you choose and why?

Answer 3

• Loop - Loop diuretics trigger prompt onset of significant diuresis
• Has vasodilator action when given IV. Reduces preload and relieves breathlessness quickly.

Question 4

Q1c) Spironolactone can be used as an effective way of preventing diuretic-
induced hypokalaemia. Name 1 other drug that has a similar affect

Answer 4

• Eplerenone (aldosterone antagonist like spironolactone)
• Amiloride (K-sparing diuretic)
• Triamterene (K-sparing diuretic)

Question 5

Q1d) What additional benefits may accrue to the patient as a result of using spironolactone?

Answer 5

• Combats effects of Hyperaldosteronism
• Reduced Mortality
• Improved symptomatic benefit

Question 6

Q1e) Digoxin, a beta-blocker and dobutamine were all considered for initial treatment but rejected. Give 1 reason for rejecting each of these.

Answer 6

• Digoxin → the patient has sinus rhythm (no evidence of benefit)
• β-Blocker → contraindicated in acute heart failure
• Dobutamine → inotropic agents should only be used to treat acute decompensation.

Question 7

Q1f) DY was finally started on an angiotensin converting enzyme inhibitor (ACE inhibitor). Name 2 precautionary measures that you would warn Mr DH about and that should be taken on starting this medication?

Answer 7

• Warn about side effects e.g. first-dose hypotension, cough, hyperkalaemia, renal impairment
• Start at a low dose and titrate up
• Check Urea and Electrolytes before initiating treatment (? hyperkalaemia or renal
  dysfunction)
• Check patient is not taking drugs that have interactions with ACE-I e.g. Ciclosporin (↑ risk of ↑K+)

Question 8

Q2) A 72-year old lady has been treated for mild heart failure for a number of years. She is admitted to hospital as an emergency one night with a 48 hour history of worsening shortness of breath.

On examination you find her to be severely unwell, coughing pink frothy sputum, with a marked tachycardia and profuse fine crackles at both lung bases. No murmurs are audible. You make a rapid initial diagnosis of left ventricular failure.

Answer 8

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Question 9

Q2a) List 2 symptoms of left heart failure

Answer 9

• Shortness of breath on exertion
• Coughing frothy pink sputum
• PND / Orthopnea

Question 10

Q2b) What 2 immediate interventions would you make?

Answer 10

• sit her up

- O2

Question 11

Q2c) Name 2 drugs which may be helpful?

Answer 11

• furosemide

- GTN

Question 12

Q2d) She improves and you are now able to hear a pansystolic murmur at the apex. What cardiac lesion is likely to be responsible for this?

Answer 12

mitral regurgitation

Question 13

Q2e) List 3 possible causes for her clinical deterioration?

Answer 13

• Myocardial Infarction
• AF
• Infection / pneumonia
• Rupture of IV Septum (causing a VSD)
• Poor compliance with Rx / fluid restriction