Heart failure exacerbation

Question 1

An independent 72 year old male presents with dyspnoea on exertion at 200m on flat surface, orthopnoea and lower limb swelling. He has no angina. He had coronary bypass surgery 17 years prior. His only medications are aspirin and rosuvastatin. How would you manage him?

Answer 1

Impression:
Given the exertional dyspnoea, orthopneoa, and LL swelling, this is likely an exacerbation of heart failure. With lower limb oedema may indicate a mixed picture of R and L heart failure. Would need to rule out other red flag diagnoses including;
- ACS
- pulmonary embolus
- Infective: pneumonia
Would need to consider potential causes of the exacerbation including arrhythmias, MI, AKI, etc.

Goals:

• assess stability, determine underlying aetiology
• implement definitive management
• ensure long-term follow-up/ appropriate management

Question 2

Heart failure exacerbation - History

Answer 2

History:

• Sx: nature (acute v chronic), exercise tolerance, characterise LL swelling
• RED FLAGS: chest pain, cough (+/- productive), fever, night sweats
• PMHx: cardiac Hx, complications, other medical conditions (prev Mi, diabetes, liver/renal failure)
• Medications: antihypertensives
• SNAP

Question 3

Heart failure exacerbation - Examination

Answer 3

Exam:

• General observation + Vitals: BP, temp, HR, sats
• Cardiorespiratory: JVP/hepatojugular reflex, bibasal crackles, etc
• Fluid assessment: extent of oedema

Question 4

Heart failure exacerbation - Investigations

Answer 4

Investigations:
- Bedside: VBG, BSL, CXR
- Bloods: FBC, BNP, LFT, blood cultures if febrile, Hba1C, lipid panel, serial trops
Imaging: CXR (for APO/ pleural effusion - kurley B, consolidations, effusion), ECHO for cardiac function/ ejection fraction.

• Undertake Wells criteria for PE.

Question 5

Heart failure exacerbation - Management

Answer 5

Management:
Unstable:
- disposition: consider escalation to cardiac/ICU care
- Otherwise APO mx (LMNOP or POND)
     - Position upright
     - 02 supplementation
     - Nitrates
     - Diuretics
     - Morphine

Stable
Non-pharmacological
- cardiac review: EF important for management course
- MDT including GP and allied health for long-term mx

Pharmacological
Manage risk factors: aim for max dose. (if HFrEF)
- ACEi/ARB
- B Blocker
- Aspirin
- Statin
- Diuretics: spironolactone
- SGLT2 inhibitors (shown to have mortality benefit)
- ARNIs

Refer to AHF heart failure flow chart.

Question 6

AHF HFrEF guideline

Answer 6

https://www.heartfoundation.org.au/getmedia/c8889851-5843-40d1-a550-e6e9a9f7d03d/Clinical_Fact_Sheet_-_Pharmacological_Management.pdf