HF (1)

Question 1

What are its risk factors?

What are the complications?

What are its differentials?

Answer 1

➊ • IHD
• Valvular Heart Disease esp. AS
• HTN
• Arrythmias esp. AF

➋ • Sudden cardiac death
• CKD
• Sexual dysfunction

➌ COPD, Asthma, PE, Lung ca.

Question 2

Classification:
What are the 2 ways to classify it by pump failure?

What are the 2 ways to classify it by anatomy?

What are its 4 stages?

Answer 2

➊ • Systolic HF - Impaired myocardial contraction → Reduced EF (< 40%)
‣ Causes - IHD, MI
• Diastolic HF - Impaired ventricular filling → Preserved EF (> 50%)
‣ Causes - HCOM, Cardiac tamponade

➋ • Left HF - Causes pulmonary congestion
‣ Presents as SOBOE, Orthopnoea, PND, Nocturnal cough
• Right HF - Causes venous congestion
‣ Presents as Peripheral oedema, Raised JVP, Hepatomegaly, Bilateral (transudative) pleural effusions

N.B. The pulmonary congestion from Left HF can push the RV into failure as well, leading to symptoms of both L+RHF i.e. CHF

➌ • Stage 1 - No symptoms during physical activity
• Stage 2 - Comfortable at rest with symptoms on normal physical activity
• Stage 3 - Comfortable at rest with symptoms on minimal physical activity
• Stage 4 - Symptoms at rest, and unable to do any physical activity w/o discomfort

Question 3

What are its key clinical features?

Answer 3

• SOBOE
• Orthopnoea - SOB when lying flat and relieved by sitting up or standing - Pts tend to use 1+ pillow at night
• Paroxysmal Nocturnal Dyspnoea (PND) - Sudden attack of SOB during the night (as if they can’t breathe)
• Nocturnal Cough +/- frothy pink sputum
• Peripheral oedema

N.B. PND occurs as, when lying flat, the fluid settles across the lung surface, and when standing, the fluid settles at the base, allowing the upper lungs to be used more effectively

Question 4

Investigations:
What should be done?

What is BNP?
→ How is it interpreted?

What are the key findings on CXR?

Answer 4

➊ • NT-proBNP
• Echo - check type and degree of failure by ejection fraction
• CXR
• ECG

➋ Released by ventricles in response to myocardial stretch
→ • Has a high negative predictive value, so if not raised, HF is unlikely
• If raised, the pt should be referred for an Echo

➌ ABCDE:
• Alveolar oedema - ‘bat wing’ perihilar shadowing
• Kerley B lines - interstitial oedema
• Cardiomegaly - cardiothoracic ratio > 0.5
• Dilated upper lobe vessels
• Pleural effusion - bilateral transudates

Question 5

Management:
What are the lifestyle changes to make?

What is included in the Quadruple therapy here?

What needs to be monitored when on all these medications?

What are pts with very severe, refractory HF at risk of?
→ What should therefore be given to reduce this risk?

Answer 5

➊ • Smoking cessation
• Low-salt diet
• Exercise

➋ The Fantastic 4:
• RAAS inhibitor - Sacubitril/Valsartan (Entresto), ACEi, or ARB
• B-blocker - Carvedilol 1st line
• Aldosterone antagonist
• SGLT2 inhibitor e.g. dapagliflozin

N.B. Loop diuretics can be given for symptomatic relief as well

➌ U&E’s - ACEi and Spironolactone can cause hyperkalaemia and renal impairment

➍ Life-threatening arrhythmias e.g. VT, VF
→ ICD