HF

Question 1

Aetiology

Answer 1

IHD, HTN, valvular disease, congenital heart conditions, endocarditis, chemotherapy,

Question 2

Symptoms/Signs

Answer 2

SOB, persistent coughing or wheezing, ankle swelling, reduced exercise tolerance, and fatigue.

Elevated jugular venous pressure, pulmonary crackles, and pulmonary oedema.

Question 3

CHF diagnosis

Answer 3

Refer urgently to be seen within 2 weeks if NT-proBNP > 2,000 ng/l
(236 pmol/l)

Refer urgently to be seen within 6 weeks if NT-proBNP 400-2,000 ng/l (47-236 pmol/l)

NT-proBNP < 400 ng/l (47 pmol/l) - HF not confirmed

Question 4

Investigations

Answer 4

Bloods, CXR, ECG, ECHO

Question 5

Advice

Answer 5

Advise to report symptoms worsening. Avoid excessive salt intake. Fluid restrict - 1.5 to 2L.
If acutely unwell with diarrhoea and vomitting, stop medications temporarily and maintain fluids.
Lifestyle advice

Question 6

Monitoring/ follow up

Answer 6

Follow up should correlate to symptom severity

Assess nutrition, medications, fluid balance (weight, JVP, oedema, auscultate lungs),

Question 7

Monitoring/ follow up

Answer 7

Follow up should correlate to symptom severity

Assess nutrition, medications, fluid balance (weight, JVP, oedema, auscultate lungs)

Question 8

Classification

Answer 8

NYHA

Class I no limitation of physical activity
ordinary physical activity does not cause fatigue, breathlessness or palpitation (includes asymptomatic left ventricular dysfunction)

Class II slight limitation of physical activity
patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, breathlessness or angina pectoris (symptomatically ‘mild’ heart failure)

Class III marked limitation of physical activity
although patients are comfortable at rest, less than ordinary activity will lead to symptoms (symptomatically ‘moderate’ heart failure)

Class IV inability to carry out any physical activity without discomfort
symptoms of congestive cardiac failure are present even at rest. Increased discomfort with any physical activity (symptomatically ‘severe’ heart failure)

Question 9

CHF Management

Answer 9

HFpEF - comorbities management. Loop diuretics to relieve symptoms.

HFpREF
ACEi and BB, add MRA if symptoms present.
Consider hydralazine and nitrate if intolerant to above.
If symptoms persist:
- consider replacing ACEi with sacubitril valsartan if ejection fraction is <35%
- add ivabradine for sinus rhythm if HR >75 and ejection fraction is <35%
- add hydralazine and nitrate (especially if African-Caribbean descent)
-digoxin for HF with sinus rhythm

For both, consider statins and antiplatelets if indicated.

Question 10

What affects BNP levels?

Answer 10

Reduced : high BMI, drugs like ACEi, African-Carribean

Increased: >70yrs, left ventricular hyertrophy, PE, HTN, DM

Question 11

Impact on lifestyle?

Answer 11

Reduced Exercise tolerance - so may no be able to continue with hobbies, sports the person enjoys
Also worry that exercise could trigger palpitations
This could lead to a loss of fitness and potentially gaining weight
Which could cause some mental health issues
Anxiety is common in newly diagnosed patients due to the increased stroke risk