Week 5/6 - D - Heart failure - Classification (Acute/Chronic, H.Fr.EF/H.Fp.E.F, Severity, Ventricle) - symptoms,diagnosis, treatment

Question 1

Define heart failure?

Answer 1

Heart failure is when the cardiac output is inadequate for the body’s requirements due as a result of a structural or functional impairment of ventricular filling or ejection

Question 2

Heart failure can be classified based on the * Time and duration? * Ejection fraction? * Symptomatic severity? Symptoms associated with heart failure can also point to which ventricle is affected

Answer 2

Time and duration - acute or chronic heart failure Ejection fraction - whether it is heart failure with preserved or reduced ejection fraction (so whether it is systolic or diastolic heart failure) Symptomatic severity - used the New York Classification of Heart failure to classify the symptomatic severity

Question 3

What is the difference between acute and chronic heart failure?

Answer 3

Acute heart failure is often used exclusively to to mean new-onset or decompensation of chronic heart failure characterised by pulmonary and/or peripheral oedema Chronic heart failure develops or progresses slowly

Question 4

What is the ejection fraction and how is it calculated?

Answer 4

Ejection fraction is the percentage of blood that is pumped out of the heart during each beat It is a measure of left ventricular function It is calculated using an echocardiogram and is * The amount of blood pumped out of the ventricle (SV = EDV-ESV) * divided by * The toal amount of blood in the ventricle (EDV) * = Ejection fraction (%) = SV divided by EDV

Question 5

Heart failure as said can be classified by * Time and duration - acute or chronic heart failure * Ejection fraction - whether it is heart failure with preserved or reduced ejection fraction * Symptomatic severity - using the New York Classification of heart failure What is the difference between heart failure with preserved or reduced ejection fraction? Are these problems with systole or diastole?

Answer 5

Heart failure with an ejection fraction * this was once described as systolic failure * In HFrEF, the LV is unable to eject an adequate amount of blood during systole Heart failure with an ejection fraction >/=50% is known as heart failure with preserved ejection fraction (HFpEF) * this was once described as diastolic failure * In HFpEF, less blood is able to fill the LV due to myocardial stiffness. Thus the LV has less blood to eject during systole.

Question 6

Aetiology of heart failure What are the different causes of * HFrEF (due to inability to eject blood during systole)? * HFpEF (due to less blood filling during diastole, due to mycoardial stiffness, therefore less blood to pump)?

Answer 6

HFrEF - causes include ischaemic heart disease, MI - affecting systole HFpEF - causes include ventricular hypertropy (eg due to hypertension), constrictive pericarditis, cardiac tamponade, obseity - affecting filling of the ventricles during diastole

Question 7

Different symptoms in heart failure can be attributed to left or right ventricular failure Both can occur at the same time What causes them?

Answer 7

Left ventricular failure - discussed the causes when taling about the ejection fractions - ischaemic heart disease, MI, hypertension Right ventricular failure - generally develops as a result of advanced left ventricular failure, can be due to lung disease (cor pulmonale - eg fibrosis, pulmonary hypertension, COPD, obesity)

Question 8

What are the classic symptoms of heart failure? (not symptoms on examination) Try and associate symptoms to left or right ventricular fialure?

Answer 8

Cardinal features are dyspnoea and fatigue Left ventricular failure Difficulty breathing at night when recumbent Orthopnea, paroxysmal nocturnal dysnponeea Poor exercise tolerance Pulmonary oedema - pink frothy sputum Right ventricular failure Peripheral oedema (ankles,calfs, thighs), ascites,

Question 9

Hoe does paroxysmal nocturnal dyspnoea present? Sign of left ventricular failure

Answer 9

Paroxysmal nocturnal dyspnea or paroxysmal nocturnal dyspnoea (PND) is an attack of severe shortness of breath and coughing that generally occur at night. It usually awakens the person from sleep, and may be quite frightening. - patient usually needs to lie on a couple of pillows at night

Question 10

What is seen on examination of a patient with heart failure? Inspection and auscultation mainly

Answer 10

Due to RVF - Elevated JVP Oedema in sacrum, feet,ankles/lower legs due Due to LVF - Displaced apex due to LV dilatation Crackles aka rales aka crepitations - pulmonary oedema Third or fourth heart sounds sometimes called a gallop rhythm

Question 11

The New York Heart Association (NYHA) functional classification - classifies the symptomatic severity of the heart failure by how much they are limited during physical activity What are the 4 stages?

Answer 11

Symptoms here usually refer to dysnponea or fatigue * Stage 1 - Heart disease present but no limitation of physical activity * Stage II - Comfortable at rest but slight symptoms of HF with ordinary activity * Stage III - comfortable at rest but marked limitation of any physical activity ie showering or walking up stairs * Stage IV - unable to carry out any physical activity or symptoms at rest

Question 12

What are the investigations used to diagnose heart failure? What other tests can be carried out?

Answer 12

Key investigations - ECG, BNP (brain natriuretic peptide - name brain because first disocvered here but also released by the heart) * If either is abnormal then proceed to Echo - main diagnostic invesitgation * If both are normal, alternative diagnosis should be considered Other tests carried out FBC, U&Es, CXR, TFTs

Question 13

ECG can be used to identify potential causes of HF, such as what?

Answer 13

ECG can identify causes of heart failure such as evidence of ischaemia, or MI - link to systolic failure, or ventricular (right or left) hypertrophy or arrhythmia

Question 14

What is BNP? (what is the other natriuretic peptide)

Answer 14

BNP is known as brain-natriuretic peptide and is produced by the ventricular tissues in the heart in response to stretch due to increased ventricular volumes and pressures (Atrial natriuretic peptide is released form the atria in response to stretching) Usuually elevated in patients with heart failure

Question 15

ECHOCARDIOGRAPHY is the key test required in the diagnosis of heart failure What can an echo tell us? What type of echo is used?

Answer 15

Echocardiocraphy usually requires a referral to secondary care -uses Doppler US to provide a 2D image of the heart * * Echo tells us the structure and function of th heart * Tells us the Left ventricular ejection fraction * May help define aetiology * Transthoracic echo (TTE) - is the preferred method for documentation of cardiac dysfunction at rest * Transoeosphageal echo (TEE) - is more inasvive and expensive

Question 16

As said, CXR is an additional test that can be carried out in patients with heart failure What does a CXR in left ventricular failure show? (these are the signs of pulmonary oedema)

Answer 16

A - Alveolar bat wings (showing alveolar oedema) B - kerley B lines (shows interstitial oedema) C - cardiomegaly - cardiothoracic ratio increased D - Dilated prominent upper lobe vessels E - pleural Effusion

Question 17

What are Kerley B lines?

Answer 17

Now known as septal lines Kerley B lines These are thin lines 1-2 cm in length in the periphery of the lung(s). They are perpendicular to the pleural surface and extend out to it. They represent thickened oedematous subpleural interlobular septa due to fluid or cellula infiltration into the lung instertitium

Question 18

Management of chronic heart failure and acute heart failure are different We will discuss chronic heart failure first What are the lifestyle modifications that are advised to those with heart failure?

Answer 18

* Stop smoking * Stop drinking alcohol * Reduce salt intake and fluid restrict * Encourage continued exercise * Keep vaccinations up to date - annual flu vaccine and one off pneumococcal vaccine * Avoid and manage exacerbating factors

Question 19

Which drugs should be avoided in patients with heart failure?

Answer 19

NSAIDs - can cause fluid retention and rate limiting calcium channel blockers - negative intotropes (decrease contractility)

Question 20

The management of HF changes dependnet on the ejection fraction of the patient * HFrEF (EF /=50%) How is HFpEF treated pharacologically?

Answer 20

Prescribe a loop diuretic eg frusemide to relieve symptoms if fluid overload * pulmonary (eg orthopnoea, paroxysmal nocturnal dyspnoea, pink forthy sputum) * or peripheral oedema (ascites, ankle/foot/leg swelling, sacral oedema) NICE reviewed the evidence on ACE-inhibitors, angiotensin-II receptor antagonists (AIIRA), and beta-blockers for treating people with HFPEF and concluded that evidence is insufficient to support their use

Question 21

Heart failure with reduced ejection fraction has many medications made available as treatment What are the first line medications given for the treatment of heart failure? Which one isn’t usually given alone due to potentially making the heart failure worse?

Answer 21

HFrEF - give frusemide to relieve symptoms The first line medications given are: * ACE inhibitors (ARBs if not tolerated) * and * Beta blockers Beta blockers should be used in caution ie start low and go slow as they can decrease myocardial contaction hence worsening heart failure

Question 22

If the person is still symptomatic (New York Heart Association classification II-IV) despite optimal treatment with an ACE-inhibitor (or AIIRA) and beta-blocker, what drug treatment is offered?

Answer 22

The patient should be offered an aldosterone anatagonist (mineralocorticoid receptor antagonist) eg spironolactone first line or eplernone

Question 23

In neither ACE inhibitors or ARBs are tolerated in patients with HFrEF (eg due to renal dysfunction), what drug treatment can be given?

Answer 23

If neither ACE inhibitors nor ARBs are tolerated, seek specialist advice and consider hydralazine in combination with nitrate (isosorbide dinitrate) for people who have heart failure with reduced ejection fraction.

Question 24

In patients who are still symptomatic despite appropriate first line treatment with ACEI/ARB, BBlocker and Aldosterone antagonist, what can be added to the treatment?

Answer 24

Digoxin may be added - especially useful in patients with heart failure and AF Ivabradine (inhibits the funny current and more effective when higher heart rate) can be given in patients with a heart rate >75bpm who remain symptomatic or in patients who cannot tolerate the BBlocker

Question 25

Drug management of HFrEF * First line therapy * ACEI/ARB (can change to hydralazine + nitrate if not tolerated) plus BBlocker * Add spironolactone (or epleronone) if symptoms continue Add digoxin or ivabradine if symptoms continue Other drug treatments which are considered in the management of heart failure is salcubitril valsartan What is sacubitril valasartan and when can it be given?

Answer 25

Sacubitril/valsartan (an angiotensin receptor neprilysin inhibitor (ANRI)) may be used in those who still have symptoms when on an ACEI, Bblocker, and aldosteron antagonist Sacubtiril is a neprilysin inhibitor - an enzyme that does many things including breakdown of BNP Valasartan is an an ARB

Question 26

What are the side effects of sacubitril/valasartan (brand name entresto)?

Answer 26

Side effects include Hyperkalaemia (Same as in an ACEi or ARB) Renal dysfunction Hypotension Contraindicated in pregnancy

Question 27

We have now fully discussed the medical management of heart failure with preserved or reduced ejection fractions What are the options should maximum medical management not manage to control the symptoms of heart failure? (refractory to medical treatment)

Answer 27

Consider cardiac resynchronisation therapy improves synchonrisation of cardiac contraction Consider mechanical assist device eg Left ventricular assist device - assists the pumping of blood through the left ventricle to the aorta Consider heart transplantation

Question 28

ACUTE HEART FAILURE Acute heart failure is often used exclusively to to mean new-onset or decompensation of chronic heart failure characterised by pulmonary and/or peripheral oedema What is the treatment of acute heart failure?

Answer 28

Give O2 Give loop diuretic - frusemide Give GTN spray to vasodilate CPAP may be required if patient continues to worsen - helps drive the fluid out of the alveolar spaces TREAT UNDERLYING CAUSE - just like in chronic heart failure

Question 29

What is cardiogenic shock and why may it occur?

Answer 29

Cardiogenic shock is a state of inadequate tissue perfusion primarily due to cardiac dysfunction. It may occur suddenly or after progressively worsening heart failure

Question 30

What drug can be given to treat cardiogenic shock if after investigations, the heart is thought to be well/over filled - a sign of it failing to pump properly?

Answer 30

Dobutamine - B1 agonist provides inotropic support by increasing contractility of the heart muscle