Heart Failure

Question 0

How should the cause of heart failure be investigated?

Answer 0

Bloods: FBC, UandEs, glucose, lipids, TFTs, cardiac enzymes

CXR - support evidence for HF, excludes other diagnoses

Urinalysis

Lung function tests

Question 1

What is the NYHA classification if heart failure severity?

Answer 1

Class 1 - no symptoms on ordinary physical activity

Class 2 - slight limitation of physical activity by symptoms

Class 3 - less than ordinary activity leads to symptoms

Class 4 - inability to carry out any activity without symptoms

Question 2

How should diagnoses be confirmed in a patient either previous Mi?

Answer 2

Patient should be referred for cardiologist assessment and Doppler echocardiography within two weeks

To assess:
Overall systolic function
Diastolic function
LV wall thickness
Valvular disease
Estimation of pulmonary artery systolic pressure

Question 3

How should diagnosis of heart failure be confirmed if no previous MI?

Answer 3

Measure BNP and NTproBNP

BNP >400 - refer for Echo in 2 weeks
BNP 100-400 - refer for echo in 6 wks
BNP <100 - heart failure unlikely

Question 4

What patient advice should be given in heart failure

Answer 4

Smoking cessation
Weight loss
Reduce salt intake
Avoid excessive dehydration
Monitor fluid retention by weighing self - if unexpected weight gain >3kg in three days, seek advice!
Reduce alcohol
Exercise (unless class 4)
Oxygen required for plane travel if class 3
May have sexual problems
Flu and pneumococcal jabs

Question 5

What are the two main types of heart failure?

Answer 5

Heart failure due to left ventricular systolic dysfunction

Heart failure with preserved left ventricular ejection fraction

Question 6

What is the management of heart failure with preserved ejection fraction?

Answer 6

Manage comorbid conditions such as:
Hypertension
IHD
DM

Consider specialist referral

Question 7

What is the treatment of heart failure due to left ventricular systolic dysfunction?

Answer 7

1st line:
Offer ACEI and beta blocker

2nd line:
Consider adding AT2 antagonist
Consider aldosterone antagonist
Consider diuretic for fluid retention
Consider digoxin

Question 8

Which patients with heart failure should receive ACEI?

Answer 8

All patients with LVEF of 40% or less

Question 9

Which patients with HF shod receive beta blockers?

Answer 9

Patients with symptomatic HF and LVEF <40%

All patients on diuretics and ACEI, even if asymptomatic

Question 10

What are contraindications for ACEI?

Answer 10

Angioedema
RAS
Hyperkalaemia
Renal impairment
Aortic stenosis

Question 11

How should ACEis be used

Answer 11

Check UandEs prrior to treatment and 1-2 weeks after

Recheck UandEs at 1, 3, 6 months after achieving maintenance dose

Start ramipril 2.5mg and titrate dose up if no problems

If renal function worsens, eliminate nephrotoxic drugs such as NSAIDs, can reduce dose or stop ACEI if creatinine rises

Question 12

How should diuretics be used?

Answer 12

Loop diuretics eg furosemide, bumetanide provide symptomatic relief

Start low and titrate upwards based on clinical response

Side effects:
hypokalaemia
hypovolaemic
Uraemia
Circulatory collapse

Question 13

What beta blockers might be used in HF?

Answer 13

Bisoprolol
Carvedilol
Metoprolol
Nebivolol

Question 14

What are the contraindications to beta blockers?

Answer 14

Asthma
2nd/3rd degree heart block
Sick sinus syndrome
Bradycardia

Question 15

How should beta blockers be used in HF?

Answer 15

Initiate at low dose, increase every 2-3 weeks

Monitor BP and HR with dose increases

Do not abruptly stop - increases risk of MI/arrhythmia

Question 16

How should at2 antagonists be used in HF?

Answer 16

Eg candesartan, valsartan

Indications: if intolerant of ACEI

Contraindications:
not with ACEI and beta blockers in HF inadequate renal function

Must monitor renal function and UandEs

Question 17

When should spironolactone be used in HF?

Answer 17

In all patients without renal dysfunction or hyperkalaemia

Question 18

What type of drugs are spironolactone and eplerenone?

Answer 18

Mineralocorticoid/aldosterone receptor antagonists

Question 19

How should spironolactone be monitored?

Answer 19

Monitor renal function and UandEs at one week and four weeks

Monitor monthly for first three months

Question 20

What are the side effects of spironolactone?

Answer 20

GI disturbances
Hyperkalaemia
Breast tenderness or enlargement

Question 21

How should digoxin be monitored?

Answer 21

Monitor UandEs

Maintain potassium at 4-5 mmol

Do not monitor routinely, but it may be necessary

Question 22

Which patients with HF should have warfarin?

Answer 22

If comorbid atrial fibrillation or thromboembolism

Question 23

Which patients with HF should have aspirin?

Answer 23

If HF with comorbid coronary heart disease

Question 24

When are calcium channel blockers indicated in HF?

Answer 24

HF with hypertension/angina

Amlodipine NOT verapamil or diltiazem

Question 25

When should implantable cardioverter defibrillators be considered in HF?

Answer 25

In patients with serious ventricular arrhythmia, eg survived VT/Vfib

In those who have LVEF <40% but expected survival with good functional status of over a year

In patients with familial cardiac conditions with high risk - QT syndrome, HOCM, brugada

Question 26

What are the options for post discharge management of HF?

Answer 26

Clinic based service:
In hospital outpatient department
Often nurse led

Home based service:
Programme with self-help manual and facilitator support
For low to moderate risk patients

Question 27

How should patients with HF be monitored?

Answer 27

Monitor at least 6 monthly
Assess:
Functional capacity
Fluid status
Cardiac rhythm
Cognitive status
Nutritional status
Review drug treatment - side effects, need for changes
Serum urea, electrolytes, creatinine, eGFR

Question 28

When is cardiac desynchronisation therapy used in HF?

Answer 28

For patients with mild (NYHA 2) symptoms as well as those more severely symptomatic

May be considered when:
Sinus rhythm
LVEF <30%
QRS is prolonged
ECG shows LBBB

Question 29

How many patients with HF die within four years of diagnosis?

Answer 29

50%