Heart Failure

Question 1

Classifications of HF

Answer 1

left - right
acute - chronic
low output (heart issue) - high output (high O2 demand)
reduced EF/systolic - preserved EF/diastolic

Question 2

Left sided HF symotoms

Answer 2

Dyspnoea and poor ETT 
Fatigue
Orthopnea and PND 
Nocturnal cough, wheeze 
Nocturia (ask during the day decresed renal plasma flow and at night when lying this increases = more filtration)
Cold peripheries

Question 3

Right sided HF symptoms

Answer 3

peripheral oedema
ascites
Nausea and anorexia (due to hepatic congestion)
facial engorgement, neck pulsitation - large A wave
expstaxis (due to increased pressure)

Question 4

Precipitants to HF?

Answer 4

Cardiac:

• arrhythmia
• MI
• valvular disease/rheumatic HD
• LHF causing RHF
• HTN
• cardiomyopathy/congential

Respiratory

• COPD (cor pulmonale)
• PE

Medications:

• stopping diuretics
• Meds causing salt retention (NSAIDs)

Other:

• anaemia
• thyrotoxicosis
• infection or fever
• anaesthesia/surgery

Question 5

Risk factors for HF

Answer 5

HTN, lyperlipidaemia, DM, smoking, obesity, inactivity, CAD, family Hx, high EtOH (dilated cardiomyopathy), haemochromotosis

Question 6

HF examination:

Answer 6

RHF = pitting oedema, JVP, ascites, heptomegaly (congestion) 
LHF = cyanosis, cool peripheries, crackles in lung bases, stony dullness (effusion)
BOTH= murmur, conjunctival/palor crease pallor, AF, parasternal heave, cheyne-stokes breathing, displaced apex, S3 (low pitched @ apex)
lying standing BP
?pacemaker or defib 
cardiac cachexia (weight loss due to HF)

Resp exam
PVD exam

Question 7

Diagnosis and classification

Differentials?

Answer 7

NYHA class I-IV
DD: nephrotic syndrome, liver disease, if only LHF think of any lung disease (eg. pneumonia, COPD)

Question 8

Investigations

Answer 8

Bloods:

• Hb to exclude anaemia
• Electrolytes and Creatinine = hyperkalaemia causing arrhythmia, hyponatraemia indicating severe long standing cardiac failure
• BNP can distinguish cardiac vs non
• Cr and eGFR ?renal failure as a cause or consequence and ok to take medications
• TFT ?thyrotoxicosis as precipitant

Imaging:
CXR - abcde

Other:

• daily weights
• ECG - ?arrhythmia, ?old infarct, ?LVH or LBBB
• ECHO - estimate EF and help identify cause
• coronary angiography +/- ETT to exclude CAD
• RV biopsy (rare)

Question 9

Management: acute and semi-acute

Answer 9

ACUTE:
sit up right, morphine, O2, GTN, Frusemide +/- thiazide, DON’T GIVE Beta Blockers

Semi-Acute:

• rate control arrhythmia (ICD or metoprolol)
• thrombolysis for acute infarct
• CABG or angioplasty for ischaemia
• med review
• control thyroid disease
• valve replacement
• transfusion for anaemia

Question 10

NP chronic management?

Answer 10

bed rest if unwell 
low salt diet 
fluid restrict (1-1.5L) 
control other CVD risk factors 
annual influenza vaccine
educate around symptoms and have action plan for exacerbations
ACP/Resus

Question 11

P chronic management

Answer 11

1. Frusemide
2. ACEi or Beta Blocker
3. add other
4. spironolactone
5. ARB/digoxin/anticoag

• ARB if ACEi not tolerated
• Avoid Ca channel blockers (negative inotrope)
• Avoid NSAIDs - can worsen renal function

Symptom improvement:
diuretics, beta blockers, ACEi, hydralazine + nitrate, dig, spiro

Survival benefit:
beta blockers, ACEi, hydralazine + nitrates, spironolactone