Heart failure

Question 1

Define what is meant by heart failure

Answer 1

This is a state where cardiac output is inadequate for the body tissue requirements

Question 2

What is the 2 main underlying pathophysiological causes of heart failure ?

Answer 2

Heart failure results from structural or functional impairment of ventricular filling or ejection of blood

Impairment of left ventricular filling:

• In diastole, the left ventricle (LV) walls relax allowing for filling of the LV cavity
• Without proper LV relaxation, the volume of blood filling the cavity is reduced, thus reducing the stroke volume, the volume of blood ejected with each contraction

Impaired ejection of blood:

• Due to LV wall damage, the LV may have reduced ability to pump or eject the blood

Question 3

What are the causes of heart failure ?

Answer 3

• Coronary Heart Disease (± MI)
• Hypertension
• Diabetes
• Dilated Cardiomyopathy
• Valve disease
• Tachycardic arrhythmias (poorly controlled AF)

Question 4

What are the 2 main types of heart failure presentations ?

Answer 4

Acute & chronic heart failure

Question 5

Define what is meant by acute heart failure

Answer 5

• Acute heart failure (AHF) is life-threatening emergency. AHF is a term used to describe the sudden onset or worsening of the symptoms of heart failure.
• Thus it may present with or without a background history of pre-existing heart failure. AHF without a past history of heart failure is called de-novo AHF.

Question 6

Define what is meant by chronic heart failure

Answer 6

If the symptoms have been going on for some time, it is called chronic heart failure.

Question 7

What are the classical symptoms of heart failure?

Answer 7

SOB

Difficulty breathing at night when recumbent:

1. Orthopnoea
2. Paroxysmal nocturnal dyspnoea

Reduced exercise tolerance

Fatigue

Tiredness

Question 8

What are the classical signs of heart failure?

Answer 8

Neck exam:

• Elevated JVP

Auscultation of the lungs:

• Rales or crackles (bibasal)

Auscultation of the heart:

• Third or fourth heart sound (S3 or S4) sometimes called a gallop rhythm
• Murmur

Oedema in dependent areas:

• Sacrum
• Feet/ankles/lower legs

Question 9

What are the 4 grades of the The New York Heart Association (NYHA) functional classification of heart failure?

Answer 9

• I = Heart disease present, but no physical limitations or dysponea from ordinary activity
• II = Comfortable at rest, slight limitations of physical activity & dysponea on ordinary activities
• III = Comfortable at rest, but marked limitations of physical activity & less than ordinary activities causes dysponea
• IV = dysponea at rest, all activities cause discomfort

Question 10

What should you initially do in all patients with suspected heart failure?

Answer 10

• Thorough history & exammination
• ECG, CXR, blood tests (including FBC, TFT’s, LFT’s, lipid profile, HbA1c, Troponin), Urinalysis, Peak flow or spirometry and a measurement of serum natriuretic peptides (NT-proBNP or BNP)

Question 11

A level of NT-proBNP or BNP makes a diagnosis of heart failure likely ?

Answer 11

NT-proBNP >400

BNP ≥100

Question 12

A NT-proBNP level of what rules out heart failure?

Answer 12

• NT-proBNP < 300ng/L
• BNP < 100

Question 13

If someone following initial investigations for heart failure has a level of NT-proBNP > 400 what is done to diagnose heart failure?

Answer 13

Transthroacic echocardiogram (2-D echocardiogram with Doppler)

Question 14

What causes of heart failure can an ECG help indentify ?

Answer 14

• Arrhythmias (irregular heart rhythms)
• Past myocardial infarction (MI)
• Left ventricular hypertrophy

Question 15

What signs on a CXR are suggestive of heart failure and how do you remember it ?

Answer 15

Remeber the signs by ABCDE

Question 16

What information do you get on transthoracic echo about heart failure ?

Answer 16

• Chamber size
• Right and left ventricular function
• Regional wall motion abnormalities (evidence of MI)
• Evidence of impaired LV filling (i.e., stiffness of the walls), a feature of diastolic dysfunction
• Valvular heart disease
• Diseases of the pericardium
• Ejection fraction

Question 17

What is the ejection fraction ?

Answer 17

• EF is the percentage of blood that is pumped out of the heart during each beat
• A normal EF is ≥50%

Question 18

What is the important of ejection fraction when assesed on echo in relation to heart failure and what are the 2 categories of heart failure based on ejection fraction ?

Answer 18

1. Heart failure with an EF ≤40% is known as heart failure with reduced ejection fraction (HFrEF)
2. Heart failure in the setting of a normal EF is known as heart failure with preserved ejection fraction (HFpEF)

Ejection fraction is key in dictating the management of heart failure

Question 19

What happens in heart failure with a preserved and a reduced ejection fraction ?

Answer 19

Question 20

Define what is meant by heart failure with a preserved ejection fraction (HFpEF)

Answer 20

• The diagnosis of Heart failure with Preserved Ejection Fraction is based on the clinical finding of congestive heart failure with the echo findings of preserved left ventricular ejection fraction and the absence of valvular abnormalities.
• LEVF ≥ 50%

Question 21

What is the generic lifestyle management of heart failure (both presrved and reduced EF)?

Answer 21

• Supervised personalised exercise-based rehabilitation programme
• Avoid salt (<6g/day) & restrict water (1.5-2L)

Question 22

What vaccinations should be given to all patients with heart failure ?

Answer 22

• A one off pnuemoccocal & annual influence
• Pnuemoccocal given every 5 years if asplenia, splenic dysfunction or CKD

Question 23

If any patient with heart failure develops signs/symptoms of fluid overload or congestion what should be given ?

Answer 23

Diuretics - typically a loop diuretic e.g. furosemide but sometimes a thiazide duiretic will suffice if fluid retention is very mild

Question 24

If a person with heart failure develops iron def. anaemia with a Hb between 9.5-13.5 what should they be given ?

Answer 24

IV iron (ferric carboxymeltose)

Question 25

What is the 1st & 2nd line pharmacological treatments of HFrEF?

Answer 25

* 1st line = ACEi & beta-blocker (if intolerant of ACEi give ARB, if intolerant of both then give Hydralazine & isosorbide dinitrate) * 2nd line = add MRA (spironolactone) if symptoms continue

Question 26

What should be measured in patients being started on an ACEi & after each dose increase?

Answer 26

Urea, Creatinine, electrolytes & eGFR

Question 27

Why are patients with heart failure typically intolerant of an ACEi or ARB?

Answer 27

Due to renal dysfunction or hyperkalaemia

Question 28

What are the 3rd line treatment options for HFrEF?

Answer 28

Either one or more of the following options: * Swab ACEi &/or ARB with sacubitril/ valasartan if ongoing symptoms * Add digoxin if still symptomatic **esp if they have AF** * Add hydralazine + isosorbide dinitrate if Afrocarribean & still symptomatic * Add Ivrabradine if they have had a previous hosp admission within 12 months & have been stabalised for ≥ 4 weeks (must have sinus rhythm, HR ≥75 & LEVF ≤ 35% * Consider ICD or cardiac resynchronisation therapy if LVEF ≤ 35% (esp if concurrent LBBB or prolonged QRS duration)

Question 29

What patents with HF does Ivrabradine not work in ?

Answer 29

If they have AF

Question 30

What is the treatment of HFpEF?

Answer 30

Tx = manage co-morbid conditions + given a personalised exercise based cardiac rehabilitation programme

Question 31

What is the treatment of end-stage refractory heart failure and its indications/contraindications ?

Answer 31

Consider referral for LVAD/cadiac transplantation Indications: * Refractory cardiogenic shock * Documented dependence on IV inotropic support to maintain adequate organ perfusion * Peak VO2 \< 10 ml / kg / min * Severe symptoms of ischemia not amenable to revascularization * Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities Contraindications: age, severe comorbidity