Heart Failure

Question 1

Outline the New York Heart Association’s classification of heart failure

Answer 1

I - No limitation of physical activity. Systolic dysfunction on echo

II - Slight limitation of physical activity. No distress at rest

III - Significant limitation of physical activity. No distress at rest

IV - Unability to carry out physical activity without distress. Symptoms at rest

Question 2

List some causes of HF

Answer 2

IHD

Valvular heart disease

Hypertension heart disease

Congenital heart disease

Cardiomyopathy

Cor pulmonale

Pericardial disease

Question 3

What is the mechanism of orthopnoea?

Answer 3

Shift of blood volume into the central circulation causes increased pulmonary capillary pressure > more oedema

Question 4

Outline the principles of long term management of HF?

Answer 4

Reduce venous pressure (without significantly reducing CO)

Block the renin-angiotension system

Block sympathetic NS stimulation

Treat underlying and precipitating causes

Question 5

What are the long term effects of increase sympathetic NS activation in HF?

Answer 5

Vasoconstriction

Ventricular arrhythmias

Direct toxic affects of adrenaline/noradrenaline

Question 6

Describe the mechanism of the spiral of fluid retention that can occur in HF

Answer 6

Decreased CO > Decrease renal perfusion > Activation of RAAS > Increase fluid and Na retention, K loss

Question 7

At what venous pressure will oedema occur?

Answer 7

>20-30mmHg

Question 8

What are some non-pharmacological intervention in HF?

Answer 8

Cardiac synchronisation with biventricular pacemaker

Implantable cardiac defibrillator

Transplant

Fluid and Na restriction

Light exercise

Smoking cessation

Question 9

Which drug classes are core for the treatment of HF and when is each used (NYHA classification)?

Answer 9

ACEi - NYHA 1-4

B-blockers - NYHA 2-4

Ivabradine - NYHA 2-4 (funny channel blocker in SA node to reduce HR)

Spirolactone - NYHA 3-4

Loop diuretics for symptomatic relief

Question 10

What is the role of calcium channel blockers in HF?

Answer 10

Non-dihydropyridines are not indicated as they provide not protection against pathological remodelling

Dihydropyridines are used for treatment of HTN and angina, they have no long term benefit otherwise

Question 11

How do you management an acute exascerbation of HF?

Answer 11

Admit

Resus, fluid and Na restriction

Diuresis to achieve fluid balance with loop diuretics

GTN to dilate coronaries and reduce preload

Morphine for anxiolytic effect

Inotrophic drugs - Digoxin

Question 12

Which beta-blockers are used in HF?

Answer 12

Metoprolol

Bisoprolol

Carvedilol

Question 13

How does treatment of diastolic HF differ from systolic?

Answer 13

ACEi, Beta-blockers, and ARBs demonstrate no mortality benefit

Mainstay of treatment is control of risk factors