Case 9 - Congestive Cardiac Failure - Progress Test

Question 1

What are the types of AF?

Answer 1

Paroxysmal - (lasts for less than 7 days and self-resolves. Must have over two episodes)

Persistent - (lasts for over 7 days and doesn’t self-resolve)

Permanatent - (cannot or deemed inappropriate to be cardioverted - treat with rate control and anticoagulation)

Question 2

When should rhythm control be used over rate control in AF?

Answer 2

Coexistent heart failure
First onset AF
Obvious reversible cause of AF

Question 3

What is first line rate control management of AF?

Answer 3

Beta blocker or calcium channel blocker (diltiazem)

Question 4

What is second line rate control management of AF?

Answer 4

2 of:

• beta blocker
• diltiazem
• digoxin

Question 5

When should cardioversion be used straight away in AF?

Answer 5

AF began less than 48 hours ago.

Heparin should be given prior to cardioversion

Question 6

How are patients cardioverted?

Answer 6

Electrical cardioversion or

Pharmacological cardioversion with flecainide / amioderane

Question 7

How long should patients be anticoagulated for before cardioversion in AF of longer than 48 hours in duration?

Answer 7

3 weeks

Question 8

After a patient with AF of duration > 48 hrs has been cardioverted, how long should they remain on oral anticoagulants?

Answer 8

at least 4 weeks

Question 9

What factors would favour a rate control strategy in AF?

Answer 9

> 65

History of ischaemic heart disease

Question 10

What factors would favour a rhythm control strategy in AF?

Answer 10

< 65 
Symptomatic 
First presentation 
Lone AF or secondary to a corrected cause 
Congestive heart failure

Question 11

How is stroke risk calculated in AF?

Answer 11

CHA2DS2-VASc score

determines if a patient should be anticoagulated

Question 12

What anticoagulation should be given to patients in AF?

Answer 12

Warfarin / NOAC

Question 13

In acute stroke patients, without haemorrhage, who have AF, when should anticoagulation be started?

Answer 13

2 weeks post stroke

Question 14

What is the most common causative organism of infective endocarditis?

Answer 14

Staph. aureus

Question 15

What is the most common causative organism of infective endocarditis if there in an indwelling line?

Answer 15

Staph. epidermidis

Question 16

What is the most common causative organism of infective endocarditis in the developing world?

Answer 16

Strep. viridans

Question 17

What are risk factors for developing infective endocarditis?

Answer 17

50% of cases occur in those with normal heart valves (commonly affecting the mitral valve)

Rheumatic fever

Prosthetic heart valve

IVDU (commonly affects the tricuspid valve)

Recent piercings

Question 18

How are cardiac murmurs graded?

Answer 18

(Levine scale)

1 - very faint 
2 - faint 
3 - easily audible, no thrill 
4 - loud, with trill 
5 - very loud, often heard over a wide area, with thrill 
6 - heard without a stethoscope

Question 19

What are common causes of heart failure?

Answer 19

• Coronary heart disease
• Hypertension
• Ischaemic heart disease
• Valvular disease
• Congenital heart disease
• Uncontrolled AF
• Thyrotoxicosis
• Anaemia
• Heart block
• COPD
• Pulmonary fibrosis
• Recurrent PE
• Primary pulmonary hypertension
• Alcohol and chemotherapy
• Chronic pericarditis (TB, lupus, viruses)
• Autoimmune conditions (eg. amyloidosis, sarcoidosis)
• Pregnacy enduced cardiomyopathy
• Acute viral myocarditis

Question 20

How is heart failure classified?

Answer 20

NYHA class I - no symptoms, no limitations on physical activity

NYHA class II - mild symptoms, slight limitation on physical activity

NYHA class III - moderate symptoms, marked limitation of physical activity

NYHA class IV - severe symptoms, unable to carry out any physical activity without discomfort

Question 21

What are causes of acute heart failure?

Answer 21

Cardiac ischaemia
Viral myopathy
Toxins
Valve dysfunction

Most common precipitating causes of decomensated heart failure are:

• acute coronary syndrome
• hypertensive crisis
• acute arrhythmia
• valvular disease

Question 22

How is acute pulmonary oedema managed?

Answer 22

Sit patient upright
Give 100% oxygen unless CO2 retention

Consider small increments of IV diamorphine or morphine if associated chest pain

Give IV furosemide 50mg (or double normal dose if already on oral diuretics)
Repeat diuretics after 30mins to 1 hr - give double 1st dose
If further diuretic required, refer to senior staff

Give IV GTN at 0.5mg/hr and titrate according to BP.
Only give if systolic BP > 90

Consider CPAP or NIV if poor response

Consider IV inotropes or invasive ventilation if not responding

Question 23

What drugs should be given to manage heart failure?

Answer 23

1st line:
ACE-i + Beta blocker
(start one at a time)

2nd line:
Aldosterone antagonist

3rd line:
(should be started by a specialist)
- Ivabradine (sinus rhythm > 75 bpm + EF < 35%)
- sacubitril-valsartan (EF < 35%, if not responding to ACE-i and beta blocker)
- digoxin (use if coexistent AF)
- hydrazline + nitrate (useful in Afro-Caribbean patients)
- cardiac resynchronisation therapy (indicated if wide QRS)

Question 24

What vaccines should be offered in heart failure?

Answer 24

Annual influenza vaccine

One off pneumococcal vaccine

Question 25

What are signs of heart failure?

Answer 25

Pulmonary oedema / pleural effusion 
Raised JVP 
Pitting oedema 
Ascites 
Tachycardia 
S3 gallop

Question 26

What criteria should be used to diagnose infective endocarditis?

Answer 26

Modified Duke criteria