Chronic heart failure

Question 1

Presentation of chronic heart failure

Answer 1

SOB worse on exertion

Cough - frothy white/pink sputum

Orthopnoea
Paroxysmal nocturnal dyspnoea - ask does the patient ever wake up at night gasping for air?

Peripheral oedema

Question 2

Diagnosis of chronic heart failure?

Answer 2

Clinical presentation

BNP (specifically “N-terminal pro-B-type natriuretic peptide” – NT‑proBNP)

Echocardiogram

ECG

Question 3

Causes of chronic heart failure

Answer 3

Ischaemic Heart Disease

Valvular Heart Disease (commonly aortic stenosis)

Hypertension

Arrhythmias (commonly atrial fibrillation)

Question 4

Management of chronic heart failure

Answer 4

Refer to cardiology specialist

Heart failure specialist nurse input

Medical management (ABAL acronym)

Surgical treatment in severe AS or MR

Also:

• Yearly flu and pneumococcal vaccine
• Stop smoking
• Optimise treatment of co-morbidities

Question 5

What is the medical management of chronic heart failure?

Answer 5

ACE inhibitor - to maximum tolerated up to 10mg OD

• Beta blocker - to maximum tolerated up to 10mg OD
• Aldosterone antagonist when symptoms not controlled with A and B and there is reduced ejection fraction (e.g. spironolactone or eplerenone)
• Loop diuretics - improve symptoms e.g. 40mg furosemide OD

Question 6

If ACEi not tolerated…

Answer 6

Use ARB instead

Question 7

Avoid ACEi in patients with…

Answer 7

Avoid ACE inhibitors in patients with valvular heart disease until indicated by a specialist.

Question 8

What blood monitoring should be done for patients receiving medical management of CCF?

Answer 8

Patients should have their U&Es monitored closely whilst on diuretics, ACE inhibitors and aldosterone antagonists as all three medications can cause electrolyte disturbances.