Chronic Heart Failure

Question 1

What is heart failure?

Answer 1

essentially the chronic version of acute heart failure. It is caused by either impaired left ventricular contraction (“systolic heart failure”) or left ventricular relaxation (“diastolic heart failure”).

This impaired left ventricular function results in a chronic back-pressure of blood trying to flow into and through the left side of the heart.

Question 2

There are some key features that patients with chronic heart failure present with:

Answer 2

• Breathlessness worsened by exertion
• Cough. They may produce frothy white/pink sputum.
• Orthopnoea(the sensation of shortness of breathing when lying flat, relieves by sitting or standing). Ask them how many pillows they use at night.
• Paroxysmal Nocturnal Dyspnoea
• Peripheral oedema (swollen ankles)

Question 3

What is Paraoxysmal Nocturnal Dyspnoea (PND)

Answer 3

• Paroxysmal nocturnal dyspnoeais a term used to describe the experience that patients have of suddenly waking at night with a severe attack of shortness of breath and cough.
• Patients will describe waking up and feeling acutely short of breath, with a cough and wheeze. They have to sit on the side of the bed or walk around the room and gasp for breath. They feel like they are suffocating and may want to open a window in an attempt to get air. Symptoms improve over several minutes.

Question 4

PND is caused by a few proposed mechanisms:

Answer 4

• Firstly, fluid settling across a large surface area of their lungs as they sleep lying flat. As they stand up the fluid sinks to the lung bases and their upper lungs clear and can be used more effectively.
• Secondly, during sleep the respiratory centre in the brain becomes less responsive so their respiratory rate and effort does not increase in response to reduced oxygen saturation like it normally would when awake. This allows the person to develop more significantpulmonary congestionandhypoxiabefore waking up and feeling very unwell.
• Thirdly, there is lessadrenalincirculating during sleep. Less adrenalin means themyocardiumis more relaxed and this worsens reduces the cardiac output.

Question 5

Diagnosis of chronic heart failure?

Answer 5

• Clinical presentation
• BNP blood test (specifically “N-terminal pro-B-type natriuretic peptide” – NT‑proBNP)
• Echocardiogram
• ECG

Question 6

Causes of chronic heart failure?

Answer 6

• Ischaemic Heart Disease
• Valvular Heart Disease (commonlyaortic stenosis)
• Hypertension
• Arrhythmias (commonlyatrial fibrillation)

Question 7

First Line Medical Treatment (ABAL)

Answer 7

• ACE inhibitor (e.g.ramipriltitrated as tolerated up to 10mg once daily)
• Beta Blocker (e.g.bisoprololtitrated as tolerated up to 10mg once daily)
• Aldosterone antagonist when symptoms not controlled with A and B (spironolactoneoreplerenone)
• Loop diuretics improvessymptoms(e.g.furosemide40mg once daily)

Question 8

Extra details on medical treatment:

Answer 8

• AnAngiotensin Receptor Blocker (ARB)can be used instead of an ACE inhibitor if ACE inhibitors are not tolerated (for examplecandesartantitrated up to 32mg once daily).
• Avoid ACE inhibitors in patients with valvular heart disease until indicated by a specialist.
• Aldosterone antagonistsare used when there is a reduced ejection fraction and symptoms arenotcontrolled with an ACEi and beta blocker.
• Patients should have theirU&Es monitored closely whilst ondiuretics,ACE inhibitorsandaldosterone antagonists as all three medications can causeelectrolyte disturbances.

Question 9

Additional management (including lifestyle):

Answer 9

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