Chronic Heart Failure

Question 1

What is systolic heart failure?

Answer 1

Impaired left ventricular contraction

Question 2

What is diastolic heart failure?

Answer 2

Impaired left ventricular relaxation

Question 3

How does chronic heart failure present?

Answer 3

Breathlessness (worsened by exertion)
Cough (+/- frothy white/pink sputum)
Orthopnoea
Peripheral oedema
Paroxysmal nocturnal dyspnoea (PND)

Question 4

What is paroxysmal nocturnal dyspnoea?

Answer 4

Waking up suddenly at night with breathless and cough (+/- wheeze)

Symptoms improve over several minutes of sitting upright and catching breath

Question 5

By what mechanisms is paroxysmal nocturnal dyspnoea thought to be caused?

Answer 5

Fluid settling occurs over a larger area of the lungs as the patient lies flat

During sleep the respiratory centre in the brain becomes less responsive and so does not respond to the decreased O2 saturations as it would if the patient was awake

There is less adrenaline circulating during sleep, therefore the myocardium is more relaxed and the cardiac output is reduced.

Question 6

What are the causes of chronic heart failure?

Answer 6

Ischaemic heart disease
Valvular heart disease
Hypertension
Arrhythmias

Question 7

What is the management for chronic heart failure?

Answer 7

Refer the patient to a cardiac specialist

If NT-probe BNP >2000 nanograms/L then urgent referral to be seen by cardiologist and have echocardiogram within 2 weeks

Explanation and advice regarding condition

Medical management

Surgical management

Input from heart failure specialist nurse

Yearly flu and pneumococcal vaccines

Optimise modifiable risk factors

Optimise treatment of comorbidities

Question 8

What is the medical management for chronic heart failure?

Answer 8

ABAL

ACE inhibitor (e.g. ramipril up to 10mg/day)
Beta blocker (e.g. bisoprolol up to 10mg.day
Aldosterone antagonist (when symptoms aren't controlled with A+B)
Loop diuretics (for symptoms)

Question 9

What can be used in place of an ACE inhibitor if it is not tolerated?

Answer 9

Angiotensin receptor blocker (ARB) - e.g. candasartan