Chronic HF

Question 1

What is the main clinical sign in chronic heart failure?

Answer 1

Pulmonary eodema

Question 2

What is HFrEF and HFpEF?

Answer 2

Heart failure with reduced ejection fraction = when the ejection fraction is less than 50%.

Heart failure with preserved ejection fraction = when someone has the clinical features of heart failure but an ejection fraction greater than 50%. This is the result of diastolic dysfunction, where there is an issue with the left ventricle filling with blood during diastole (the ventricle relaxing).

Question 3

What are the causes of chronic HF? (5)

Answer 3

• Ischaemic heart disease
• Valvular heart disease (commonly aortic stenosis)
• Hypertension
• Arrhythmias (commonly atrial fibrillation)
• Cardiomyopathy

Question 4

What are the key symptoms of chronic HF? (6)

Answer 4

• Breathlessness, worsened by exertion
• Cough, which may produce frothy white/pink sputum
• Orthopnoea, which is breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use)
• Paroxysmal nocturnal dyspnoea (more detail below)
• Peripheral oedema
• Fatigue

Question 5

What signs on examination are seen in chronic HF? (8)

Answer 5

• Tachycardia (raised heart rate)
• Tachypnoea (raised respiratory rate)
• Hypertension
• Murmurs on auscultation indicating valvular heart disease
• 3rd heart sound on auscultation
• Bilateral basal crackles (sounding “wet”) on auscultation of the lungs, indicating pulmonary oedema
• Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck
• Peripheral oedema of the ankles, legs and sacrum

Question 6

What symptom would a patient describe if they have paroxysmal nocturnal dyspnea?

Answer 6

suddenly waking at night with a severe attack of shortness of breath, cough and wheeze.

may describe having to sit on the side of the bed or walk around the room, gasping for breath. They may feel suffocated and want to open a window to get fresh air. Symptoms improve over several minutes.

Question 7

What are the 3 possible causes of paroxysmal nocturnal dyspnea?

Answer 7

Fluid settling across lungs

Respiratory centres in brain become less responsive

Less adrenalin therefore reduced cardiac output

Question 8

What are the 3 main investigations in chronic HF?

Answer 8

ProBNP
ECG
ECHO

Question 9

What is the New York heart association classification?

Answer 9

used to grade the severity of symptoms related to heart failure

Question 10

What is class I of the New York heart association classification?

Answer 10

No limitation on activity

Question 11

What is class II of the New York heart association classification?

Answer 11

Comfortable at rest but symptomatic with ordinary activities

Question 12

What is class III of the New York heart association classification?

Answer 12

Comfortable at rest but symptomatic with any activity

Question 13

What is class IV of the New York heart association classification?

Answer 13

Symptomatic at rest

Question 14

What are the 5 principles of management of chronic HF?

Answer 14

• R – Refer to cardiology
• A – Advise them about the condition
• M – Medical treatment
• P – Procedural or surgical interventions
• S – Specialist heart failure MDT input, such as the heart failure specialist nurses, for advice and support

Question 15

Patient has chronic heart failure and BNP is between 400-2000. When should they have their echo?

Answer 15

Within 6 weeks

Question 16

Patient has chronic HF and bnp is above 2000. When should they have an echo?

Answer 16

Within 2 weeks

Question 17

At what point in chronic HF should echo urgency go from within 6 weeks to within 2 weeks?

Answer 17

When BNP increases above 2000

Question 18

What additional management should be offered in chronic HF? (5)

Answer 18

• Flu, covid and pneumococcal vaccines
• Stop smoking
• Optimise treatment of co-morbidities
• Written care plan
• Cardiac rehabilitation (a personalised exercise programme)

Question 19

What is the first line medical management of chronic HF?

Answer 19

• A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated
• B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated
• A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone)
• L – Loop diuretics (e.g., furosemide or bumetanide)

Question 20

What is the max dose of Ramipril given in chronic HF?

Answer 20

10mg OD

Question 21

What is the max dose of Bisoprolol given in chronic HF?

Answer 21

10mg OD

Question 22

What chronic HF treatment should be avoided in patients with vascular heart disease?

Answer 22

ACEi

Question 23

What additional specialist medical treatments can be given in chronic HF? (5)

Answer 23

• SGLT2 inhibitor (e.g., dapagliflozin)
• Sacubitril with valsartan (brand name Entresto) - need a 36hr washout of ACEi/ARBs before starting this
• Ivabradine
• Hydralazine with a nitrate
• Digoxin