Clinical Management of Heart Failure

Question 1

What is required for an effective cardiac cycle?

Answer 1

Adequate myocardial contractility
Effective Blood supply
Effective conduction system
Effective valve function

Question 2

What is heart failure?

Answer 2

Complex clinical syndrome where the heart in unable to maintain adequate circulation of blood resulting in structural/functional abnormalities to the heart and reduced cardiac output. This must be with symptomatic effects for the patient most commonly dyspnea, odema, paraoxysmal nocturnal dyspnea, fatigue.

Question 3

What are some key signs of heart failure?

Answer 3

Elevated jugular venous pressure
Pulmonary crackles
Peripheral oedema.

Question 4

What are the key features of the pathophysiology of congestive heart failure?

Answer 4

Heart structural and functional abnormalites - cardiac dilation and hypertrophy - ineffective cardiac output
1) systemic and pulmonary venous congestion as unable to drain into heart
2) kidenys activate RAAS - worsens heart strain by increasing pre-load and afterload via salt and water retention increase.
Cause ADH secretion from the brain.
3) Increased sympathetic nervous systemic activity - cause increased HR and attempt to increase contractility - failed, worsends heart work load.
Neuro-hormonal responses only worsend heart failure by increasing demand on heart, can lead to further structural and functional abnormalities.

Question 5

What is the epidemiology behind CHF?

Answer 5

More common in men
Average age of diagnosis is 78 years
Around 200,000 new cases a year

Question 6

What is the prognosis like when diagnosed with CHF?

Answer 6

40% of patients die within 1 year
10% every year after
(this is lower 1yr survival than breast, uterus and prostate cancer)
Patients often have a poor quality of life - 40% suffer from depression.

Question 7

What are some irreversible causes of heart failure symptoms?

Answer 7

Ischaemic heart disease - weakned areas of ischemic damage
Hypertensive heart disease - left ventricle hypertrophy
Lung disease - pulmonary hypertension - right ventricular hypertrophy
Congential heart disease - structural and functional impairment from birth
Genetic cardiomyopathies - Dilated or hypertrophic

Question 8

What are some potentially reversible causes of heart failure symptoms?

Answer 8

Infection - tackle infection without damagin heart tissue - e,g anti-virals
Pregnancy - due to increased blood volume and physiological stress.
Valvular heat disease - replace valve - aortic stenosis

Question 9

What are the reversible causes of heart failure symptoms?

Answer 9

Arrhythmias - reduce CO and increased risk of caridomyopathy
Cardiotoxins - e.g alcohol
Thyroid disease /anaemia - cardiac stress through tachycardia and attempt to increase SV.

Question 10

What some of the different types of heart failure?

Answer 10

Reduced ejection fraction - HFrEF
Preserved ejection fraction - HFpEF
mid range ejection fraction - HFmrEF
systolic v diastolic dysfunction
Left v right
Cor pulmonale
Low output v high output
Valvular
Arrhytmic

Question 11

What are some potential differential diagnosis for CHF?

Answer 11

Characterised by volume overload or dyspnoea
Volule overload - liver disease, acute renal failure, nephrotic syndrome.
Dyspnoea - PE, COPD, chest infection (pneumonia), pulmonary fibrosis,

Question 12

What investigations should be ordered when a patient presents with suspected heart failure as a differential diagnosis?

Answer 12

NT pro-BNP test
Chest x-ray (fluid in lungs and cardiomyopathy)
Complete spirometry
Orders U&Es, FBCs, LFTs and TFT
Complete ECG.
Echocardiogram.

Question 13

What are some typical signs of heart failure?

Answer 13

Elevated jugular venous pressure
Hepatojugular reflux
Third heart sound (gallop rhythm)**
Laterally displaced apical impulse.

Question 14

What are some typical symptoms of heart failure?

Answer 14

Breathlessness
Orthopnoea
Paroxsymal nocturnal dyspnoea
Reduced exercise tolerance
Fatigue, tiredness, increased time to recover after exercise
Ankle swelling

Question 15

What are some less common symptons of heart failure?

Answer 15

Nocturnal cough
Wheezing
Blaoted feeling
Loss of appetite
Confusion
Depression
Palpitations
Dizziness
Syncope
Bendopnea

Question 16

What are some less specific signs of heart failure?

Answer 16

Weight gain
Weight loss
Tissue wasting
Cardiac murmur
Peripheral odema
Pulmonary crepitations
Reduced air entry and dullness to percussion at lung bases (pleural effusion)
Tachycardia
Irregular pulse
Tachypnoea
Hepatomegaly
Ascites
Oliguria
Narrow pulse pressure.

Question 17

What is the purpose of an NT-proBNP test in heart failure?

Answer 17

Higher levels of NT-proBNP indicate heart failure is more likely.
Is easily measurable by blood tests
Note can not be used as a positive diagnosis test
However is levels are below 400 ng/L can be used as a negative test to rule out heart failure.

Question 18

What conditions may cause a raised NT pro_BNP levels?

Answer 18

Heart failure
Acute and chronic renal failure
Hypertension
Pulmonary disease - p HTN, COPD, PE, adult respiratory distress syndrome
All cause stress/stretching on the cardiomycotes.

Question 19

What preventative treatment may be given to a patient with heart failure?

Answer 19

An anti-coagulant - if has an arrhythmia such as A.fib.

Question 20

What is the key information that an echocardiogram would test us when investigation a patient with suspected heart failure?

Answer 20

Ejection fraction %
Hear rate and rhythm
Conclusion on RV and LV thickness and structural changes, also functional ability.
Valvular abnormalities

Question 21

How can heart failure be classified by ejection fraction?

Answer 21

reduced ejection fraction - less than or equal to 40%
mid range ejection fraction - between 40-50%
preserved ejection fraction - more than or equal to 50%

Normal ejection fraction - 50 to 70% is considered normal.

Question 22

Should a patient with severe odema be given IV or oral diuretics?
Why?

Answer 22

IV
Higher bioavailability - will help to clear the fluid overload faster.

Question 23

What are some more advanced tests that may be done to work out the severity/confirm CHF?

Answer 23

Cardio MRI
Stress echo

Question 24

What are the two different ways that drugs for CHF may be thought of?

Answer 24

Symptomatic - diuretics, oxygen
Prognostic - cardiac glycosides, ARNI

Question 25

What drugs are evidence for heart failure management?

Answer 25

ACEi, ARB, BB, MRA, Avabradine, ARNI, SGLT2 - all decrease mortality and morbidity Note BB and MRA have no evidence that they improve quality of life, all the others do.

Question 26

How should we manage patient with a HFrEF?

Answer 26

First line should be a class 1 drug: ACEi/ARNI, beta blocker, MRA, dapagliflozin/empagliflozin (SGLT2 inhibitor), loop diuretic for fluid retention. If LVEF is below 35% and QRS <130ms if appropriate should offer an ICD. This is a class I recommendation in ischemia pathology and a class IIa in a non-ischemic pathology. If LVEF <35% and QRS >130ms - offer cardiac resynchronization therapy. Class one recommendation is QRS more than 150, class IIa is between 130 and 149. If LVEF is above 35% or divide therapy not indicated/appropriate consider therapies with class II recommendations.

Question 27

What is the ESC evidence class for heart failure?

Answer 27

Ranks each treatment/intervention for how useful it could be based on clinical evidence in certain conditions - hence if it should be recommended Class I - is beneficial, useful, effective - is recommended Class II - conflicting evidence about usefulness - IIa should be considered and IIb may be considered Class III - treatment is not useful and may cause harm - is not recommended.

Question 28

What beta blocker is recommended in CHF?

Answer 28

Bisporolol - is more cardioselective than atenolol. Atenolol - may have some effect at beta 2 despite being beta 1 selective B - taken once a day as longer half life, A - take multiple times a day B - metabolised in liver A - more risk for kidney.

Question 29

What are the four pillars in the treatment of heart failure?

Answer 29

Use of four different drug classes - all classes should be used in a patient, should be gradually introduced and titrated up to maximal tolerated dose if possible Four classes are: ARNI, BB, MRA, SGLT2i

Question 30

How many times are each of the four key drug classes tirated in a CHF patients journey?

Answer 30

ARNI - twice (three dif doses total) BB - four doses total (three titrations) MRA - two doses total (two tirtarations) SGLT2i - one dose total - dose not need titrating.

Question 31

How often is a patient on medication for CHF reassessed?

Answer 31

Whilst being titrated on medications every 2-4weeks for an increase in dose/change of dose Once receiving all medications at maximum tolerated dose may be reviewed in 3 months - may consider non-medical treatment options such as ICD to help patient.

Question 32

What are some of the problems with titrating medication in patients with CHF?

Answer 32

Risk of hypotension, postural hypotension, kidney injury. Takes a long period of time, must start again if one medication is changes/stopped (often by GP or in hospital appointment outside and unrelated to cardiologist work)

Question 33

What are some potential non pharmacological management plans for patients with CHF?

Answer 33

Devices: Cardiac Resynchronisation Therapy (CRT pacing) Implantable Cardioverter Defibrillator (ICD) Advanced HF therapy offered at specialist centre - LVAD (bridge to transplant) then a transplant.

Question 34

What are the treatment guidelines for CHF patients with a minimally reduced ejection fraction? 40-50%

Answer 34

Class I - Diuretics, dapagliflozin/empagliflozin (SGLT2i) Class IIb - ACEi/ARNI/ARB, MRA and BB

Question 35

What CHF patients tend to have a preserved ejection fraction?

Answer 35

More common in women Older Wide range of mulit-morbidities

Question 36

What are the treatment recommendations for a CHF patients with a preserved ejection fraction?

Answer 36

Diuretics for fluid retention Dapagliflozin/empagliflozin Treamtne for aetiology - CV and non-CV co-morbidities.

Question 37

What are some non-pharmacological management stratergies for CHF?

Answer 37

Abstinence - smoking, alcohol Salt restrictions Fluid restrication Weight loss/healthy diet Heart failure rehab - recommended by NICe for all HF patients, if tolerable, improve symptoms.

Question 38

What does the disease progression of heart failure tend to look like?

Answer 38

Difficult to predict, patients tend to have frequent admissions to hospital with a poor quality of life, may suffer from depression/anxiety. Some patients will receive palliative care. Before treatment low - increases in most at treatment starts - Tends to be slow but steady decline - causing long term limitations of function - with some periods of rapid decline during serious episodes - recovers from most episodes until fatal episode. Difficult to predict what episode will be fatal. A LVAD or transplant can restore function to near maximal.

Question 39

What is the disease trajectory like for a demantia patient?

Answer 39

Prolonged dwindling Low level of functioning for a long period of time Slowly decreases until death,

Question 40

What is the disease trajectory like for most cancer patients?

Answer 40

High qualit of life for most of the time With a short period of evident decline, just before death, smooth and steady decline to death.