CVS 10 Heart Failure - Investiagtions + Management

Question 1

Classifications of heart failure

Answer 1

Class I
Class II
Class III
Class IV

Question 2

Describe Class I heart failure

Answer 2

No symptomatic limitation of physical activity

Question 3

Describe Class II heart failure

Answer 3

Slight limitation of physical activity
Ordinary physical activity results in symptoms
No symptoms at rest

Question 4

Describe Class III heart failure

Answer 4

• Marked limitation of physical activity
• Less than ordinary physical activity results in symptoms
• No symptoms at rest

Question 5

Describe Class IV heart failure

Answer 5

• Inability to carry out physical activity without symptoms
• May have symptoms at rest
• Discomfort increases with any degree of physical activity

Question 6

Key points for investigating heart failure

Answer 6

• history, clinical examination, investigations
• type of heart failure - HFrEF, HFpEF, LV/RV, high output cardiac failure
• cause of heart failure - IHD, hypertension etc.

Question 7

Types of management of heart failure

Answer 7

• Symptomatic treatment - furosemide
• Prognostic treatment - HFrEF only

Question 8

Prognositic treatment of heart failure

Answer 8

• cardiac rehabilitation
• ACE inhibitors/AngII receptor blockers
• Beta blockers
• Mineralcorticoid receptor antagonist e.g. spironolactone
• Sacubitril valsartan, SGLT2 inhibitors
• Biventricular pacemaker or defibrillator

Question 9

Effect of IV furosemide

Answer 9

Venodilatory effect immediately
Onset diuretic action 30 mins, peaks 60-90mins - decreases circulating volume > decreases afterload > increases CO

Question 10

Monitoring of IV furosemide

Answer 10

HR
BP
CXR
pO2
Fluid balance
Hourly urine output
Daily weights - 1kg loss per day aim

Question 11

Effects of beta blockers

Answer 11

Decrease HR
Decrease BP - reduced CO > lower O2 demand
Reduced mobilisation of glycogen
Negate unwanted effects of catecholamines

Question 12

Investigations for heart failure

Answer 12

FBC - check for anaemia
U+E
Brain natriuretic peptide
ECG
Chest X ray
Echocardiogram
Coronary angiography

Question 13

Why do you want to check for anaemia on a FBC in relation to heart failure?

Answer 13

Anaemia can worsen heart failure
Increased work of heart to meet O2 demand

Question 14

What is brain natriuretic peptide produced by?

Answer 14

Stretching of ventricles
To try reduce BP by increasing Na + fluid loss

Question 15

What does an elevated brain natriuretic peptide level suggest?

Answer 15

Heart failure

Question 16

Management of acute heart failure

Answer 16

O2
IV furosemide
Heparin
Ventilators support
IV nitrates secondary

Question 17

Management of chronic heart failure

Answer 17

• Correct underlying cause
• **non pharmacological treatment:
  -Reduce salt intake
  -Increase aerobic exercise
  -Reduce alcohol intake
• Pharmacological therapy:
  -ACE inhibitors
  -ARB
  -B blockers
  -Aldosterone receptor antagonist - spironlactone
  -Diuretics

Question 18

Aim of pharmacological therapy of chronic heat failure

Answer 18

Reduced afterload
Increase CO

Question 19

What is the best way to diagnose pulmonary oedema?

Answer 19

Chest X ray

Question 20

Patient presents with symptoms of heart failure at rest, what classification of heart failure is this?

Answer 20

Class IV

Question 21

Non pharmacological treatment of chronic heart failure

Answer 21

• reduce salt + liquid intake
• avoid salt substitutes
• reduce alcohol

Question 22

What is the mechanism of action of Sacubitril?
What drug is it often co prescribed with?

Answer 22

• neprilysin inhibition
• inhibitors natriuretic inactivating enzyme > increases effects of ANP/BNP > natriueiss
• stops bradykinin breakdown > vasodilation
  .
• valsartan (ARB)

Question 23

What addition meds can be given is first line treatment of heart failure isn’t successful

Answer 23

• Sacubitril valsartan
• ivabradine
• digoxin
• hydralazine + nitrate (especially if Afro-Caribbean)