CVS: Heart Failure

Question 1

What are the typical symptoms of heart failure?

often non-specific

Answer 1

• SOB on exertion, at rest, when lying flat (orthopnoea), nocturnal cough, PND
• Fluid retention: ankle oedema, sudden weight gain
• Fatigue, decreased exercise tolerance.
• Lightheadedness, syncope
• Palpitations

NICE suggests further investigations for anyone with breathlessness, fatigue or ankle swelling

Question 2

What are risk factors for HF, which should be asked about?

Answer 2

• IHD, previous MI
• HTN
• AF
• Diabetes
• Drugs, alcohol
• Family history of HF, or sudden cardiac death under age 40.

Question 3

What signs on examination would suggest HF?

Answer 3

• tachycardia, irregular HR
• laterally displaced apex beat
• heart murmurs
• 3rd or 4th heart sounds (gallop rhythm)
• HTN
• Raised JVP
• Enlarged liver (engorged)
• tachypnoea, bibasal fine creps, pleural effusions
• Ankle oedema, sacral oedema, ascites
• Obesity

Question 4

Which investigations should be done in all patients with suspected HF?

Answer 4

• N-terminal pro-B-type natiuretic peptide level (NT-pro-BNP) first line
• 12 lead ECG

when the LV is stretched, the concentrations of NT-proBNP increase markedly.

Question 5

What NT-proBNP level suggests urgent referral to specialist and ECHO needed? How soon should they be seen?

Answer 5

> 2000 ng/litre

Should be seen within 2 weeks.

Question 6

What level of NT-proBNP suggests need for referral to specialist and ECHO within 6 weeks?

Answer 6

400–2000 ng/L

These patients may well have a raised NT-proBNP secondary to heart failure

Question 7

What NT-proBNP result would make a diagnosis of HF unlikely?

Answer 7

<400 ng/litre

• In an untreated patient- diagnosis of HF less likely
• Look for alternative causes for the symptoms
• If still concerned - discuss with specialist

Question 8

BNP has high sensitivity and NPV, but has variable specificity. What does this mean?

Answer 8

• it is very good at ruling HF out if it is <400.
• But other factors can cause raised BNP as well as HF

Question 9

What other factors can raise the BNP?

Answer 9

• Age over 70 years.
• Left ventricular hypertrophy, myocardial ischaemia, or tachycardia.
• Right ventricular overload.
• Hypoxia.
• Pulmonary hypertension.
• Pulmonary embolism.
• Chronic kidney disease (eGFR< 60 )
• sepsis.
• Chronic obstructive pulmonary disease (COPD).
• Diabetes mellitus.
• Liver cirrhosis.

Anything that would increase cardiac load, or the heart muscle to be overstretched

Question 10

Which factors can lower the BNP level?

Answer 10

• Body mass index (BMI) greater than 35 kg/m2 (obesity)
• Drugs (the prognostic meds): including diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin-II receptor antagonists (AIIRAs), beta-blockers, and mineralocorticoid receptor antagonists (such as spironolactone).
• African-Caribbean family origin.

Question 11

Which other investigations should be done in primary care for suspected HF?

Answer 11

• ECG
• CXR
• Blood tests: U&E, FBC and iron studies (transferrin saturation and ferritin), TFTs, LFTs, HbA1c, lipid profile.
• Urine dipstick for blood and protein.
• peak flow and/or spirometry.

Question 12

What are the different types of heart failure?

Answer 12

• heart failure with reduced ejection fraction (HFrEF)
• heart failure with preserved ejection fraction (HFpEF)
• right heart failure (secondary to chronic lung disease)

Question 13

What is the ejection fraction?

Answer 13

• a measurement, expressed as a percentage
• of how much blood the left ventricle is able to pump out with each contraction
• e.g. an ejection fraction of 60% means that 60% of the total amount of blood in the left ventricle is pushed out with each heart beat

Question 14

How is HFpEF different to HFrEF?

Answer 14

• HFrEF - the left ventricle is unable to pump out all the blood - usually due to problem with the ventricle muscle. e.g. after MI
• HFpEF - the muscle does not relax properly to allow filling, even though contraction is normal, to give a normal EF.
• They can have the same signs and symptoms.

Normal EF is >50%

Question 15

What is first line treatment for heart failure with reduced EF?

Answer 15

• ACEI and BetaBlocker
• start one at a time
• Use ACEI first if diabetes or signs of fluid overload.
• B-blocker should only be started once person is stable (no fluid overload or hypotension)
• Do not start ACEI in valve disease (until been assessed by specialist)
• Give ARB if cannot tolerate ACEI (due to cough)
• start low and titrate up ACEI

Question 16

How should ACEI be monitored?

Answer 16

• start low and titrate up ACEI
• check U&E and BP first then 1-2 weeks after starting treatment. Check U&E 1-2 weeks after each dose increment.
• Once stable, check U&E every month for 3 months and then 6 monthly and at any time if the person becomes acutely unwell.
• Check BP 4 weeks after each dose increase

Question 17

Which B-blockers are licensed for treatment of HF in the UK?

Answer 17

• bisoprolol, carvedilol, and nebivolol.

Question 18

What advice should be given to patients starting a B-blocker for heart failure?

Answer 18

• symptoms may worsen, but then should improve slowly over 3-6 months.
• seek medical advice if worsening fatigue, weight gain, or SOB
• do NOT stop them suddenly - risk of rebound myocardial ischaemia or arrhythmias- seek specialist advice 1st

Question 19

What should be done if the HR decreases to 50 bpm or less on a beta blocker for HF?

Answer 19

• half the dose
• seek specialist advice if severe deterioration
• review other drugs that slow HR (digoxin, diltiazem, verapamil)
• ECG - exclude Heart Block

Question 20

What should be done if BP is low on B-blocker for HF?

Answer 20

• may not need to change if asymptomatic
• if symptomatic - stop nitrates, CCBs, reducing diuretic dose if no sign of fluid overload.
• Specialist advice if symptoms persist.

Question 21

What should be done if HF is clinically deteriorating on B-blocker?

Answer 21

• For increased fluid overload — increase diuretic. If this does not work, consider halving the dose of beta-blocker.
• For marked fatigue — halve the dose of beta-blocker, review pt in 1–2 weeks, and seek specialist advice.
• For serious deterioration — halve the dose or stop the beta-blocker and seek specialist advice.
• Review the person in 1–2 weeks and if there is no improvement, seek specialist advice.

Question 22

What is the target dose of bisoprolol for HF?

Answer 22

10mg OD

Question 22

What are the contraindications for B-blockers?

Answer 22

• severe asthma
• severe bradycardia (HR <60)
• second or third degree Heart block (unless Pacemaker in place)
• uncontrolled HF - severe congestion (need diuretics 1st)
• sick sinus syndrome
• Systolic BP <90, or symptomatic hypotension
• severe PAD
• prinzmetal’s angina
• frequent hypoglycaemia

Question 23

What is the treatment for fluid overload in heart failure?

Answer 23

• loop diuretic
• if HFpEF - offer low to medium dose loop diuretic (<80mg furosemide a day). If no response - request specialist advice

Question 24

If a patient with HFrEF remains symptomatic on ACEI and B-blocker, which medication can be added in?

Answer 24

* mineralocorticoid receptor antagonist (MRA. e.g. spironolactone)

Question 25

What vaccinations should people with HF be offered?

Answer 25

Annual flu vaccine Pneumococcal (only needed once)

Question 26

What advice should HF patients be given about salt intake?

Answer 26

* avoid excessive salt (<5g salt each day which is 2.5g sodium) * Do not use salt substitutes - often high in potassium

Question 27

What advice should HF patients be given about fluid balance?

Answer 27

* severe symptomatic heart failure should restrict fluid intake (less than 1.5–2 L a day to relieve symptoms, or consider a weight-based fluid restriction such as 30 mL/kg body weight) * advise to monitor weight at home- same time of day. If gain >2kg in 3 days - seek medical advice/increase diuretic

Question 28

What should HF patients do if acutely unwell e.g D&V?

Answer 28

* maintain fluid intake * stop ACEI, ARB, diuretic and MRA until they recover and are eating and drinking normally * seek medical advice

Question 29

What advice should be given to HF patients about driving?

Answer 29

* group1 - can continue to drive as long as no distracting symptoms, and no symptoms at rest (NYHA I, II, III). No need to notify DVLA. MUST STOP if symptoms distract or NYHA IV - symptoms at rest and NOTIFY DVLA. * group 2 - Can drive if LVEF >=40% and NYHA I or II - no distracting symptoms and no symptoms at rest - MUST NOTIFY DVLA. MUST STOP if distracting symptoms NYHA III or IV. Can re-license if LVEF >=40% and NYHA I or II with controlled syx. ## Footnote also specific regs for angina, LBBB, ICDs

Question 30

When should a patient be referred for specialist treatment (MDT HF team or cardiology)?

Answer 30

* BNP >2000 -refer within 2 weeks * BNP 400-2000 - refer within 6 weeks. * NYHA class IV (severe HF) * No responding to treatment in 1ry care * Valvular heart disease * LVEF <=35%

Question 31

If a patient with HFpEF has worsening symptoms despite loop diuretic, what should be done?

Answer 31

* refer for specialist advice * Dapagliflozin and empagliflozin are options for treating symptomatic chronic heart failure with preserved or mildly reduced ejection fraction on the advice of a heart failure specialist.

Question 32

When can people can be regarded as being in end-stage heart failure?

Answer 32

if they are at high risk of dying within the next 6–12 months.

Question 33

What are common symptoms and signs of end stage HF?

Answer 33

* Pain. * Breathlessness. * Persistent cough. * Fatigue. * Limitation of physical activity. * Depression and anxiety. * Constipation. * Loss of appetite and nausea. * Oedema. * Insomnia. * Cognitive impairment. * Low BP * Not tolerating prognostic medications * Escalating diuretics - no longer working * Hospitalisations * End-organ dysfunction - renal * Increasing Defib shocks by ICD.

Question 34

How should people with HF be followed up in 1ry care?

Answer 34

* dedicated HF MDT * at least every 6 months if stable * consider BNP monitoring if <75years to guide drug treatment * monitor symptoms: SOB, oedema, syncope/presyncope - if any presyncope/syncope - refer cardio (may be due to VT) * Check HR and examine heart - ECG if arhythmia. Fluid status. * Assess function with NYHA classification * Assess for anxiety/depression * Nutrition * medication R/V * cardiac rehab referral * Imms UTD * Monitor U&E every 6 months * contraceptive/pregnancy advice

Question 35

What is quadruple therapy in HFrEF?

Answer 35

* Beta blocker * ACEI/ARB/ARNI (angiotensin receptor/neprilysin inhibitor e.g. entresto) * MRA (mineralocorticoid antagonist- spironolactone) * SGLT2i (sodium-glucose co-transporter 2 (SGLT2) inhibitors - dapagliflozin) * They are medications which improve prognosis - should all be offered unless specific contraindications. * Start all 4 at low dose, following up with repeat U&E and BP in 1-2 weeks, and uptitration. This gives a better chance of heart remodelling, reduced symptoms, improved function on ECHO and improved QoL.

Question 36

What are the contraindications to SGLT2-inhibitor (dapagliflozin)?

Answer 36

* eGFR <15 * severe hepatic impairment * T1DM - due to high risk of it causing DKA * Urogenital infection/perineal abscess/fournier's gangrene. * Recurrent UTIs/urosepsis/pyelonephritis

Question 37

What is the NYHA classification for HF? | 4 stages

Answer 37

1. NYHA I: asymptomatic, no limitation to ordinary physical activity (walking, climbing stairs) 2. NYHA II: mild symptoms. Slight limitation during ordinary physical activity. 3. NYHA III: moderate symptoms. Marked limitation - symptoms with less than ordinary exercise e.g walking short distances. Only comfortable at rest. 4. NYHA IV: severe symptoms. Symptoms at rest.