Heart failure

Question 1

three main underlying causes of heart failure

Answer 1

coronary artery disease
diabetes mellitus
hypertension

Question 2

heart failure may also be called

Answer 2

congestive heart failure CHF
congestive cardiac failure CCF

Question 3

pathogenesis of heart failure

Answer 3

pressure or volume overload increases the work on the myocardium
this is initially compensated by cardiac hypertrophy
chronic overload leads to decompensation where the cardiomyocytes lose their contractility
stroke volume and output is reduced

Question 4

classification by ejection fraction

Answer 4

HFrEF (reduced): <40%, (previously called systolic failure)
HFmrEF (mildly reduced): 40-49%
FHpEF(preserved): >50%, ( previously called diastolic failure)

Question 5

symptoms at presentaton

Answer 5

dyspnoea
cough
fatigue
poor exercise tolerance
ankle swelling

Question 6

signs at presentation

Answer 6

tachycardia
additional heart sounds/murmurs
elevated jugular venous pressure
tachypnoea
bilateral lung base crackles
enlarged liver
peripheral oedema

Question 7

ECG might show

Answer 7

acute or previous ischaemia, arrhythmia and other abnormalities that may suggest causative or exacerbating aetiologies such as IHD

Question 8

laboritory tests

Answer 8

FBC, UECs, LFTs, troponin, BSL
consider serum BNP or NT-proBNP when diagnosis unclear

Question 9

imaging

Answer 9

CXR - classic findings include alveolar oedema, Kerley B lines, cardiomegaly, upper lobe diversion and pleural effusion
echocardiography - can differentiate between HFrEF and HFpEF, s well s highlight other abnormalities or causative factors
may also consider stress testing or cardiac MRI

Question 10

differential diagnosis

Answer 10

for shortness of breath:
- COPD, sleep apnoea
for peripheral oedema:
- venous insufficiency, thrombosis
- CKD and/or nephrotic syndrome
- cirrhosis
- calcium-channel blockers

Question 11

specific treatments for underlying causes

Answer 11

lower blood pressure
revascularisation or drug therapy for coronary artery disease
manage diabetes
arrythmias
excess alcohol intake
use of recreational stimulant drugs
cardaic amyloidosis, haemochromatosis, thalassaemia, chemotherapy toxicity)
valvular heart ddisease
hyperthyroidism
chronic lung disease
pulmonary embolism
pericardial effusion

Question 12

drug therapy for HFrEF

Answer 12

all patients with HfrEF should be started on
ACEI/ARB
beta blocker
aldosterone antagonist
SGLT2
Loop diuretic can be dded to therapy at any stage to control symptoms of congestion

Question 13

when should you add the beta blocker

Answer 13

for patients with clinical signs of congestion (eg. breathlessness, peripheral oedema) defer starting the beta blocker until the patient is euvolaemic

Question 14

how long does starting all the medications take

Answer 14

start all 4 classes of drugs within 2-4 weeks of diagnosis
increase doses of ACEI and BB every 2-4 weeks up to the maximum tolerated dose
start all 4 drugs before starting up titration
optimisation of therapy may take 2-3 months

Question 15

first line choices for ACEI/ARB

Answer 15

either an ACE or sacubitril+valsartan (non-pbs)
ARBs are second line

Question 16

starting the patient on a beta blocker

Answer 16

can initially worsen the symptoms
do not start during acute decompensation or if the patient has congestion
start with low dose and increase gradually
monitor symptoms and measure weight daily

Question 17

what should you monitor during dog optimisation period

Answer 17

symptoms, fluid status, kidney function, electrolyte concentrations

Question 18

beta blocker examples

Answer 18

bisoprolol
nebivolol
metoprolol succinate

Question 19

aldosterone antagonist examples

Answer 19

eg. eplerenone or spironolactone

Question 20

SGLT2 inhibitor examples

Answer 20

dapagliflozin
empagliflozin

Question 21

hyperkalaemia risk

Answer 21

in patients with kidney impairment
the combnation of aldosterone antagonist and renin-angiotensin system inhibitor cn cause life threatening hyperkalaemia
a small rise in serum potassium (within normal range) may occur and may be transient

Question 22

starting an SGLT2

Answer 22

eg. dapagliflozin or empagliflozin

Question 23

when to start a loop diuretic

Answer 23

can be used in patients with heart failure to reduce signs and symptoms of congestion
eg. furosemide or bumetanide

Question 24

how to treat patients with HFpEF

Answer 24

SGLT2 inhibitor eg. empagliflozin and dapagliflozin
this is the only routine drug that should be prescribed for all patients with HFpEF

Question 25

what else might you prescribe for someone with HFpEF

Answer 25

drugs for their comorbidities/underlying causes eg. blood pressure reducing medication, beta blockers for afib or fast resting ventricualr rate or coexisting coronary artery disease

Question 26

lifestyle advice for HF

Answer 26

drug management to support adherance fluid management advice sodium restriction advice - no added salt diet, excessive salt intake can precipitate or worsen heart failure regular assessment for depression - depression is a common comorbidity obesity management advice dietitian input physical activity support

Question 27

drug management advice to support adherance might include

Answer 27

- when and why dose adjustments are needed - adverse events - regurlalry updated drug list should be supplied to care team - do not use NSAIDs or pseudoephidrine

Question 28

fluid mangement advice might include

Answer 28

- use daily weight charts as an indictor of fluid retention - use fluid management program - limit fluid intake to 1.5L per day - manage night time symptoms with recliner or extra pillows

Question 29

complications of HF

Answer 29

pleural effusion acute decompensation of CHF sudden cardiac death acute renal failure chronic renal insufficiency anaemia

Question 30

What common issues are encountered in heart failure management when drug therapy is initiated?

Answer 30

Asymptomatic fall in blood pressure or rise in serum creatinine (up to 30%) or serum potassium (within normal range) ## Footnote These changes may be transient and should be evaluated in the clinical context.

Question 31

What should be considered if a patient on combination therapy has symptomatic hypotension?

Answer 31

Change timing of doses (eg. split into morning and night), review volume status, stop treatments that reduce blood pressure but do not improve outcomes in HFrEF ## Footnote Examples of such treatments include those for prostate enlargement and calcium channel blockers.

Question 32

What is the preferred approach if a patient remains symptomatic with hypotension without congestion?

Answer 32

Reduce the dose of renin-angiotensin system inhibitor (or other vasodilators) and loop diuretic in preference to reducing beta blocker dose ## Footnote This is unless the heart rate is less than 50 beats/minute.

Question 33

What action should be taken if kidney function continues to deteriorate without signs of congestion?

Answer 33

Initially reduce or withhold the loop diuretic cease any NSAIDs ## Footnote Review the patient's volume status and medical therapy.

Question 34

What should be considered for patients with hyperkalaemia?

Answer 34

Ensure no potassium supplement is taken, review diet, decrease dose of renin-angiotensin system inhibitor or mineralocorticoid receptor antagonist ## Footnote Withhold mineralocorticoid receptor antagonist if serum potassium is greater than 5 mmol/L.

Question 35

What is the association between iron deficiency and heart failure?

Answer 35

patients with heart failure are at increased risk of developing iron deficiency Iron deficiency with or without anaemia in heart failure is associated with increased mortality

Question 36

What benefits does intravenous iron therapy provide to patients with HFrEF and iron deficiency?

Answer 36

Improves symptoms, exercise tolerance, quality of life, and may reduce hospitalisation ## Footnote This is applicable for patients with or without anaemia. consider investigations to identify cause of iron deficiency if appropriate