Heart Failure

Question 1

What is heart failure?

Answer 1

Syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction in which the heart is unable to pump blood at a rate required by metabolizing tissues

Question 2

What is the difference between left and right side heart failure?

Answer 2

Left

• Back up in lungs

Right

• Back up in body

Question 3

What are the causes of left sided heart failure?

Answer 3

IHD/CAD/MI

Valvular disease

Respiratory disease/COPD

HTN crisis

Congenital

Cardiomyopathy

Arrythmia

Question 4

What are the causes of right sided heart failure?

Answer 4

Left

Pulmonary stenosis

Cor-Pulmonale

Question 5

What is the name for heart failure that affects both sides?

Answer 5

Congestive heart failure

Question 6

Describe the presentation of left sided heart failure?

Answer 6

Dyspnoea/Orthopnoea

Fatigue

Bibasal crackles

Cyanosis

Displaced apex beat

Cardiac wheeze

Productive cough with pink frothy sputum, suggesting end stage heart failure

Cardiac cachexia/weight loss

Pulsus alternans

Question 7

Describe the presentation of right sided heart failure?

Answer 7

Ascites and Abdominal distention

Peripheral oedema

Hepatomegaly

Raised JVP

Right ventricular heave

Question 8

What are signs of severe heart failure?

Answer 8

Hypotension

Cool peripheries

3rd and 4th heart sounds

Gallop rhythm

Question 9

What investigations are used in the diagnosis and monitoring of heart failure?

Answer 9

>Brain B Natriuretic Peptide

• If high levels, arrange specialist investigation within 2 weeks
• If low levels, arrange specialist investigation within 6 weeks

ECG

• Left ventricular hypertrophy/long QRS

ECHO

CXR

FBC

• Anaemia

LFTs

• Low albumin

U&E

Cardiac enzymes/troponin

• Rule out MI

Question 10

What is first line investigation for HF?

Answer 10

BNP

Question 11

What is BNP and why is it used in HF diagnosis/monitoring?

Answer 11

B-type natriuretic peptide is a hormone produced mainly by the left ventricular myocardium in response to strain/stretching

High values associated with poor prognosis

Low values suggests effective treatment

Question 12

What factors increase BNP levels?

Answer 12

Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia, including PE
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis

Question 13

What factors decrease BNP levels?

Answer 13

Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists

Question 14

What is a low level of BNP?

Answer 14

<100 pg/ml

Question 15

What is a raised level of BNP?

Answer 15

100-400 pg/ml

Question 16

What is a high level of BNP?

Answer 16

>400 pg/ml

Question 17

What is looked at in an ECHO when assessing HF?

Answer 17

Left ventricular ejection fraction

Question 18

What value is a normal left ventricular ejection fraction?

Answer 18

50-80%

Question 19

What left ventricular ejection fraction suggests mild HF?

Answer 19

40-50%

Question 20

What left ventricular ejection fraction suggests moderate HF?

Answer 20

30-40%

Question 21

What left ventricular ejection fraction suggests severe HF?

Answer 21

<30%

Question 22

What CXR signs are seen in HF?

Answer 22

A: Alveolar oedema, bat wings

B: Kerley B Lines, interstitial oedema

C: Cardiomegaly

D: Dilated veins

Question 23

What is the non-pharmacological management of HF?

Answer 23

Lifestyle modifications

Annual influenza vaccine

Once off pneumococcal vaccine

Question 24

What are the steps in HF management?

Answer 24

1st line

• ACEI or B blockers
• One should be started at a time, use clinical judgement to determine which one
• Use both if reduced LVEF

2nd line

• Aldosterone antagonists

3rd line

• Digoxin

If pharmacological methods fail, cardiac resynchronisation therapy

Question 25

What is the iconic duo in initial HF management?

Answer 25

Bisoprolol and Ramipril

Question 26

What is the mechanism of action of loop diuretics?

Answer 26

Increase the excretion of sodium and water from the kidney

Question 27

Give an example of a loop diuretic

Answer 27

Furosemide Bumetanide

Question 28

Give side effects of loop diuretics

Answer 28

Hypotension Hyponatraemia Hypokalaemia, Hypomagnesaemia Hypochloraemic alkalosis Ototoxicity **Hypocalcaemia and osteoporosis** Renal impairment (from dehydration + direct toxic effect) Hyperglycaemia (less common than with thiazides) Gout

Question 29

Give an example of a K+ sparing diuretic

Answer 29

Spironolactone

Question 30

Give features of digoxin toxicity

Answer 30

N&V Confusion Yellow-green vision Bradycardia, AV block Gynaecomastia

Question 31

When should digoxin concentrations be measured if toxicity is suspected?

Answer 31

8-12 hours of last dose

Question 32

How is digoxin toxicity managed?

Answer 32

Digibind Correct arrhythmias Monitor potassium

Question 33

What B Blockers are most suitable in HF?

Answer 33

Bisoprolol Carvedilol

Question 34

What medications should be avoided in HF?

Answer 34

NSAIDS Verapamil

Question 35

Give the management for acute HF exacerbations

Answer 35

Sit patient upright Oxygen Opiates, reduce dyspnoea and anxiety IV Loop diuretics/furosemide **CPAP**, used if not responding to furosemide Inotropic agents/IV dobutamine, if above fails Mechanical circulatory assistance

Question 36

What scale is used to classify stages of HF?

Answer 36

New York Association Scale Classification

Question 37

Describe stage 1 HF

Answer 37

Asymptomatic, no dyspnoea

Question 38

Desribe stage 2 HF

Answer 38

Mild dyspnoea and slight limitations during ordinary activity

Question 39

Describe stage 3 HF

Answer 39

Marked limitation in ordinary activity, comfortable only at rest

Question 40

Describe stage 4 HF

Answer 40

Dyspnoea at rest, severe limitations on activity