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Define heart failure

A syndrome of impaired ability to maintain sufficient cardiac output to meet the body's requirements (Normal CO is 5-25L/min).


How can heart failure be classified?

  • Ejection fraction
    • HF w/ reduced ejection fraction (HF-REF): LVEF <40%
    • HF w/ preserved ejection fraction (HF-PEF)
  • Acute vs chronic
  • New York Heart Association (NYHA) functional classification


What is congestive heart failure?

HF with evidence of sodium and water retention


List three complications of heart failure

  • Arrhythmias: esp. AF and ventricular arrhythmias
  • Depression
  • Cachexia
  • CKD
  • Sexual dysfunction
  • Sudden cardiac death


Give five causes of heart failure

  • Myocardial disease: CAD; Cardiomyopathy (dilated is commonest); HTN
  • Valvular heart disease
  • Pericardial disease
  • Congenital heart disease
  • Arrhythmias
  • High output state: eg. anaemia; thyrotoxicosis; sepsis; cirrhosis
  • Volume overload: CKD; nephrotic syndrome
  • Obesity
  • Drugs: alcohol; cocaine; NSAIDs; B-blockers; CCBs


Outline the NYHA classification of heart failure


Suggest three symptoms of chronic heart failure

  • ​Exertional dyspnoea
  • Dyspnoea at rest
  • Orthopnoea
  • Nocturnal cough
  • Paroxysmal nocturnal dyspnoea
  • Oedema; weight gain
  • Fatigue; reduced exercise tolerance
  • Light headedness; syncope


Suggest five signs of chronic heart failure

  • Tachycardia
  • Laterally displaced apex beat; cardiomegaly
  • S3 or S4 (gallop rhythm)
  • HTN
  • Raised JVP
  • Hepatomegaly
  • Tachypnoea; basal crepitations; pleural effusion
  • Dependent oedema; ascites
  • Obesity


Request three investigations for suspected heart failure

  • NT-proBNP
    • 400ng/L+: Specialist assessment and echocardiography
  • 12-lead ECG
  • CXR
  • FBC; U+Es; LFTs; TFTs; HbA1c; fasting lipids
  • Urine dipstick
  • Lung function tests
  • SPECT or PET: MI as underlying cause of heart failure
  • Cardiac MRI
  • Cardiac biopsy if cardiomyopathy suspected
  • Exercise test: predicts admission and mortality 24hr


What radiological findings are seen in a CXR with heart failure?


What are the symptomatic management options for suspected heart failure?

Loop diuretics if symptoms are sufficiently severe, any of:

  • Furosemide 20-40mg OD
  • Bumetanide 0.5-1.0mg OD
  • Torasemide 5-10mg OD

Add thiazide-like diuretics if loop diuretics become inadequate

Monitor daily U+Es due to risk of hypokalaemia


Provide three lifestyle advice and modifications in heart failure management

  • Education: esp. weight monitoring and adjusting diuretic doses
  • Consider salt and fluid restriction; avoid salt substitutes with K+
  • Smoking and alcohol cessation
  • Cardiac rehabilitation
  • Vaccinations: Annual influenza vaccine; one time pneumococcal vaccine
  • Cannot drive large lorries and buses if symptomatic


Outline the first-line medical treatment of chronic HF-REF

  • ACEi and Beta-blocker
    • Start one, add second once patient is stable
  • Monitor U+E; eGFR; and BP prior to starting ACEi
  • Consider
    • ARBs if ACEi intolerance
    • Hydralazine + nitrate plus specialist input if ACEi and ARB intolerance


Outline second-line medical treatment of chronic HF-REF

Add spironolactone to previous ACEi + Beta-blocker therapy


What specialist treatments are available for HF-REF

  • Ivabradine
  • Sacubitril valsartan
  • Hydralazine + nitrate
  • Digoxin
  • ICD; cardiac resynchronisation therapy


What management changes are needed for HF-REF with co-morbid CKD?

  • CKD 1-3 (eGFR 30+): offer standard treatment
    • CKD (eGFR <45): lower doses/slower titration of ACEi/ARB
  • CKD 4-5 (eGFR <30): renal input


List five causes of acute heart failure

  • Acute complication of MI
  • Exacerbation of HTN or valvular heart disease
  • Arrhythmias
  • Failure of prosthetic heart valve
  • VSD
  • Cardiomyopathy
  • Negative inotropic drugs
  • Acute myocarditis
  • Pericardial disease
  • Left atrial myxoma


Describe four presenting features of acute LV failure

  • Acute dyspnoea
  • Cough + pink frothy sputum
  • Orthopnoea and PND
  • Collapse; cardiac arrest; shock
  • Autonomic: Pale, sweaty, tachycardia (gallop rhythm)
  • Fine basal bilateral crepitations


Request two investigations for suspected acute heart failure

  • BNP or NT-proBNP
  • CXR
  • ECG
  • Echo


Outline the initial management of acute LV failure

  • A-E assessment
  • Sit upright
  • High-flow oxygen 100% 15L/min
  • IV Furosemide 40-80mg
    • Closely monitor U+Es; weight; urine output
    • Consider adding spironolactone
  • Consider CPAP
    • Acute presentation; failure to respond; deteriorating
  • Treat underlying cause and any associated problems