Lecture 10.2 - Investigation and management of heart failure

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Questions and Answers

Which of the following is NOT a diagnostic biomarker for cor pulmonale from COPD?

Holter monitoring

Troponin levels (correct)

Echocardiography

Blood gas analysis

What is the primary goal of patient education and lifestyle changes in heart failure management?

To reduce symptoms

To improve exercise tolerance

To cure heart failure

To modify risk factors (correct)

Which of the following pharmacological interventions has been developed to reduce the progression of heart failure?

Beta blockers

ACE inhibitors

Diuretics

All of the above (correct)

According to the New York Heart Association (NYHA) functional classification, which class is characterized by a marked limitation of physical activity?

Class III Signup and view all the answers

What is the primary purpose of annual flu vaccine and one-off pneumococcal vaccine in heart failure management?

To prevent infections Signup and view all the answers

Which of the following is a key component of supervised exercise-based rehabilitation in heart failure management?

Regular exercise sessions Signup and view all the answers

What is the primary purpose of measuring BNP in patients with suspected heart failure?

To risk stratify patients and determine the urgency of referral Signup and view all the answers

What is the significance of a low N-terminal pro-B-type natriuretic peptide level (< 4000 ng/L) in patients with suspected heart failure?

It has a strong negative predictive value for heart failure Signup and view all the answers

What is the primary investigation for the confirmation of heart failure?

Echocardiography Signup and view all the answers

What is the main determinant of a transthoracic echocardiography (TTE) in patients with heart failure?

Ejection fraction of the heart Signup and view all the answers

What is the significance of an elevated respiratory rate in patients with heart failure?

It is an effect of noradrenaline to maintain cardiac output Signup and view all the answers

What is the purpose of performing a chest X-ray in patients with suspected heart failure?

To assess for cardiomegaly Signup and view all the answers

What is the significance of a displaced apex beat in patients with heart failure?

It is a sign of cardiomegaly Signup and view all the answers

What is the purpose of performing an electrocardiogram (ECG) in patients with suspected heart failure?

To evaluate cardiac rhythm and conduction Signup and view all the answers

What is the significance of a low oxygen saturation in patients with heart failure?

It is a sign of hypoxia Signup and view all the answers

What is the purpose of performing urinalysis in patients with suspected heart failure?

To evaluate kidney function Signup and view all the answers

What is the primary mechanism of action of angiotensin-converting enzyme (ACE) inhibitors?

Prevent the conversion of angiotensin I to angiotensin II Signup and view all the answers

Which of the following medications is NOT a recommended first-line treatment for heart failure with reduced ejection fraction?

Sacubitril/valsartan Signup and view all the answers

What is the primary effect of mineralocorticoid receptor antagonists on the kidney?

Reduce sodium reabsorption Signup and view all the answers

What is the primary benefit of loop diuretics in heart failure?

Reduce symptoms of pulmonary and peripheral oedema Signup and view all the answers

What is the primary mechanism of action of beta blockers in heart failure?

Reduce heart rate and increase ventricular filling time Signup and view all the answers

Which of the following devices is used to monitor heart rate and deliver a strong electrical shock to restore a normal heartbeat?

Implantable cardiac defibrillator Signup and view all the answers

What is the primary benefit of cardiac resynchronisation therapy?

Send electrical signals to ventricles to make them pump together Signup and view all the answers

Which of the following medications may cause dry cough in approximately 20% of patients?

Lisinopril Signup and view all the answers

Study Notes

Management of Heart Failure

Patient education and lifestyle changes are vital parts of overall management, including:
- Stopping smoking
- Making adaptations in the home
- Getting annual flu and one-off pneumococcal vaccines
- Participating in supervised exercise-based rehabilitation
- Screening for depression and anxiety
- Managing co-morbidities
Effective drug therapies have been developed to reduce the progression of heart failure, but it cannot be 'cured'

Classification of Heart Failure

New York Heart Association (NYHA) functional classification:
- Class I: No symptomatic limitation of physical activity
- Class II: Slight limitation of physical activity with no symptoms at rest
- Class III: Marked limitation of physical activity with no symptoms at rest
- Class IV: Inability to carry out physical activity without symptoms
Heart failure can also be classified based on symptoms experienced by patients

Diagnosis of Heart Failure

First step: Take a detailed history and perform a clinical examination
Next step: Measure BNP to risk stratify patients and determine the urgency of referral
Then: Perform an ECG on all patients
Consider further blood tests, chest radiograph, urinalysis, and lung function testing (if alternative diagnosis is suspected)

History Taking in Heart Failure

Exercise tolerance: How far can the patient walk before becoming breathless? Has this changed?
Orthopnoea: How many pillows do they need to sleep? Do they sleep upright in an armchair?
PND: Do they wake in the middle of the night feeling breathless?
Bendopnea: Do they experience SOB when bending forward?
Cough: Is it often dry, pink, frothy, or sputum-rarely?
Weight change: Have they experienced gain or loss?
Comorbidities: Do they influence the presentation, clinical course, prognosis, and response to therapy?
Social and family history

Physical Examination in Heart Failure

General:
- Lower limb swelling
- Breathlessness (especially after stairs)
- Tachycardia
Cardiovascular/Respiratory:
- Displaced apex beat
- Bibasal crackles
- Sacral oedema

Bedside Investigations in Heart Failure

Temperature: Normal
Oxygen saturation: May be hypoxic
Blood pressure: Likely elevated due to hypertension
Respiratory rate: Can be elevated, especially in R heart failure or after exertion
Heart rate: Likely elevated due to the effect of noradrenaline on maintaining CO

Investigations in Heart Failure

Severe symptoms: Need admission to hospital
12-lead ECGs: All patients with suspected chronic heart failure should have an ECG
Blood tests:
- N-terminal pro-B-type natriuretic peptide level
- Urea and electrolytes, eGFR, FBC, iron studies, TFT, LFT, HbA1c, fasting lipids
- Urine dipstick
Chest X-ray

N-terminal Pro-B-type Natriuretic Peptide Level

Cardiac neurohormone synthesized in ventricular cardiomyocytes in response to increased stress on the ventricular wall
Released in equal amounts to BNP but degrades less quickly
Low levels of NT-pro-BNP (< 4000 ng/L) have strong negative predictive value for heart failure (97%)

Blood Tests in Heart Failure

U&E and eGFR: Markers of kidney function
FBC and iron studies: Anaemia (presence of anaemia has a poorer prognosis)
LFT: Marker of hepatic congestion
TFT: Marker of increased metabolic demand

Chest X-ray in Heart Failure

Sensitive marker of cardiomegaly
The heart width should not make up more than 50% of the thoracic window

Echocardiography in Heart Failure

Transthoracic echocardiography (TTE) is the main investigation for confirmation of heart failure
Ejection fraction helps differentiate the type of heart failure
TTE identifies valvular abnormalities, filling abnormalities, and changes in contraction (regional wall motion abnormalities)

Other Possible Investigations in Heart Failure

Cardiac MRI (cMRI): Useful if TTE is non-diagnostic
Coronary angiogram: Identification and treatment of coronary artery disease
Lung function tests: If right-sided heart failure is suspected

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Learn about the diagnosis and management of Chronic Obstructive Pulmonary Disease (COPD), including Holter monitoring, patient education, and lifestyle changes.