Download Question 1

Case 1052: Heart Failure
Authors and Affiliations
Dr Michael Cilento
Dr Josephine Thomas
Royal Adelaide HospitalThis case focuses on the investigation and management of heart failure
Case Overview
Learning Objectives
†¢ Definition of heart failure
†¢ The symptoms and clinical signs of heart failure
†¢ Relevant investigations in assessment of heart failure
†¢ A focus on the pharmacological management and evidence
†¢ The importance of a holistic approach to treatment
†¢ Poor prognosis following a diagnosis of heart failure
Question 1 : FT
Question Information:
A 72 year-old woman presents to hospital after waking at night with shortness of breath.
On history you find she recently moved from interstate. While living interstate 7 months ago she had a
NSTEMI underwent percutaneous coronary intervention (PCI) with a drug-eluting stent (DES), she does
not have a GP or cardiologist in her new hometown yet.
Further history reveals that over the past few months she has been experiencing increasing shortness
of breath throughout the day as well. She becomes breathless walking to the shop at the end of her
road (about 100m), and finds she tires much more easily when hanging out the washing. Her ankles are
always swollen by the end of the day.
Recently she has been sleeping on 3 pillows, on the night of presentation she awoke gasping for breath
and stood by an open window to get some fresh air. Her breathing did not improve and thus she rang
an ambulance.
Question:
You suspect she now has heart failure, define heart failure.
Choice 1: null Score : 0
Choice Feedback:
The definition of CHF is somewhat controversial. Below are some popular key definitions:Heart failure is
a complex clinical syndrome that can result from a structural or functional cardiac disorder that impairs
the ability of the ventricle to fill or eject blood.
†“ Journal of Cardiac Failure, June 2010
CHF is a complex clinical syndrome with typical symptoms (e.g. dyspnoea, fatigue) that can occur
at rest or on effort, and is characterised by objective evidence of an underlying structural abnormality or
cardiac dysfunction that impairs the ability of the ventricle to fill with or eject blood (particularly during
physical activity). A diagnosis of CHF may be further strengthened by improvement in symptoms in
response to treatment.
- National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (Chronic
Heart Failure Guidelines Expert Writing Panel). Guidelines for the prevention, detection and
management of chronic heart failure in Australia. Updated October 2011.
A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of
haemodynamic, renal, neural and hormonal responses.
†“ Poole-Wilson, 1987
Question 2 : SC
Question Information:
The New York Heart Association (NYHA) provides a simple way of classifying a patient's symptoms
based on the impact they have on their daily function. Although it is difficult to predict prognosis in an
individual, patients with symptoms at rest (NYHA class IV) have a 30†“ 70% annual mortality rate,
whereas patients with symptoms with moderate activity (NYHA class II) have an annual mortality rate of
5†“ 10%.
As a reminder...
your patients history reveals that over the past few months she has been experiencing increasing
shortness of breath throughout the day as well. She becomes breathless walking to the shop at the end
of her road (about 100m), and finds she tires much more easily when hanging out the washing. Her
ankles are always swollen by the end of the day
Question:
Based on this history provided which NYHA classification are her symptoms most consistent with over
the last few months?
Choice 1: NYHA I: No limitation of physical activity. Score : 0
Choice Feedback:
Ordinary physical activity does not cause undue fatigue, palpitations, dyspnoea, or anginal pain.
"I feel fine"
Choice 2: NYHA II: Slight limitation of physical activity. Score : 1
Choice Feedback:
They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or
anginal pain.
"It's hard getting up the stairs"
Choice 3: NYHA III: Marked limitation of physical activity Score : 0
Choice Feedback:
They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal
pain.
"I'm alright if I'm sitting down"
Choice 4: NYHA IV: Inability to carry on any physical activity without discomfort Score : 0
Choice Feedback:
Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity
is undertaken, discomfort is increased.
"I can't get out of bed"
Question 3 : MS
Question Information:
You perform a clinical examination of your patient.
Question:
Which of the following signs result predominantly from right ventricular dysfunction?
Choice 1: Bibasal crepitations on lung auscultation Score : 0
Choice Feedback:
a sign of pulmonary congestion
Choice 2: Raised JVP Score : 1
Choice Feedback:
raised due to the increased venous pressure which is a reflection of right heart preload
Choice 3: Oedema Score : 1
Choice Feedback:
may be apparent in the form of bilateral lower limb oedema, sacral oedema, ascites, or small pleural
effusions
Choice 4: Hepatomegaly Score : 1
Choice Feedback:
due to increased venous pressures transmitted by the hepatic vessels
Choice 5: Displaced apex beat Score : 0
Choice Feedback:
the apex beat becomes displaced primarily as a result of dilatation of the left ventricle
Question 4 : FT
Question Information:
Performing an ECG is an essential part of the assessment of a patient with suspected heart failure.
Question:
What features might you expect to see on the ECG of your patient with heart failure?
Choice 1: null Score : 0
Choice Feedback:
There are no specific features that will 'confirm' a diagnosis of heart failure on ECG. However there are
some common findings which may point to evidence of old ischaemia, hypertrophy, and in some
instances rhythm disturbances.
General findings: increased QRS voltage; increased QRS duration; left axis deviation; repolarization
(ST-T) changes.
Cornell voltage criteria for ECG diagnosis of LVH:
†¢ For men: S in V3 plus R in aVL >2.8 mV (28 mm)
†¢ For women: S in V3 + R in aVL >2.0 mV (20 mm)
Question 5 : MS
Question Information:
As part of the 'work-up' of this patient a chest x-ray is performed.
Question:
Cardiomegaly (greater than the width of one hemithorax) is a feature you may see in left ventricular
failure. Which of the following features may also be seen in this patient?
Choice 1: Hyperexpansion of lungs Score : -1
Choice Feedback:
this is a feature of COPD
Choice 2: Upper lobe venous diversion Score : 1
Choice Feedback:
a reflection of increased venous pressures
Choice 3: Kerley-B lines Score : 1
Choice Feedback:
fine peripheral septal lines that reflect interstitial oedema; named after Peter J Kerley (an English
radiologist who also described Kerley-A and Kerley-C lines on CXR)
Choice 4: Flattening of the hemidiaphragms Score : -1
Choice Feedback:
this is a feature of COPD
Choice 5: Bilateral effusions Score : 1
Choice Feedback:
small bilateral pleural effusions can be seen in heart failure, unilateral or grossly asymmetrical effusions
require careful consideration of potential differential diagnoses
Choice 6: Bat's wing sign Score : 1
Choice Feedback:
the term "Bat's wing" is sometime used to describe perihilar alveolar oedema, typically a finding of acute
pulmonary oedema.
Question 6 : FT
Question Information:
You next order a panel of blood tests that will all be useful in the initial evaluation of a patient with heart
failure. Use the free text area to briefly state how each test will help in your assessment.
Question:
The blood tests you order are:
†¢ Complete blood exam (CBE)
†¢ Serum electrolytes, urea and creatinine (EUC)
†¢ Liver function tests (LFT)
†¢ Fasting glucose
†¢ B-type natriuretic peptide (BNP)
Choice 1: null Score : 0
Choice Feedback:
CBE †“ may identify concurrent or alternate diagnoses, anaemia and infection may exacerbate heart
failure
EUC †“ baseline measurements necessary when initiating diuretics or ACEi, hyponatraemia can be a
marker of severe HF (although may be the result of excessive diuresis), renal impairment may
contribute to heart failure
LFT †“ may be deranged secondary to hepatic congestion
Glucose - Diabetes mellitus (DM) increases the risk of heart failure (HF) independent of coronary heart
disease
Plasma BNP - The natriuretic peptides atrial natriuretic peptide (ANP) and B-type natriuretic peptide
(BNP) have diuretic, natriuretic, and hypotensive effects. The release of both ANP and BNP is
increased in heart failure in response to high ventricular filling pressures.
Although not a routine test, an NT-proBNP >1000ug/L suggests heart failure as a cause of
breathlessness.
Question 7 : MS
Question Information:
The most useful and important diagnostic test in the evaluation of a patient with suspected heart failure
is echocardiogram. Measurement of the Left Ventricular Ejection Fraction (LV EF) via echo can confirm
the presence of left ventricular systolic dysfunction.
Question:
What LVEF percentage would confirm the presence of LV systolic dysfunction?
Choice 1: LVEF 55-70% Score : 0
Choice Feedback:
The normal heart pumps just over half the hearts blood volume with each beat, this is the normal range.
Choice 2: LVEF <40% Score : 1
Choice Feedback:
This confirms the diagnosis of heart failure.
However note that someone with 'diastolic heart failure' may have a normal EF. The term 'diastolic heart
failure' is an old term which has now been replaced by 'Heart Failure with preserved systolic function'
(or 'HFPSF') which represents impaired filling of the LV in response to a volume load despite normal
ventricular contraction.
Choice 3: LVEF <35% Score : 1
Choice Feedback:
While of course this value is also below 40% and thus consistent with heart failure, it is important to
note that an EF
An implanted cardiac defibrillator (ICD) may be indicated for these patients.
Question 8 : MS
Question Information:
Echocardiogram confirms this patient has a LV ejection fraction of
You find her past history includes hypertension and dyslipidaemia. She is a current smoker, and drinks
2 glasses of wine per night.
Current medications
†¢ Aspirin + Clopidogrel (100mg/75mg) daily
†¢ Atenolol (50mg) daily
†¢ Atorvastatin (40mg) nocte
†¢ Calcium carbonate (1000mg) daily
Question:
Which of the following changes to her current medication list have been shown to improve mortality?
Choice 1: ceasing Clopidogrel Score : 0
Choice Feedback:
The combination of Aspirin + Clopidogrel is essential in maintaining the patency of her cardiac stent
over the first 12 months following stent insertion. Thereafter aspirin alone is usually sufficient.
Choice 2: commencing an ACE-inhibitor Score : 2
Choice Feedback:
Angiotensin converting enzyme (ACE) inhibitors are the cornerstone of medical therapy in heart failure
with systolic dysfunction (EF
The mortality benefit of ACE-inhibitors is supported by numerous large prospective clinical trials
Trial Reference Drug NYHA Mortality (%change)
CONSENSUS NEJM 1987 Enalapril IV 32.6-52.4 (27%)
SOLVD NEJM 1992 Enalapril II/III 35.2-39.7 (16%)
SAVE NEJM 1992 Captopril I/II 20.4-24.6 (19%)
Choice 3: commencing a loop diuretic (eg. frusemide) Score : 0
Choice Feedback:
A patient presenting with severe heart failure will require frusemide therapy initially. Most symptoms and
signs of heart failure are due to retention of salt and water and the consequent rise in cardiac filling
pressures. Diuretics help control congestive symptoms and signs, however have not been shown to
improve mortality in clinical trials.
Choice 4: commencing an aldosterone-antagonist (eg. spironolactone) Score : 1
Choice Feedback:
An aldosterone antagonist should be considered in any diuretic regimen, as this has been shown to
improve survival and reduce complications. The RALES, EPHESUS, and EMPHASIS-HF trials have
proved that these drugs reduce mortality from progressive heart failure and sudden death.
Aldosterone receptors within the heart can mediate fibrosis, hypertrophy and arrhythmogenesis.
Therefore, blockade of these receptors with agents such as spironolactone, which is traditionally
considered a potassium-sparing loop diuretic, may provide benefit.
Choice 5: changing atenolol to a different beta-blocker Score : 1
Choice Feedback:
Beta-blockers in heart failure have been shown to improve symptoms, reduce mortality, and reverse
cardiac remodeling.
Not all beta-blockers are equal!
Randomised controlled trial data supports the use of carvedilol, bisoprolol, extended release metoprolol
succinate (Metoprolol XL) and nebivolol since these beta blockers have been shown to reduce all-cause
mortality and decrease hospitalization in patients with HF and left ventricular systolic dysfunction (LVEF
≤ 35-40 percent).
For further reading search the following trials: Merit-HF, CIBIS-II, US Carvedilol Trials, Copernicus
Choice 6: increasing statin dose to 80mg Score : 0
Choice Feedback:
Clinical trials (CORONA and GISSI-HF) have evaluated the efficacy of statins on mortality in patients
with systolic heart failure. They found no benefit from initiating statin therapy in patients with
symptomatic systolic heart failure.
However, most patients at the time they develop heart failure will already be on a statin for secondary or
primary prevention of atherosclerotic cardiovascular disease, and should continue it for this indication.
Question 9 : SC
Question Information:
Each patient requires careful consideration of the risks and benefits of commencing a new medication.
Question:
Which of the following is a contraindication for the use of a beta-blocker in heart failure?
Choice 1: Diabetes Score : 0
Choice Feedback:
In patient†™s with heart failure due to systolic dysfunction, a meta-analysis including 1883 diabetics
and 7042 nondiabetics, the survival benefit with beta blocker therapy was significant for both those with
diabetes and for those without.
- Shekelle PG, J Am Coll Cardiol. 2003;41(9):1529.
Choice 2: COPD Score : 0
Choice Feedback:
Beta-1 selective beta blockers (eg, metoprolol or atenolol) appear to be safe in patients with COPD,
even when there is a bronchospastic component. More limited data suggest that non-specific beta
blockade (eg, carvedilol) may be safe in the setting of COPD as well, but less well tolerated in patients
with asthma.
Choice 3: Erectile dysfunction Score : 0
Choice Feedback:
All patients with heart failure should be offered both ACEi and beta-blocker therapy, including older
adults and patients with peripheral arterial disease (without critical limb ischaemia), or erectile
dysfunction.
Choice 4: Asthma Score : 1
Choice Feedback:
Beta-blockers are contraindicated in severe or poorly controlled asthma as they can precipitate
bronchospasm.Beta1-selective beta-blockers (eg metoprolol) may be considered by specialists for
patients with COPD or well-controlled asthma, because they have valuable morbidity and mortality
benefits in heart failure and ACS.
Choice 5: Peripheral vascular disease Score : 0
Choice Feedback:
All patients with heart failure should be offered both ACEi and beta-blocker therapy, including older
adults and patients with peripheral arterial disease (without critical limb ischaemia), or erectile
dysfunction.
Choice 6: None of the above Score : 0
Choice Feedback:
Beta-blockers are contraindicated in severe or poorly controlled asthma as they can precipitate
bronchospasm.
Question 10 : FT
Question Information:
Management of heart failure includes a variety of non-pharmacological measures. One such measure
includes giving your patient an explanation of the heart failure syndrome.
Question:
What other measures or advice will you give your patient?
Choice 1: null Score : 0
Choice Feedback:
The following issues should be addressed as part of a comprehensive approach to heart failure
management:
†¢ Explanation of the heart failure syndrome
†¢ Medication management advice
†¢ Fluid restriction
†¢ Sodium restriction
†¢ Obesity
†¢ Assessment for depression
†¢ Physical activity
†¢ Education on symptom management
The benefits of comprehensive management plans for patients with heart failure include better symptom
control and less need for hospital admission. Therapeutic guidelines provide concise summaries of the
utility of all of the issues in this question, as do the Heart Foundation.
- National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (Chronic
Heart Failure Guidelines Expert Writing Panel). Guidelines for the prevention, detection and
management of chronic heart failure in Australia. Updated October 2011
Question 11 : SC
Question Information:
Australia has an ageing population.
Question:
What is the median survival following a diagnosis of heart failure?
Choice 1: 3-4 years Score : 1
Choice Feedback:
The combination of an ageing population with advances in modern therapeutic interventions has
resulted in an increasing incidence of many chronic diseases, including heart failure. Despite
improvements in therapy, mortality in heart failure remains high.
The two main causes of death in heart failure are sudden arrhythmic death and progressive pump
failure with haemodynamic deterioration
Choice 2: 5-10 years Score : 0
Choice Feedback:
Choice 3: 10-12 years Score : 0
Choice Feedback:
Choice 4: 12-15 years Score : 0
Choice Feedback:
Synopsis
Definition
The definition of heart failure remains somewhat controversial, it is a complex clinical syndrome that
can result from a structural or functional cardiac disorder that impairs the ability of the ventricle to fill or
eject blood. This is accompanied by a typical pattern of haemodynamic, renal, neural and hormonal
responses.
Heart Failure in Australia
An estimated 30,000 Australians are diagnosed with heart failure each year, with the Heart Foundation
stating recurrent admissions cost the national economy more than $1 billion each year.
Differential diagnosis
This clinical case focussed on a patient who developed heart failure as a result of a previous ischaemic
injury. Ischaemic heart disease and hypertension are common precipitants to heart failure. However,
each patient requires an individualised assessment as the differential diagnosis of heart failure or
cardiomyopathy can be extremely broad.
Symptoms and signs
One of the main features of heart failure is a history of progressive dyspnoea, orthopnoea or
paroxysmal nocturnal dyspnoea. Patients may also subjectively notice increasing peripheral oedema.
The assessment of a patient with suspected heart failure requires close examination of the cardiac and
respiratory systems. The hallmark clinical findings are predominantly a result of ventricular failure,
venous congestion, and fluid overload.
Investigations
Simple investigations provide a wealth of information in the initial assessment of a patient with
suspected heart failure. The ECG can give clues to left ventricular hypertrophy and old ischaemic injury.
At presentation the CXR often reveals typical features of pulmonary congestion and cardiomegaly.
While †˜ routine†™screening of complete blood picture, biochemistry, liver enzymes and fasting
glucose can give clues to precipitating or concurrent diseases.
Echocardiography
Ultrasound imaging of the heart with echocardiography is the most useful diagnostic test in the
evaluation of a patient with suspected heart failure. Measurement of the Left Ventricular Ejection
Fraction (LV EF) can confirm the presence of systolic dysfunction (EF
It is important to recognise the clinical syndrome previously known as †˜ diastolic heart failure†™,
which is now known as †˜ Heart Failure with Preserved Systolic Function†™(HF-PSF). This
syndrome represents patients who clinically have heart failure but a normal ejection fraction.
Pharmacological management
A number of medications have been shown in large clinical trials to improve mortality in patients with
heart failure with systolic dysfunction (EF
†¢ ACE inhibitors
†¢ Beta-blockers (bisoprolol, carvedilol, long-acting metoprolol)
†¢ Aldosterone antagonists
In the acute setting patients will require diuresis (often intravenously), and may require longer-term oral
diuretics to help with symptoms of fluid overload, eg:
†¢ Loop diuretics (eg. frusemide)
Therapy should also include appropriate primary or secondary prevention of cardiovascular disease,
often this may include:
†¢ Antiplatelet therapy (eg. aspirin, clopidogrel)
†¢ Anticoagulation (eg. warfarin, where there are appropriate indications)
†¢ Lipid management (eg. statins)
Comprehensive management approach
As with any chronic disease the most effective management plans for heart failure patients include a
multi-modal approach. This should aim to empower patients with knowledge of the disease, provide
them medication management advice, and support them in aiming to decrease their cardiovascular risk
and maintain physical activity.
Large hospitals often have access to specialist heart-failure nurses to help facilitate a holistic approach
to care. The Heart Foundation also has a number of excellent resources for patients.