Practice Nurse

Investigation and management of heart failure

Heart failure is a common presenting condition in primary care and this resource covers the presenting features of the condition, its investigation and touches upon its treatment. Again, heart failure is a large component of the Quality Outcomes Framework (QOF). This resource designed around 10 assessment questions tests your knowledge of the investigation and management of typical clinical cases of heart failure. On successful completion of the resource you will be presented with a certificate for 1hr of continuous professional development which can be included in your annual portfolio.

On completion of this resource you should be able to:

Understand the terms used and the clinical presentation of patients presenting with heart failure

Develop a structured approach to the investigation of patients with heart failure

Understand the medical management of patients with heart failure.

On completion of this module you should be able to:

A 72 year old male presents with shortness of breath on exertion and has some problems with shortness of breath on lying down. What is the latter termed?

One might often see in the notes - dyspnoea on exertion, meaning shortness of breath and also orthopnoea ie shortness of breath on lying flat. Other symptoms of heart failure include ankle swelling and paroxysmal nocturnal dyspnoea - getting up in the middle of the night, breathless.

Question 1

A 76 year old male with a history of ischaemic heart disease associated with heart failure attends clinic. He informs you that he is able to walk approximately 100m on the flat before becoming breathless and is able to climb a flight of stairs with difficulty. How would you grade this level of heart failure?

There is the New York Heart Association classification of heart failure which is widely used to grade a patient

Grade 1 relates to no limitation on ordinary physical activity.

Grade 2 is reflected by slight limitation on exertion

Grade 3 is marked limitation of physical activity

Question 2

A 65 year old man attends clinic. Six years ago he had a heart attack but has done well since. However, over the last six months he has become more breathless on exertion and is able to walk approximately 100m on the flat before being breathless. He also informs you that he now needs to sleep with 3 pillows at night as he can become breathless when he lies flat. He currently takes lisinopril, aspirin and bisprolol. On examination, there are no specific abnormalities to find, his blood pressure is 108/74 mmHg and pulse 64bpm regular. Which of the following is the most appropriate approach to his management?

The patient has a previous history of MI and has now appeared to have developed some symptoms of heart failure. According to NICE guidance the patient should be referred for echocardiography and cardiological assessment, to be seen within a two week timeframe.

Question 3

A 75 year old male attends clinic complaining of some tiredness, ankle swelling and breathlessness on exertion. A diagnosis of heart failure seems probable from the features and examination. Which blood test should be performed that would have prognostic as well as diagnostic value?

Brain natriuretic peptide (BNP) should be measured in any patient suspected of having heart failure as it is useful both diagnostically and prognostically. BNP is a chemical which seems to be released in direct correlation to ventricular volume expansion and pressure overload, therefore a higher level is expected in left ventricular failure (heart failure), and higher levels tend to go with more significant symptoms. A BNP concentration above 400 pg/ml reflects a poorer prognosis.

Question 4

A 75 year old woman is diagnosed with mild heart failure (NYHA grade 2). She is treated appropriately with lisinopril, aspirin and bisoprolol. Which of the following should she be offered?

Newly diagnosed patients should be offered a supervised rehabilitation programme delivering a menu of education and appropriate exercise. Patients with heart failure can suffer from shortness of breath, fatigue and depression, all which can hamper a patient's ability and motivation to exercise. The goal of rehabilitation is to improve a patient's lifestyle and exercise tolerance. Exercise rehabilitation has been shown to reduce the number of hospital admission and improve quality of life, compared to patients with standard care.

Guidelines for diagnosis and management of heart failure

Question 5

A 55 year old man with a history of ischaemic heart disease has been started on ramipril, aspirin, simvastatin and carvedilol. He returns to clinic 3 months later now complaining of a chronic irritating cough. Which of the following would be appropriate for this patient?

Approximately 30% of patients treated with an ACE inhibitor develop a cough. This is a result of the ACE inhibitor causing an accumulation of histamine within mast cells. In these patients the most appropriate approach is to stop the ACE inhibitor and switch to an angiotensin receptor antagonist such as losartan, eprosartan, candesartan etc.

National guidelines on management of heart failure

Question 6

A 70 year old male comes to clinic with a six month history of shortness of breath particularly on exertion. He feels that his ability to exercise has gradually deteriorated and he now sleeps on at least two pillows at night. There is nothing to find on clinical examination. He has a pulse of 78 bpm regular and a blood pressure of 142/88 mmHg. Which of the following tests would be most appropriate for this patient?

The most appropriate tests in patients with suspected heart failure would be urea and electrolytes (U+Es) as well as ECG. The ECG in particular can be quite revealing demonstrating, for example, left ventricular hypertrophy. It is also necessary to guide treatment decisions, for example pacing in bradycardia and rate control in AF. A normal ECG would make left ventricular systolic dysfunction unlikely, but does not rule it out entirely.

Information on heart failure - diagnosis and investigations

Question 7

A 68 year old man with a history of heart failure related to ischaemic heart disease comes along to clinic as he has had problems with deteriorating shortness of breath on exertion. Currently he takes bisoprolol, ramipril, frusemide, long acting nitrate and aspirin. It is considered that he requires another treatment. Which of the following medications should next be added to his treatment?

The most appropriate treatment to add to his current anti-failure regime would be the potassium sparing diuretic spironolactone. This has been demonstrated in clinical trials to be a useful adjunctive treatment improving mortality and morbidity. One should be careful with the combined use of spironolactone and ACE inhibitors as potassium needs to be checked.

Question 8

A 72 year old male with a history of angina attends clinic as he gets breathless on exertion. He informs you that after climbing a flight of stairs he often becomes aware of breathlessness and can walk approximately 150m on the flat. The doctor that saw him suspected a diagnosis of heart failure and measured a beta-natriuretic peptide concentration at the last visit which was 250 pg/ml (30-100). What should be done with this patient?

This patient's BNP is elevated and according to NICE criteria, the patient should be referred for echocardiography and cardiology assessment being seen within 6 weeks. This is because an elevated BNP is associated with an adverse prognosis. A BNP level above 400 pg/ml merits a more urgent specialist review within 2 weeks.

Question 9

A 76 year old female is diagnosed with mild congestive heart failure associated with ischaemic heart disease. Besides the management of her heart failure, which of the following should be offered to this patient?

As well as an annual influenza vaccination, patients with heart failure should also receive a one off pneumococcal vaccination. Pulmonary infections, such as the flu, are not only more common and more severe in patients with heart failure but they can also worsen the heart failure itself.

Investigation and management of heart failure

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