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Medical management of Cardiac failure in Plab

Discovery of this pathophysiology revolutionized the medical management of Chronic Heart Failure.
So, It’s worth spending a couple of minuets on this very simplified explanation.

Pathophysiology of HF
• In heart failure, the pumping ability of the heart is reduced.
• When heart’s pumping ability reduced, the pressure generated by the heart going to be reduced
even though circulating blood volume remained unchanged.

The very important point is: In heart failure, patient has normal/high plasma volume in
the body. However, his hormonal systems sense that the patient is hypovolemic. So those
hormonal systems works against hypovolemia and retain more fluid. How?

Because of this pressure reduction due to heart failure, as described above

• Baro-receptors activates the sympathetic NS and at the same time inhibits parasympathetic NS
which together increase the HR and BP
• Due to this pressure reduction renal blood flow also going to be lower which in turn activates
Renin-Angiotensin-Aldosterone- system. (RAAS) which leads to more fluid accumulation.

When sympathetic NS stimulated, it produces vasoconstriction too. This vaso -

constriction reduce the renal blood flow further and activates the RAAS further.

• More accumulation of fluid compromise the hearts pumping ability further and this becomes a
vicious cycle.
• Therefore, if you want to treat the heart failure, you must break this vicious cycle at some point.

We break this vicious cycle by blocking the actions of those hormones involve here. How?

Sympathetic outflow Beta-blockers

Renin --
Angiotensin ACEI (ex: Ramipril) and ARB (ex: Losartan)
Aldosterone Aldosterone inhibitors (Ex: Spironolactone)
ACEI- Angiotensin Converting Enzyme inhibitors ARB- Angiotensin Receptor Blockers

This is how we developed the new strategy to treat Chronic heart failure (CHF).
All those medications in the chart (together with nitrates) have shown increase the prognostic value
(reduce the mortality) in chronic heart failure patients.

Use of diuretics in heart failure

• Diuretics are mainly used in acute severe heart failure conditions in order to remove the extra
fluids which are accumulated slowly by the above hormones. Long term use will not improve
mortality. Of course, it can relieve the symptom.
Our goal is to minimize the diuretics usage as much as possible meanwhile, titrate the ACEI & Beta
blockers to a level which can prevent acute heart failure exacerbation.

When to use morfine in heart failure

• Morphine is given in acute severe heart failure condition to reduce anxiety. Because, anxiety
increases the sympathetic outflow, iv/sc morfin are beneficial against acute heart failure.

Place for Digoxin in heart failure

Digoxin is indicated only in a place where patient has heart failure with Atrial fibrillation.
Digoxin has reduce the number of hospital admissions, But dont reduce the mortality in CHF patients.

Role of nitrates cardiac failure

• Nitrates can dilate the capacitance blood vessels and redistribute the fluids from the lung. So, it
can reduce the pulmonary oedema by shifting fluids to the capacitance veins from the lungs.
• Buccal nitrate, GTN can be used in acute cardiac failure. Beware! BP can fall sharply, So
patient must have a Better BP before you administer buccal nitrates.
• Long acting nitrates (ISMN and ISDN) has shown that they improve the mortality due to CHF.

Diagnosis of heart failure

• Cardiac echo is the gold standard.
• We look specially for ejection fraction, cardiac muscle motility. However, In diastolic heart
failure EF can be normal.
• BNP (Brain natriuretic peptide) often elevated in heart failure. Can be used for monitoring the
therapy.

Beta-blockers reduce the contractility of the cardiac muscles. So, avoid giving in an acute severe heart
failure conditions ex: in severe pulmonary edema. However, when the condition improved, beta-
blockers can be introduced very slowly.

Important mcq points

If a patient presents with severe pulmonary oedema with brethlessness- Choose loop diuretics
If a patient presents with exertional dyspnea due to HF - 1st choice ACEI/ARB.

Very severe Acute HF patients specially with low BP can be managed with ionotrops, NIPPV or CPAP

Reminding some clinical features mcqs

• In Left HF – patient develops pulmonary oedema
• In Right HF - Patient develops ankle edema, in severe cases liver enlargement
• In congestive HF – Both Right and Left cardiac failure features are there
Now we ace the Plab mcqs with our knowledge!
Here we go…………………...

Heart failure mcqs

01 A 72year old man previous MI presents with
severe pulmonary oedema. His ECG shows
atrial fibrillation with a ventricular rate of
135 beats/minute. Bp 100/80mmHg What is
the most appropriate immediate
management?
A. Metoprolol
B. Amiodarone
C. Digoxin
D. DC shock
E. Warfarin
02 A 3 year old boy with VSD waiting for
surgery presents with severe congestive
cardiac failure. What is the most appropriate
immediate management?
A. ACE inhibitors
B. Propranalol
C. Nitrates lV
D. Chest Xray
E. lV furosemide
03 A 70 year old man with Chronic cardiac
failure on treatment via cardiology clinic.
On review he describes worsening of heart
failure symptoms. Examination; He was
found to have a palpable thrill in the right
Second intercostal space, which radiates to
the neck. What is the most appropriate
management?
A. ACE inhibitors
B. Beta blockers
C. Spironolactone
D. Aortic valve replacement
E. Heart transplant
04 A 65 year old man who smokes 10cigarettes/
day since last 40 years, hypertension on
enalpril 10mg /daily has woken up four times
in the previous month with feeling of
thumping in the chest and develops
paroxysms of cough at the same time. On
sitting up for about two minutes and taking a
few deep breaths the sensation subsides over
a further minute. Her ECG shows sinus
 rhythm. What is the most appropriate
investigation which confirm the diagnosis?
A, 24 hours ECG
B. Chest Xray
C. Cardiac Echo
D. Echocardiogram
E. Renal function test
05 A 68 year old man with type 2 diabetes was
investigated for exertional dyspnea.
Echocardiography shows left ventricular
dysfunction with moderate reduction in
Ejection fraction. What is the most
appropriate management?
A. Digoxin
B. Bisoprolol
C. Angiotensin converting enzyme inhibitor
D. Salt reduction
E. Clopidogrel
06 A 65 year old man who presents with an
irregular heart beat and breathlessness for
last 10days. His symptom becomes worser
last 2-3days. Examination shows raised
jugular venous pressure (JVP), ankle oedema
and with the signs of pulmonary oedema.
ECG showing uncontrolled atrial fibrillation
with ventricular rate 145/min. What is the
most appropriate management?
A. Verapamil
B. Beta blockers and anticoagulants
C. Digoxin
D. Amiodarone
E. Digoxin and anticoagulant
07 A 65-year-old man with Type 2 diabetes had
a myocardial infarction 2 months ago . He is
presents to the A&E with acute severe
breathlessness. Ex: Lungs: basal crackles.
What is the most appropriate immediate
management?
A. Frusemide iv
B. Beta blocker iv
C. Buccal nitrate
D. Frusemide oral
E. Spironolactone
08 A 65-year-old woman with APC resisstance
on lifelong warfarin has a history of multiple
pulmonary emboli and presents with
increasing severe lower limb pitting oedema.
 likely diagnosis?
A. DVT
B. Pulmonary regurgitation
C. Nephrotic syndrome
D. Drug induced
E. Cor pulmonale
09 A 55 year old man with cardiomyopathy and
refractory pulmonary edema. He was
prescribed frusemide and cardiac failure was
prescribed furosemide by the GP. But patient
still continues to deteriorate in spite of
frusemide treatment. What is the most
appropriate medicine to add?
A. Spironolactone
B. Ramipril
C. CPAP
D. Bisoprolol
E. Thiazide
10 The morbidity of CHF has been reduced by
following drugs, except
A. ACEI
B. Beta blockers
C. Spironolacton
D. Nitrates
E. Digoxine
11 64year old man with severe congestive
cardiac failure treated vigorously with iv
frusemide in the ward. What is the electrolyte
abnormality you will see in this patient?
A. Low Na+, Low K+
B. Low Na+, Normal K+
C. High Na+, Low K+
D. High Na+, High K+
E. Low Na+, High K+
12 A 70 year old man with newly diagnosed
heart failure presents for a review. His blood
tests shows hyperkalemia with K 6.1. What is
the likely cause?
A. Atenolol
B. Losartan
C. Verapamil
D. Amiodarone
E. Nifedipine
13 A 59 year old man who smoke since his age
of 20, 15cig/day with past history of
hypertension on Amlodipine 5mg/daily now
 complaining of increasing fatigue and
shortness of breathfor last 6 weeks. He has
been sleeping with 3 pillows. Otherwise he
gets orthopnea. On examination, pulse is 90/
min, BP 160/95. On auscultation, there are
basal crackles. No ankle oedema. Most
likely diagnosis.
A. Atrial fibrillation
B. COPD
C. Right ventricular dysfunction
D. Left ventricular dysfunction
E. Congestive cardiac failure
14 A 63 year old lady with COPD for last 15
years noticed recent swelling of her ankles.
On examination shows bilateral pitting
oedema in the ankles, raised JVP with
hepatomegaly. Most likely clinical diagnosis.
A. DVT
B. Budd-chiary disease
C. Right heart failure
D. Left heart failure
E. COPD exercebation
15 66year old man presents with moderate The most common causes of transudative effusions are
breathlessness to the GP centre. He has no heart failure, cirrhosis with ascites, and
cough or sputum production. No fever. Chest hypoalbuminemia (usually due to the nephrotic
syndrome).
X-ray was taken which shows a small pleural The most common causes of exudative effusions are
effusion. Which one of the following is the pneumonia, cancer, pulmonary embolism, and TB
most likely diagnosis?
A. Acute renal failure
B. Pneumonia
C. COPD
D. Pulmonary embolism
E. Cardiac failure
16 Which of the following drug against CHF
doesn’t improve the morbidity of CHF ?
A. ACEI
B. Beta blockers
C. Spironolacton
D. Nitrates
E. Frusemide
17 67year old man with COPD present to A&E
with shortness of breath. Despite repeated
inhalations together with steroids patients
condition remains the same. Treating
emergency doctor suspect pulmon edma
secundary to left ventricular failure. But lung
auscultation hardly reveal anything because
 hyperexpansion. What is the single most
blood test which can help differentiate COPD
from left ventricular failure
A. ABG
B. BNP
C. Chest Xray
D. Ddimer
E. Serum electrolytes

Answers
1. C 10. E
2. E 11. A
3. D 12. B
4. C 13. D
5. C 14. C
6. C 15. E
7. A 16. E
8. E 17. B
9. B