Heart failure

Please read the following guideline on heart failure which is fairly up to date but written for a rich
country where treatment is free. It is also written by a respected authority who are not dependent
on drug advertisements. Be prepared to cost your intervention based on the article (e.g. be aware of
medications and costs of tests needed when blood tests to monitor treatment need to be done). If
you find any other guideline that is directed at primary care do bring them along.

https://www.nps.org.au/australian-prescriber/articles/chronic-heart-failure

Q1. A 33 year old woman presents with increasing breathlessness on effort so that she is now able to
walk only 200m on flat ground without stopping to get her breath.

a. What class of breathlessness is this? (NYHA class)

b. What are the immediate causes of these symptoms that go through your mind?

She has no fever. Has a cough at night but no sputum. She has mild ankle edema at end of day.
No chest pain on effort. Normal menstrual cycles She says she has lost a little weight and has
occasional diarrhoea but no symptoms of GI blood loss. No relevant past medical history or
medications.

Context: From a poor socio-economic group. 2 children Agricultural worker Supportive husband
also agricultural worker.

Individual factors: Needs to get back to work. Does not understand why she is sick and feels may
possibly be due to a curse by someone jealous of her.

OE: Health workers did basic assessment and history P120 BP 155/80 Rpt 158/ 82 RR 20 at rest
Weight 40kg BMI 18 T 37C Sats 98%on air, Haemoglobin 8g% Comfortable at rest but pale and a
little sweaty. Fine tremor noted No obvious goitre JVP sitting +4 HS normal Chest few fine basal
rales both sides Minimal pedal edema both ankles. You think she is in heart failure ECG shows
sinus tachycardia with few supraventricular ectopics.

c. Do you think this is likely to be heart failure with or without LV dysfunction? Why?
d. What do you think are possible causes?
e. An echocardiogram can only be done in a place 3h travel away and she is unable to go there
at this stage. What investigations would you order taking into account her contextual factors
and your inability to provide limited subsidy for Rx.
f. What treatment will you give pending the results which will be available in 3-4 days?
g. What is the commonest cause of heart failure with preserved LV ejection fraction >50% and
so what must you focus on treating?

2. A 42 year old man had an acute MI 2 years ago followed by an angiogram which showed LAD 90%
block treated by stenting that vessel. There was diffuse disease of the circumflex and RCA which
were not treatable by stent or CABG. EF then was 35% on echo. He has been seeing the cardiologist
occasionally and collecting medications irregularly. He now presents with reduced effort tolerance
NYHA III with breathlessness and orthopnoea. Cough only at night, dry no fever or weight loss. He
admits he has not been collecting medications 4w No chest pain
Context: Daily wages in agriculture No assets. Children studying +1 and one in college doing BEd.
Wife also same occupation. Continues to smoke 10/ day Occasional alcohol use once monthly during
village functions about 4 standard drinks.

Individual factors: Getting upset he cannot work, finding it hard to support children’s education and
medication costs

Medications: Metoprolol 50mg bd Irbsartan 150mg once daily Aspirin 75mg daily Clopidogrel 75mg
daily Rosuvastatin 10mg daily Isosorbide mononitrate 60mg daily

OE HW assessment P 90pm BP160/90 x 2 RR 18 T37 Sats 98RA Weight 53kg BMI 19

No pallor JVP sitting +4 HS 3/6 pansystolic murmur at apex radiates to axilla Chest fine basal crackles
both bases Moderate pedal edema

ECG Old anterior infarct nil else

a. Would you do any investigations? Assume you are in a Govt PHC and can send blood to your
district hospital
b. How will you manage him now in the PHC- he will not go anywhere else now?
c. Is an echo urgent if it involves travel a long way and costs Rs 900 at the center closest to
you?
d. 1 week later he feels much better with your treatment of aspirin, frusemide and enalapril.
His haemoglobin is 11g% creatinine 0.6mg% Cholesterol 180mg% How would you now
optimise his treatment in your Govt PHC?
e. What will guide your choice of beta blockers? You may want to read
http://www10.who.int/selection_medicines/committees/expert/20/applications/
Atenolol.pdf which is an exhaustive review of atenolol vs other beta blockers. You may want
to read the background section about the drive for bias in clinical trials and the conclusion
section only – because it’s a long and complicated review but very thorough. It mainly
concerns with the use of beta blockers in hypertension but is relevant to heart failure also.
What do you think about atenolol in heart failure?

3. A 51 year old previously well lady presents with to your rural PHC with severe chest pain of 4h
duration suggestive of MI and the ECG already done by HW shows STEMI anterior leads. She is obese
you think her BMI could be 28 very breathless. P100 Regular BP 170/100 RR 34 Sats 88% RA T 35C
Blood glucose 190mg % (10.5mmol/l) JVP +5 sitting HS 1, 2 Chest bilateral basal rales. HW tell you
they are from a small scale landowning farmer family with dry land. They have 2 working children in
nearby cities. She fears she is going to die and is terribly anxious.

a. before you arrive what standing orders for medications should health workers have given already
for this kind of presentation?

b. 108 ambulance has been called but the travel to district or refrerral hospital will take 1 hour for
ambulance to arrive and 2 hours to reach. The referral/ district hospital has no interventional
cardiology and that will take another 3 hours travel. So you have thrombolysed the patient but what
else will you do if the HW have already given standing order interventions?