Heart Failure on the CCFP exam

Approach

• Every new case needs a cause. A blocked artery, a leaky valve and a hole in the heart are each treated differently.
• In adults, look for blocked heart arteries, high blood pressure, valve disease, alcohol, thyroid disease and a fast or irregular rhythm.
• In a baby with fast breathing, hard feeds, a murmur and a big liver, think of a hole between the pumping chambers. Refer to a children's heart specialist.

Approach

• Ask about breathlessness on effort or lying flat, waking up short of breath, swollen ankles and weight gain.
• In older adults, heart failure can show up as tiredness, doing less, confusion or falls rather than breathlessness.
• Examine for raised neck veins, crackles at the lung bases, an extra heart sound and leg swelling.
• Look for causes of tiredness that sit alongside it: anemia, thyroid disease, kidney disease, depression and drug side effects.
• If heart failure is possible, test for it rather than blaming age.

Approach

• Ejection fraction is the share of blood the left ventricle pumps out with each beat. Heart failure can occur with a normal value.
• This is heart failure with preserved ejection fraction (HFpEF). The heart squeezes well but is stiff and fills poorly.
• It is common in older adults and in people with high blood pressure, diabetes, obesity, kidney disease or atrial fibrillation.
• Treat the fluid and the conditions that drive it. Check current Canadian advice on drug treatment for this type.

Approach

• Grade each visit with the New York Heart Association (NYHA) class (table below). Record it so you can see change.
• Ask what the patient can do: how far they walk, stairs, washing, dressing, shopping and cooking.
• For someone who lives alone, ask the direct question: can they manage safely at home this week?
• In a baby, the feed is the effort. Ask how long a feed takes, and whether the baby sweats or stops to breathe.
• Questions about causes and triggers matter, but they do not grade how limited the patient is.

Approach

• Run through the usual triggers: missed pills, salty food, infection and a new rhythm problem. Also check for ischemia (poor blood flow to the heart), high blood pressure and new drugs.
• Ask about pain pills bought over the counter. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen hold fluid, raise blood pressure and worsen kidney function. Avoid them in heart failure.
• Remove the trigger. A bigger diuretic dose alone leaves the cause in place.
• Check creatinine and potassium against the patient's baseline. Kidney disease often comes with heart failure and shapes drug choices.
• Do not stop survival drugs when kidney tests and potassium are at baseline. That gives up their benefit.
• A patient who speaks in full sentences, has normal oxygen and has support at home can often be treated at home.

Approach

• Reduced ejection fraction: use four drug classes. First, an angiotensin receptor–neprilysin inhibitor (ARNI) such as sacubitril–valsartan, or an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB).
• Add a beta-blocker proven in heart failure, a mineralocorticoid receptor antagonist (MRA) such as spironolactone, and a sodium-glucose cotransporter 2 (SGLT2) inhibitor.
• Start low and raise doses step by step. Fit the order to blood pressure, heart rate, potassium and kidney function.
• A diuretic clears fluid and eases breathing. Digoxin may ease symptoms. Neither replaces the four classes.
• Switching from an ACE inhibitor to sacubitril–valsartan: stop the ACE inhibitor at least 36 hours first. Together they raise the risk of angioedema (face and throat swelling).
• Start sacubitril–valsartan once the patient is stable, not during a flare. Raise the dose every 2 to 4 weeks as tolerated, and check potassium.

Approach

• Weigh every morning on the same home scale, after passing urine, before breakfast, in the same clothes. Write it down.
• Agree on a weight gain that means calling the clinic. Too small a number sets off alarms from normal day-to-day change.
• Fluid builds up for days before the ankles swell. The scale shows it first.
• Advise a low-salt diet and regular exercise. Canned and processed foods carry hidden salt.
• On spironolactone, avoid potassium pills, salt substitutes and high-potassium foods such as bananas, prunes, raisins and orange juice.
• Take every pill every day, and help the patient stop smoking.

Approach

• Read these as warning signs: repeat admissions or emergency visits, rising diuretic needs, and symptoms at rest or with little effort.
• Other signs: low blood pressure or falling kidney function that forces survival drugs down or off, poor appetite and weight loss.
• First rule out a fixable cause: missed pills, salt, a new drug, infection or a rhythm problem.
• Refer to a heart failure clinic or a cardiologist to review advanced options.
• Start talking about goals of care and the likely course. See the next section.

Approach

• Ask what he and his daughter know and what matters most to him. Share information with his consent.
• Be honest that the course has ups and downs and that time is hard to predict. Sudden death can happen.
• Do not delay palliative care for someone with serious illness and distress. It can run alongside heart treatment.
• Start advance care planning early: who decides if he cannot, and what he wants. Revisit it as things change.
• Palliative care runs alongside heart treatment. It does not mean stopping every heart drug.