Heart Failure a Workbook

This workbook is designed to be an interactive resource to help you explore the disease of heart failure by presenting a combination of resource links, questions and activities. Work through the activities in numerical order to help you get the most from this document that is intended to complement the face to face and assessment activities undertaken during the MCALS module. As always, discussion is encouraged with both your fellow students and lecturing team. Feel free to contact me to clarify any points at alan.rice@sgul.kingston.ac.uk I have started some discussion boards for you to discuss any difficult points that research cannot overcome. Heart failure is a significant disease, more prevalent in the elderly population which is expanding. It is highly relevant to Paramedics as the management of pre-hospital care differs from many other similar presentations. I hope you are able to benefit from this workbook. Regards, Alan.

Activity 1 REVISION: This activity is designed to refresh and possibly introduce some terms associated with the underlying pathophysiology of heart failure. Answer the questions without any specific preparation. This should help you gauge your own knowledge and help you discern whether you need to research further before continuing with the workbook. Answers are not provided! 1. Define heart failure?

2. Define acute heart failure?

3. Define chronic heart failure?

4. What is preload?

5. What is afterload?

6. What is LVEF or Left ventricular ejection fraction?

7. What defines congested heart failure?

8. What side of the heart is associated with congested heart failure?

9. List the common causes of acute heart failure:

10. List the common causes of chronic heart failure:

Review the following articles relating to heart failure:

1. NICE guidelines for chronic heart failure (how much of this can we relate to our practice?): http://www.nice.org.uk/CG5 2. JRCALC guidelines (unlike previous guidelines there is now a shift towards presenting evidence): http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcst akeholderwebsite/guidelines/pulmonary_oedema_2006.pdf 3. NHS guidance (who is this targeted towards): http://www.nhs.uk/Conditions/Heart-failure/Pages/Introduction.aspx 4. The use of nitrates in the pre-hospital arena (critically review this study): http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4HP4NXR9&_user=121744&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchS trId=1041334946&_rerunOrigin=google&_acct=C000010020&_version=1&_urlVersion=0&_ userid=121744&md5=caf8723d2b510a3d5d78353b29c95b60 5. Cardiac arrest and heart failure (again, critically review the study do the presenting rhythms surprise you?): http://circ.ahajournals.org/cgi/reprint/80/6/1675.pdf

Activity 2 FURTHER EXPLORATION: Download the following article from the US: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=72 Although the article is not specific to UK based treatment it does offer an overview of the hospital based classification, assessment and treatment of heart failure. It is reasonably current (2002). Read through the article and answer the following questions. They are designed to encourage thinking and may not have distinct answers as above:
1. How do mortality rates compare with patients presenting with and without pulmonary oedema? Can you account for any reason for this?

2.

What is the mortality rate of people presenting with both myocardial infarction and heart failure? Can you relate this presentation with patients you have seen in practice?

3.

The article lists the following as possible causes. Can you define any of these causes? Coronary artery disease Hypertension Valvular disease Cardiomyopathy Idiopathic cardiomyopathy Alcoholic cardiomyopathy Toxin-related cardiomyopathy (e.g., adriamycin) Postpartum cardiomyopathy Hypertrophic obstructive cardiomyopathy (HOCM) Tachyarrhythmia-induced cardiomyopathy Infiltrative disorders (e.g., amyloid) Congenital heart disease Pericardial disease Hyperkinetic states Anemia Arteriovenous fistula Thyroid disease Beri-beri From the list above, do you think we can identify any of these conditions in the pre-hospital environment?

4.

5.

Review the presented classifications found on page 3. How do the different classifications relate to outcomes? Can you categorise any patients you have met in practice into these classifications?

6.

The article suggests that the following mechanisms occur during heart failure how would stimulation of these systems present in a patient in the pre-hospital setting? activation of renin-angiotensin system activation of sympathetic nervous system

Activity 3 ECGs and heart failure: The following ECG was taken from an elderly lady, known heart failure patient who has become unwell recently. She reports no chest pain but has become increasingly fatigued and is unable to walk far without becoming short of breath. What clinical features can you discern from this ECG:

The following ECG was taken from a 50 year old male patient who was obese, smoked and had a history of childhood lower leg fractures. What risk factors can you identify with the history and ECG that would increase the risk of heart failure and why?

Activity 4 ASSESSMENT & MANAGEMENT: Consider the following statements. Do you agree or disagree with the statements? Why?

1. Salbutamol should not be administered to a patient with acute heart failure.

2. Acute heart failure with pulmonary oedema is relatively easy to diagnose.

3. Furesomide is a well proven treatment that improves survival rates in patients with acute heart failure.

4. CPAP is a complex treatment unsuitable for pre-hospital care.

5. Presence of pedal oedema is an accurate indicator that a patient is acutely unwell and requires aggressive treatment.

6. Pulmonary oedema is best auscultated as crackles in the apex of the lungs.

7. Raised JVP can be an indicator of heart failure.