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Ok. Hi, everyone. And thank you so much for joining us on a Thursday evening in your spare time for this talk. My name is Debbie Falconer. I'm a cardiology registrar and I currently work in a North Central Thames region and we're really, really lucky tonight to be having a talk given by doctor, a cane. Um, so she is a consultant in um cardiac MRI and heart failure working at Wolverhampton Trust and I heard her speak multiple times at conferences on both clinical and nonclinical topics and she's really fantastic. So we're very, very lucky to have her here tonight and I'll be moderating. So please feel free to enter any questions that you have in the chat. I will try to answer as best as I can. But if there's anything that requires something more specialist or a consultant input, then we'll have a chance to ask, aha during the talk as well. Um And another thing on feedback forms, they will be posted at the end of the talk by Emily who will also talk about getting certificates and things for attending. So, yeah, I hope you really enjoy this talk and yet type in any questions that you have so over to you doctor? Thank you so much, Debbie. Thanks for the kind introduction. Um ok, so today I'll be speaking to you on what to do if my patient has heart failure. So the objectives of this talk are to understand the classification of heart failure, how we can manage acute heart failure patients and what kind of examination, findings and investigations we would do and also how to manage an outpatient with heart failure. So, if we first look at the classification of heart failure, this is according to the 2021 E SE guidelines for the diagnosis and treatment of acute and chronic heart failure. So, this guideline is uh defining heart failure by the left ventricular ejection fraction. Ok. So we can see that heart failure with reduced ejection fraction is classified when the left ventricle is less than 40%. And this is on echocardiography and they have symptoms and signs of heart failure. If the LV ejection fraction is 41 to 49% then it's heart failure with mildly reduced ejection fraction. And if the ef is actually more than 50% they have symptoms and signs of heart failure, elevated anti pro BMP. There's other echo findings that we see like a dilated left atrium, um elevated filling pressures demonstrating that the heart is actually stiff. This would be in keeping with heart failure with preserved ejection fraction and we're actually seeing more and more of these cases. And the importance of classifying them into these different classifications is because the treatments will vary according to the type of classification of heart failure that you have. Um So there's sort of the four pillars which is for the less than 40%. But with preserved ejection fraction, there are less options, but there are more treatment options emerging because more patients are developing heart failure with preserved ejection fraction. And actually half my clinic is often patients like this and you will be seeing more patients like this on the wards and in clinics as well. So it's really important to know how to treat each type of classification of heart failure. And now this classification only really looks at the left ventricular ejection fraction. But we know that patients can also have RV impairment with a preserved LV ejection fraction. So that's not included in this classification, but that is another type of heart failure where the RV is impaired and they get more sort of peripheral edema, liver congestion um and that can be picked up on the echo. But again, there's less treatment options for that and it's not in this particular classification. So um I'm going to talk about three cases today um just to help illustrate the learning objectives. So case one is a 28 year old female. So um as a consultant cardiologist in heart failure, I see all kinds of patients, but I really love my job because I do see young patients as well and I specialize in young patients that need referral for advanced heart failure therapies. Um So this is a young patient with heart failure. Um She's 28 years old. She's presented with worsening shortness of breath, paroxysmal nocturnal dyspnea and orthopnea. She has a background of hypertension and she had a previous pregnancy where she developed preeclampsia. And following that pregnancy, she gained a lot of weight and her BMI is now 51. So she's presented to A&E her respiratory rate is elevated. Her saturations are fine. Her BP is elevated and she's tachycardic. Now, I've highlighted the things I read as they're important, they're abnormal. OK? And then she's had her baseline blood tests and it's important um when we're treating or looking at our diagnosing our heart failure patients, that we get a good set of baseline blood tests. So, as well as our E and and our ft, we get our anti pro B MP, which you can see is elevated. She's had a troponin which is elevated but static. Um But this is important to try and establish the etiology of her presentation. Um She's also had ad dimer which is elevated and her CRP is normal. We also should be checking iron studies and we can see that she's iron deficient. Um her TSH is normal and her HB A1C is normal. So I have a heart failure panel on our blood system, um which checks all these things in patients presenting with heart failure or who I see as an outpatient. Um So we can see there are quite a sort of abnormalities here in her admission blood tests and this is her ECG. So she's got sinus tachycardia. There's a bit of a sort of movement artifact here. Um But she is tachycardic. Now, it's really important when you see patients with decompensated heart failure, who are tachycardic to understand what this tachycardia means. We don't know in her case yet what her ejection fraction is. But if patients who have known impaired ejection fraction are tachycardic on admission and overloaded. It's really important that we don't try to beta block them to suppress this tachycardia because actually if we remember the equation that cardiac output equals heart rate, time stroke volume, they have a low stroke volume. So the heart rate is increasing to compensate to allow them to have some cardiac output and some BP. And if we then go on to beta block them or continue their regular beta blockers, we are actually going to cause them to decompensate and, and or an arrest because it's not really going to help. They need that tachycardia to facilitate their cardiac output. Ok. So it's important to note that she is tachycardic, she's not septic and the CRP is seven. So it's not caused by that. It's actually because she has heart fail and she's trying to maintain the cardiac output and she does have a good high BP in keeping with her past medical history. So, what investigation would you do next? I'm going to run this poll. Um, I hope it's working. Yeah, it looks like it's working. Ok. Ok. I will. It's asking me to answer the question as well. We've got four responses so far up to 20 now. Lovely. Yeah, I'm not sure if I, oh yeah, it's still going. Ok. Yeah, I'm still getting a few more trickling in. Ok. So the majority is saying chest X ray, which is correct. Um And the other tests are obviously useful. The venous blood gas is useful c is useful, but we've got the blood test, we've got the ECG, the next test we would want is the chest X ray. So this is her chest X ray. So she's got cardiomegaly. You can see how enlarged that cardiac silhouette is. We can see that she's got a lot of pulmonary edema, pulmonary congestion, upper lobe diversion here, no significant pleural effusions, but this is a congested chest X ray and a big heart. So how are we going to manage this patient? So, remember, we don't have an echo yet, so we don't know that she's got a diagnosis of hef ref but looking at the um presentation, looking at her chest X ray, um we're going to do an at assessment of this patient. We'd start oxygen if she's desaturating. But she isn't. Um We would give her some frusemide. So if the frusemide naive, I would give a 40 IV of Frusemide. But with her BMI of being 51 I'd give her ACI V of Frusemide and I'll then start a maintenance continuous frusemide infusion of 240 mgs over 24 hours. Um And it's important to get that started early um because that allows a gentle sort of continuous removal of fluid with, with the frusemide because often you have patients that might be hypertensive. And if you prescribe boluses, then they're not given once they move to the ward because the BP is too low or if the kidney function deteriorates, then again, the nurses may not give the, the, the frusemide, but it, it's better if it's a continuous infusion because you can even reduce the infusion. Um But the importance is that they're getting regular continuous frusemide to offload them. Um In this case, you can consider a GTN infusion. Again, that's to help vasodilation and offloading. She has a good BP. And then, so she would accommodate that, but some patients have a low BP. So they wouldn't tolerate that. We would need to catheterize her or at least monitor her urine output. That's really, really important. Um because we need to know exactly how much fluid is coming out and exactly how much fluid is going in. We need to fluid restrict her to 1.5 L and we need to measure her day late. And this is important to ensure we're getting and achieving a good diuresis. So she should be losing 1 kg per day of fluid. And if she's not, then we need to increase her diuretic regime. Um And at this point, she's in A&E so we need to arrange admission to the ward for her. Um So I'm not sure how well this projects for you, but this is taken from the ESC guidelines again about how to manage a patient with acute decompensated heart failure. So, she's congested and fluid overloaded. Um She's not hypoperfused in that she's got a good BP. So we've given her loop diuretics, we're aiming for congestion relief. But if we don't get adequate diuresis, we can increase the diuretics and increase and, and consider add additional diuretics on top. Um But if this then pushes her into renal impairment, we may have to consider renal replacement therapy as well.