Zero to GP - GP Revision Podcast

Heart Failure - Essential GP Revision

• Thomas Watchman • Season 1 • Episode 15

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SPEAKER_00

Hi, this is Tom from Zero to GP. In this episode, I'm going to be going through heart failure, all the key stuff you need to know for your GP exams, particularly the AKT exam. The format of this episode, as always, is I'm going to present cases and ask you questions. Your job is to come up with your answer, ideally, write the answer down or say it out loud to really commit to it and know whether you know that information. And then we'll go through the explanation. I'm excited to announce that tickets are now available. You can purchase tickets to the AKT revision course. The next one is going to be 13th of September 2026 in London. I've done several courses so far, and they've got amazing feedback. People have written to me to say they've smashed their AKT exam. I highly recommend it. We go through everything you need, the core key information for the AKT exam on the day, a day-long teaching with me. And then you get the revision book and the revision flashcards to take away and keep prep preparing for your exams. So 13th of September in London, tickets are available now. There's a link in the description. But for now, let's get straight into this episode on heart failure. So our first patient is a 72-year-old man, and he presents to you as his GP with breathlessness on exertion. He says, every time I get going, I get really breathless. And I have to keep stopping, catching my breath, and then I can go a bit further. He's also noticed that if he lies flat, he gets breathless. So he's breathless on lying flat. And he describes this scenario where he wakes up from sleep in the middle of the night and he's acutely breathless. And he may describe sitting on the edge of the bed and trying to catch his breath or going to the window and opening the window because he feels kind of suffocated, waking up in the middle of the night. He's also noticed ankle swelling. And you look back on his notes, he's got a past medical history of angina. So he's got some coronary artery disease, and he's got hypertension. So the first question is, which is going to be really easy for you, is what's your suspected diagnosis? Of course, the suspected diagnosis here is heart failure. That's the name of the video. If you didn't get that one, uh you're going to struggle with the rest of the questions here. Okay, onto the the second question, which is what at this point we're just suspecting heart failure. We don't have any uh evidence of what the diagnosis is. We haven't confirmed the diagnosis. But at this point, what treatment could you offer him just for his symptoms in the short term? So we're suspecting heart failure, provided he's got no contraindications, you could offer him a loop diuretic. And this would help clear some of the fluid that might be congesting his lungs and his heart, and um clear some of the ankyl edema that he has as well. So loop diuretic examples include fruismide or bumetinide. The next question is what's the initial specific test that you can do to uh assess for heart failure. So the initial specific test is the NT Pro BNP blood test. And this looks for uh B type natrietic peptide, which is released by the heart when the heart is overloaded and stretched. So if this blood test comes back with a high result, that could indicate heart failure. So the next question is what action are you gonna take in general practice with this new presenting patient based on the BNP blood test result? So you're gonna if the BMP result is raised, you're gonna refer the patient for specialist assessment and an echocardiogram to image the heart and look how the heart is functioning. But the urgency of your referral will depend on the BMP blood result. So if the result is 400 to 2000, this they should be seen and assessed within six weeks. So they should have that specialist assessment and an echocardiogram. And if it's over 2000, that should be within two weeks. So 400 to 2000, they should be seen within six weeks. Over 2000, they should be seen within two weeks. Okay, so you've got this 72-year-old man, he's got suspected heart failure, he's got breathlessness and ankyledema, and his NT-proBNP blood result comes back at 3,100. Next question is what essential baseline investigation do you need to organize in general practice when you're seeing this new presentation of suspected heart failure? Well, we we know that he's gonna get an echocardiogram. What other baseline investigation does he need in primary care? He needs an ECG. And this is obviously to see if he's got any arrhythmias, heart block, any other kind of um abnormalities on the ECG that could make his heart failure worse.

SPEAKER_01

What other tests are you going to consider?

SPEAKER_00

So as a GP, you're going to organize a bunch of tests or consider a bunch of tests, and these are to kind of baseline assessments, but also to look for other possible causes of his symptoms of breathlessness and ankyloedema. So he needs blood tests, baseline blood tests are really important. Um, you know, if he's got uh uh anemia or a thyroid problem or kidney failure or other things like that, that they could cause ankyledema, breathlessness, fatigue, and so on. So he needs to rule out those kind of things, so blood tests. Also a urine dipstick test, because if you've got someone presenting with, say, ankyledema and fluid overloaded, maybe they have neprotic syndrome or some other renal pathology. So you're looking for blood in the urine and protein in the urine. You consider a chest x-ray, because someone with a lung abnormality, even something like lung cancer, could present with breathlessness and lung function tests. So if you've got somebody who's got COPD or pulmonary fibrosis or some other lung pathology, they could also have breathlessness, uh ankyledema, and even that could cause heart failure. So these are the other tests to consider as part of your baseline assessment. The next question is what drugs would you review and stop? So you've got somebody who's got suspected heart failure or very likely heart failure. You look through their medication lists, certain medications will worsen or can cause heart failure. Which ones are you going to stop? So the key ones I would suggest looking out for in your exams and stopping are NSAIDs. So ibuprofen, neproxin, any kind of NSAIDs can worsen heart failure. Specific types of calcium channel blockers that would be used for angina or agrial fibrillation, so verapamil or deltiasm, these will worsen heart failure. And a diabetes medication called pyoglitazone, you'd need to stop this because this precipitates and worsens heart failure. So these are the three key ones I would suggest remembering and looking out for. Okay, so we've got the 72-year-old man, he's now confirmed to have heart failure with reduced ejection fraction. So he's had his echocardiogram and they've confirmed it and told you it's reduced ejection fraction. Next question is what are the first line drugs that are going to be started in this patient? So there's four key first-line drugs for heart failure with reduced ejection fraction.

SPEAKER_01

So I got four key drugs.

SPEAKER_00

I remember them with the ABAS pneumonic, ABAS. The first A is for ACE inhibitor, for example, ramapril. The B is for beta blocker, for example, bisoprolol. This the third A is for aldosterone antagonist. So this is medications that block the action of aldosterone. For example, spironolactone or a plerinone. And the final one, the S, is for SGLT2 inhibitor, for example, dapoglyflosin. So this is usually used for type 2 diabetes, but it's now also used for chronic kidney disease and heart failure. So these are the four key ones to remember. The next question is what non-drug-based intervention are you going to recommend or offer to him? The answer here is a cardiac rehabilitation program. So this is a personalized program where they look at the patient's symptoms and they offer things like exercise therapy and things to try and improve those symptoms. So each patient should be offered this when they're diagnosed with heart failure. Next question is let's say this patient's on the four first-line drug treatments for heart failure, and despite getting to the maximum dose and everything is kind of titrated as needed, they're still having symptoms. What's the initial option if their symptoms are not controlled on these initial first-line drugs? So this is a specialist medication. So this would be initiated under the heart failure specialist team, maybe by the heart failure nurses, and that's sucubratril with valsartan, which is the trade name is Entresto. So this is a combination medication which includes valsartan, which is an angiotensin II receptor blocker. And you wouldn't normally prescribe ACE inhibitors and angiotensin II receptor blockers together. So if they're starting this new medication, the succubratril and valsartan, they'll need to stop the ACE inhibitor. So the next question is if you're switching the ACE inhibitor to this new uh entresto drug, um what's what are you gonna do? How are you gonna switch from the ACE inhibitor to this new drug? Are you just gonna stop one the next day? Uh cross-titrate, how are you gonna do it? So you need to stop the ACE inhibitor first and then wait at least 36 hours before starting the new drug, the Circuitri and Valsartan. The reason for stopping at least 36 hours before starting the new drug is that if there's an overlap between the two, there's a risk of angiodema, so swelling of the subcutaneous tissue. So lots of swelling under the skin. And that angiodema can be problematic or rarely it can be uh quite quite an issue if it affects the um the airway. Okay, so you've got a 72-year-old man. He's confirmed to have heart failure, and he started on treatment. This is a section is kind of about following him up. So the first question is what blood monitoring are you gonna do as a minimum? What do the nice clinical knowledge summaries suggest you need to monitor as a minimum in this patient?

SPEAKER_01

So there's three things that are recommended.

SPEAKER_00

The first is his renal profile, so his usenese. The second is his hemoglobin, so a full blood count to make sure he's not becoming anemic, can develop anemia of chronic disease. And the third thing they recommend is iron studies because he may become iron deficient even with a normal hemoglobin, and that can worsen his symptoms. So usenese, FBCs, and iron studies. The iron studies means monitoring his transfer his sorry his ferritin and transferrin saturation. Okay, next is what do you uh what monitoring could you do on his blood test in this patient to help guide treatment to see whether treatment is successfully uh helping his heart failure? So the key thing you could monitor is his NT Pro BNP blood test. Remember, this is the BNP blood test is the screening test to see whether somebody might have heart failure. Um, but you can actually monitor this while the patient is on treatment to see how well controlled the heart failure is. So obviously, if the heart failure is well controlled, the BNP blood test will start to come down and improve. And if it's not well controlled, it will uh it will be high. The next question is what key complication do you need to monitor for very closely in patients who are taking ACE inhibitors, angiotensin 2 receptor blockers, and mineralocorticoid receptor antagonists like um aspirinolactone.

SPEAKER_01

What is the key complication you need to monitor for?

SPEAKER_00

The key one is hyperkalemia, so a raised potassium. So ACE inhibitors, ARBs, and aldosterone antagonists, they all reduce the action of aldosterone. Now remember aldosterone leads to sodium reabsorption and potassium secretion in the kidneys. So if you reduce the action of aldosterone, you get less potassium excretion in the kidneys, so more potassium is retained in the body. So particularly in patients who are on two of these medications, say uh ramopril and sporonolactone, that can really increase the potassium level and cause hyperkalemia. So they need close monitoring of their usenese blood tests for that. The next question I have in this section is how are you gonna assess his functional capacity? You want to make a kind of objective assessment to see what's his functional capacity at the moment, what tool are you gonna use? You can use the New York Heart Association Classification, the NYHA classification. And this goes from class one to class four. Class one is where they have really no limitations on their activities, so they're they're essentially asymptomatic, and then class four is where they have symptoms at rest, they're uncomfortable with their heart failure symptoms at rest, and then two and three are kind of grades in the middle. So on to the last section, which is a new case, which is a 65-year-old woman, and she presents with symptoms, and then she's confirmed to have heart failure with preserved ejection faction.

SPEAKER_01

So my first question here is what defines preserved ejection faction?

SPEAKER_00

So when you see a patient who's got heart failure with preserved ejection fraction, it means the left ventricular ejection fraction is above or equal to 50%, which is normal. What does that mean? That means every time the left ventricle pumps and squeezes, at least 50% of the blood in the left ventricle is pumped out into the body. If you've got somebody with heart failure with reduced ejection fraction, less than 50% of the blood in the left ventricle is pumped out with each beat. So heart failure with preserved ejection fraction means the left ventricle is still managing to pump blood normally out of the heart and around the body. The cause of heart failure with uh preserved ejection fraction is impaired filling of the left ventricle. And this could be because the left ventricle is particularly stiff or it's just not filling very well. And this is what's causing their heart failure. The next question is in somebody with heart failure with preserved ejection faction, what are the first-line drugs? So if you've got reduced ejection faction, you have those A-BAS drugs. What about if you have preserved ejection faction? What are the first-line drugs? As opposed to the four of reduced ejection fraction. So the first line drugs for preserved ejection fraction are an aldosterone antagonist, for example, spirenolactone or a plerinone, and an SGLT2 inhibitor, for example dapoglyflosine. So these are the only two for preserved ejection fraction. You'll notice that ACE inhibitors and beta blockers are missing from this list. And that's because they're not used in preserved ejection faction. They're not contraindicated, so they might be used for another reason, for example, angina or hypertension, but in this case, uh sorry, in preserved ejection faction, they're not used as a first-line drug. So thanks for listening to this episode on heart failure. Hopefully it was helpful. Again, I recommend checking out the links in the description to the AKT revision course and zero to gp.com. And I'll see you in the next episode.