Cardiology for MRCP Part 1

A 68-year-old man has 3 months of worsening exertional breathlessness, orthopnoea and ankle swelling. His jugular venous pressure is raised, he has bibasal crackles and pitting oedema, and echocardiography shows a dilated left ventricle with an ejection fraction of 30%. His NT-proBNP is markedly raised. What is the most likely diagnosis?

1. Liver cirrhosis with ascites Fluid build-up caused by high pressure in the liver's blood vessels. It does not fit a raised NT-proBNP together with a reduced ejection fraction of 30%.
2. Nephrotic syndrome Swelling caused by heavy protein loss in the urine and a low albumin level. Here, a raised NT-proBNP together with a reduced ejection fraction of 30% points elsewhere.
3. Heart failure correct Correct. Breathlessness on exertion, orthopnoea (breathlessness lying flat) and fluid overload, together with a reduced ejection fraction and a raised NT-proBNP, point to heart failure with a reduced ejection fraction.
4. Chronic obstructive pulmonary disease Breathlessness in a smoker with narrowed airways. But a raised NT-proBNP together with a reduced ejection fraction of 30% does not point to it.
5. Anaemia Breathlessness on exertion with a low haemoglobin (red blood cell) level. That does not match a raised NT-proBNP together with a reduced ejection fraction of 30%.

The point: Heart failure is a syndrome of breathlessness, tiredness and fluid build-up caused by a structural or functional problem with the heart. Doctors split it by the left ventricular ejection fraction (the percentage of blood the left ventricle pumps out each beat) into reduced (40% or less), mildly reduced and preserved categories. This split matters because only the reduced-fraction group has drugs proven to change the course of the disease. A raised natriuretic peptide (BNP or NT-proBNP) supports the diagnosis, and echocardiography confirms it: this heart ultrasound measures the ejection fraction and looks for a valve, ischaemic or infiltrative cause. In heart failure with a reduced ejection fraction, four types of drug each lower the risk of death on their own: an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin receptor-neprilysin inhibitor), a beta blocker, a mineralocorticoid receptor antagonist and a sodium-glucose cotransporter-2 (SGLT2) inhibitor. These are the four pillars of therapy. Loop diuretics ease congestion and symptoms but do not change how long the patient lives. Device therapy, such as cardiac resynchronisation or an implantable defibrillator, is used in some patients with a low ejection fraction and a broad QRS or a high risk of dangerous heart rhythms. Acute pulmonary oedema (fluid suddenly flooding the lungs) is treated by sitting the patient up, giving high-flow oxygen, an intravenous loop diuretic and nitrates, with non-invasive ventilation if the patient is not improving.

Source: ESC guidelines for the diagnosis and treatment of acute and chronic heart failure European Society of Cardiology · tier 2, specialty society or college

A 68-year-old man has 3 months of worsening exertional breathlessness, orthopnoea and ankle swelling. His jugular venous pressure is raised, he has bibasal crackles and pitting oedema, and echocardiography shows a dilated left ventricle with an ejection fraction of 30%. His NT-proBNP is markedly raised. What is the most appropriate management?

1. Cardiac resynchronisation or defibrillator therapy A device fitted in some patients with a low ejection fraction. That does not match a raised NT-proBNP together with a reduced ejection fraction of 30%.
2. Intravenous loop diuretic, oxygen and nitrates The treatment given straight away for acute pulmonary oedema. Here, a raised NT-proBNP together with a reduced ejection fraction of 30% points elsewhere.
3. A beta blocker licensed for heart failure Another pillar drug that lowers the risk of death, started once the patient is stable. It does not fit a raised NT-proBNP together with a reduced ejection fraction of 30%.
4. An ACE inhibitor titrated to the maximum tolerated dose correct Correct. An ACE inhibitor is one of the pillar drugs that lowers the risk of death in heart failure with a reduced ejection fraction. The dose is increased step by step to the highest the patient can tolerate.
5. A loop diuretic for symptom relief Eases congestion but does not change how long the patient lives. But a raised NT-proBNP together with a reduced ejection fraction of 30% does not point to it.

The point: Heart failure is a syndrome of breathlessness, tiredness and fluid build-up caused by a structural or functional problem with the heart. Doctors split it by the left ventricular ejection fraction (the percentage of blood the left ventricle pumps out each beat) into reduced (40% or less), mildly reduced and preserved categories. This split matters because only the reduced-fraction group has drugs proven to change the course of the disease. A raised natriuretic peptide (BNP or NT-proBNP) supports the diagnosis, and echocardiography confirms it: this heart ultrasound measures the ejection fraction and looks for a valve, ischaemic or infiltrative cause. In heart failure with a reduced ejection fraction, four types of drug each lower the risk of death on their own: an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin receptor-neprilysin inhibitor), a beta blocker, a mineralocorticoid receptor antagonist and a sodium-glucose cotransporter-2 (SGLT2) inhibitor. These are the four pillars of therapy. Loop diuretics ease congestion and symptoms but do not change how long the patient lives. Device therapy, such as cardiac resynchronisation or an implantable defibrillator, is used in some patients with a low ejection fraction and a broad QRS or a high risk of dangerous heart rhythms. Acute pulmonary oedema (fluid suddenly flooding the lungs) is treated by sitting the patient up, giving high-flow oxygen, an intravenous loop diuretic and nitrates, with non-invasive ventilation if the patient is not improving.

Source: ESC guidelines for the diagnosis and treatment of acute and chronic heart failure European Society of Cardiology · tier 2, specialty society or college

A 68-year-old man has 3 months of worsening exertional breathlessness, orthopnoea and ankle swelling. His jugular venous pressure is raised, he has bibasal crackles and pitting oedema, and echocardiography shows a dilated left ventricle with an ejection fraction of 30%. His NT-proBNP is markedly raised. What is the most appropriate definitive treatment?

1. A mineralocorticoid receptor antagonist A pillar drug that lowers the risk of death. It does not fit a raised NT-proBNP together with a reduced ejection fraction of 30%.
2. Cardiac resynchronisation or defibrillator therapy A device fitted in some patients with a low ejection fraction. That does not match a raised NT-proBNP together with a reduced ejection fraction of 30%.
3. A loop diuretic for symptom relief Eases congestion but does not change how long the patient lives. Here, a raised NT-proBNP together with a reduced ejection fraction of 30% points elsewhere.
4. A beta blocker licensed for heart failure Another pillar drug that lowers the risk of death, started once the patient is stable. But a raised NT-proBNP together with a reduced ejection fraction of 30% does not point to it.
5. A sodium-glucose cotransporter-2 inhibitor correct Correct. An SGLT2 inhibitor is one of the four pillar drugs. It lowers the risk of death and hospital admission and completes the disease-changing treatment.

The point: Heart failure is a syndrome of breathlessness, tiredness and fluid build-up caused by a structural or functional problem with the heart. Doctors split it by the left ventricular ejection fraction (the percentage of blood the left ventricle pumps out each beat) into reduced (40% or less), mildly reduced and preserved categories. This split matters because only the reduced-fraction group has drugs proven to change the course of the disease. A raised natriuretic peptide (BNP or NT-proBNP) supports the diagnosis, and echocardiography confirms it: this heart ultrasound measures the ejection fraction and looks for a valve, ischaemic or infiltrative cause. In heart failure with a reduced ejection fraction, four types of drug each lower the risk of death on their own: an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin receptor-neprilysin inhibitor), a beta blocker, a mineralocorticoid receptor antagonist and a sodium-glucose cotransporter-2 (SGLT2) inhibitor. These are the four pillars of therapy. Loop diuretics ease congestion and symptoms but do not change how long the patient lives. Device therapy, such as cardiac resynchronisation or an implantable defibrillator, is used in some patients with a low ejection fraction and a broad QRS or a high risk of dangerous heart rhythms. Acute pulmonary oedema (fluid suddenly flooding the lungs) is treated by sitting the patient up, giving high-flow oxygen, an intravenous loop diuretic and nitrates, with non-invasive ventilation if the patient is not improving.

Source: ESC guidelines for the diagnosis and treatment of acute and chronic heart failure European Society of Cardiology · tier 2, specialty society or college