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 retention from portal hypertension. A raised NT-proBNP with a reduced ejection fraction of 30% makes it a mimic.
2. Nephrotic syndrome Oedema from heavy proteinuria and low albumin. A raised NT-proBNP with a reduced ejection fraction of 30% redirects it.
3. Heart failure correct Correct. Exertional breathlessness, orthopnoea and fluid overload with a reduced ejection fraction and a raised NT-proBNP is heart failure with a reduced ejection fraction.
4. Chronic obstructive pulmonary disease Breathlessness with a smoking history and airflow obstruction. A raised NT-proBNP with a reduced ejection fraction of 30% raises it.
5. Anaemia Breathlessness on exertion with a low haemoglobin. A raised NT-proBNP with a reduced ejection fraction of 30% makes it worth checking.

The point: Heart failure is a clinical syndrome of breathlessness, fatigue and fluid retention arising from a structural or functional cardiac abnormality, and it is separated by the left ventricular ejection fraction into reduced (40% or less), mildly reduced and preserved categories, because only the reduced-fraction group has disease-modifying drug therapy. The diagnosis is supported by a raised natriuretic peptide (BNP or NT-proBNP), and confirmed by echocardiography, which measures the ejection fraction and looks for the valvular, ischaemic or infiltrative cause. In heart failure with a reduced ejection fraction the four pillars of therapy each reduce mortality independently: an angiotensin-converting enzyme inhibitor (or an angiotensin receptor-neprilysin inhibitor), a beta blocker, a mineralocorticoid receptor antagonist and a sodium-glucose cotransporter-2 inhibitor. Loop diuretics relieve congestion and symptoms but do not change prognosis. Device therapy with cardiac resynchronisation or an implantable defibrillator is considered in selected patients with a low ejection fraction and broad QRS or a high arrhythmic risk. Acute pulmonary oedema is treated with sitting up, high-flow oxygen, intravenous loop diuretic and nitrates, with non-invasive ventilation for the patient who is not responding.

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 investigation?

1. Transthoracic echocardiography correct Correct. Echocardiography measures the ejection fraction and identifies the underlying cause, and it is what confirms the diagnosis after a raised natriuretic peptide.
2. Chest radiograph Shows cardiomegaly and pulmonary congestion. A raised NT-proBNP with a reduced ejection fraction of 30% supports it.
3. Bloods for renal function, full blood count and thyroid Finds reversible contributors. A raised NT-proBNP with a reduced ejection fraction of 30% makes it useful.
4. Coronary angiography For an ischaemic cause where revascularisation is considered. A raised NT-proBNP with a reduced ejection fraction of 30% makes it selective.
5. 12-lead ECG Looks for ischaemia, arrhythmia and left ventricular hypertrophy. A raised NT-proBNP with a reduced ejection fraction of 30% makes it routine.

The point: Heart failure is a clinical syndrome of breathlessness, fatigue and fluid retention arising from a structural or functional cardiac abnormality, and it is separated by the left ventricular ejection fraction into reduced (40% or less), mildly reduced and preserved categories, because only the reduced-fraction group has disease-modifying drug therapy. The diagnosis is supported by a raised natriuretic peptide (BNP or NT-proBNP), and confirmed by echocardiography, which measures the ejection fraction and looks for the valvular, ischaemic or infiltrative cause. In heart failure with a reduced ejection fraction the four pillars of therapy each reduce mortality independently: an angiotensin-converting enzyme inhibitor (or an angiotensin receptor-neprilysin inhibitor), a beta blocker, a mineralocorticoid receptor antagonist and a sodium-glucose cotransporter-2 inhibitor. Loop diuretics relieve congestion and symptoms but do not change prognosis. Device therapy with cardiac resynchronisation or an implantable defibrillator is considered in selected patients with a low ejection fraction and broad QRS or a high arrhythmic risk. Acute pulmonary oedema is treated with sitting up, high-flow oxygen, intravenous loop diuretic and nitrates, with non-invasive ventilation for the patient who is not responding.

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 Device therapy in selected low-ejection-fraction patients. A raised NT-proBNP with a reduced ejection fraction of 30% makes it an escalation.
2. Intravenous loop diuretic, oxygen and nitrates The immediate treatment of acute pulmonary oedema. A raised NT-proBNP with a reduced ejection fraction of 30% makes it urgent.
3. A beta blocker licensed for heart failure A second-pillar mortality-reducing drug once stable. A raised NT-proBNP with a reduced ejection fraction of 30% makes it essential.
4. An ACE inhibitor titrated to the maximum tolerated dose correct Correct. An ACE inhibitor is a first-pillar, mortality-reducing drug in heart failure with a reduced ejection fraction and is titrated to the maximum tolerated dose.
5. A sodium-glucose cotransporter-2 inhibitor An SGLT2 inhibitor is one of the four pillars that reduces death and hospitalisation, added to complete disease-modifying therapy, and a raised NT-proBNP with a reduced ejection fraction of 30% here points elsewhere.

The point: Heart failure is a clinical syndrome of breathlessness, fatigue and fluid retention arising from a structural or functional cardiac abnormality, and it is separated by the left ventricular ejection fraction into reduced (40% or less), mildly reduced and preserved categories, because only the reduced-fraction group has disease-modifying drug therapy. The diagnosis is supported by a raised natriuretic peptide (BNP or NT-proBNP), and confirmed by echocardiography, which measures the ejection fraction and looks for the valvular, ischaemic or infiltrative cause. In heart failure with a reduced ejection fraction the four pillars of therapy each reduce mortality independently: an angiotensin-converting enzyme inhibitor (or an angiotensin receptor-neprilysin inhibitor), a beta blocker, a mineralocorticoid receptor antagonist and a sodium-glucose cotransporter-2 inhibitor. Loop diuretics relieve congestion and symptoms but do not change prognosis. Device therapy with cardiac resynchronisation or an implantable defibrillator is considered in selected patients with a low ejection fraction and broad QRS or a high arrhythmic risk. Acute pulmonary oedema is treated with sitting up, high-flow oxygen, intravenous loop diuretic and nitrates, with non-invasive ventilation for the patient who is not responding.

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