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Heart failure

Clinical Discipline(s)/Organ System(s)
Cardiology, Cardiovascular System, Palliative Medicine
Progress Test Topic(s)
Cardiovascular
Description
A 82 year old NZ European man is sent to hospital by his GP because of worsening shortness of breath and fatigue. This has been going on for a few weeks now. He has noted that his ankles are swollen and he reports he had a 'heart attack' 5 years ago. He mentions to you that he's lived a good life and 'wants to be allowed to die with dignity and not be stuck on machines keeping him alive'.
Applied Science for Medicine 
   - Physiology of the renin-angiotensin-aldosterone system
   - Production and function of B-type natriuretic peptide (BNP)
   - Principles of Starling's curve and forces
   - Physiology and different waveforms of jugular venous pressure wave
   - Principles of cardiac re-modelling
   - Aetiology and pathophysiology of heart failure
   - Pharmacology of angiotensin converting enzyme inhibitors, beta adrenoceptor blocking drugs, angiotensin II receptor antagonists, spironolactone, digoxin, sympathomimetics
   - Describe principles of dose-response relationships, drug distribution and repeated drug dosing
Clinical and Communication Skills 
   - History from a breathless patient; consideration of symptoms of heart failure
   - Examination of the cardiovascular system; recognise pulmonary oedema and clinical signs of heart failure
   - Assess fluid status
   - Perform and interpret an ECG
   - Differential diagnosis of breathlessness
   - Interpret electrolytes, BNP, chest X-ray
   - Indications for echocardiogram, angiogram, myocardial perfusion scans, cardiac MRI
   - Classify heart failure by severity [New York Heart Association (NYHA) Functional Classification] and into left, right; systolic, diastolic
   - Management of acute and chronic heart failure: medical,non-medical, electrophysiological/surgical intervention, palliative
   - Role of the heart failure specialist nurse and palliative care services
   - Complications of heart failure
   - Prognosis of heart failure
Personal and Professional Skills 
   - Advance directives and care planning
   - Professional obligations and personal response to withholding and withdrawing treatment
   - Advocacy for patients
Hauora Māori 
   - Awareness of differing risk profiles for Māori (and other disadvantaged populations) compared with non-Māori in New Zealand presenting with dyspnoea (e.g. rheumatic heart disease, tuberculosis)
   - Understanding of inequities in outcomes for Māori with heart failure compared with non-Māori, and application of this to clinical decision making and management
   - Understanding of the role of kaupapa Māori health policies, services and research in reducing heart failure inequalities
   - Ensuring a culturally safe environment in palliative care
Population Health 
   - Causes of heart failure and opportunities for prevention
   - Population groups most severely affected by heart failure
   - Cost-effectiveness of heart failure treatment
   - Social and ethnical barriers to access to healthcare
Conditions to be considered relating to this scenario
Common
acute coronary syndrome (STEMI, NSTEMI and unstable angina), cardiomyopathy (alcoholic, idiopathic, hypertensive, ischaemic), myocarditis, chronic obstructive pulmonary disease, pneumothorax, pneumonia, pulmonary embolism, nephrotic syndrome
Less common but 'important not to miss'
pancreatitis, acute kidney injury, adult respiratory distress syndrome (non-cardiogenic pulmonary oedema)
Uncommon
amyloidosis, sarcoidosis, pulmonary fibrosis, neurogenic pulmonary oedema, high altitude pulmonary oedema
Related Scenarios
[Chronic shortness of breath]