Step 2 – Practice learning objectives with virtual patient

Interactive Consultation Practice:

Objective: Develop and refine your consultation skills using a virtual patient interface.

Procedure:

• Review the written segments below, that detail the case explained in the Step 1 video.
• Formulate questions for each segment of the case.
• Use the virtual patient interface, located on the right side of your screen, to practice your consultation skills.
• Engage with the virtual patient by posing your formulated questions and interacting based on the provided text.
• Note: This step is optional but highly recommended for a comprehensive understanding and hands-on experience. When you’ve finished your practice select ‘Mark Complete’ to proceed to your assessment.

Learning Objectives

By the end of this module you will be able to:

• Identify the common risk factors for heart failure
• Be familiar with key investigations for workup of a patient suspected to have heart failure
• Understand the latest guidelines for managing chronic heart failure

Meet Bob

• Bob is a 65-year-old male who is new to your GP clinic
• He is a retired accountant and enjoys gardening in his spare time.
• He has come to you today due to shortness of breath on exertion.

Learning Objectives - History

Bob’s history is suggestive of a chronic cardiovascular condition, as opposed to an acute or respiratory condition:

• Symptoms gradually worsening over past 6 months
• SOBOE, orthopnoea, reduced exercise tolerance, ankle swelling 
• Absence of cough, sputum production, and chest tightness 

Bob has multiple risk factors for heart failure:

• HTN, previous MI, probable undiagnosed OSA
• Old age, male, positive family Hx for cardiac disease

Other modifiable potential risk factors:

• Hyperlipidemia, obesity, diabetes, heavy smoking and alcohol use

Remember to ask about the patient’s  functional capacity

• NYHA classification provides a simple way of grading functional capacity i.e. extent of heart failure
• It provides a good marker of prognosis

Red flag conditions to keep in mind and exclude:

• MI, pericardial disease, pulmonary embolism, aortic dissection, pneumonia

Learning Objectives - Physical Exam

• The apex beat is laterally displaced
• Presence of third heart sound, but no murmurs 
• JVP likely elevated
• Peripheral oedema up to ankles bilaterally
• Signs of bilateral pleural effusion present

Learning Objectives - Investigations

• Echo is key for diagnosis of heart failure
• • Measures ejection fraction to determine if pt has heart failure with reduced (<50%) or preserved (>50%) EF
  • Looks for any wall motion abnormalities 
  • Determines wall thickness and size of chambers
• BNP/NT-proBNP can support the diagnosis and suggests disease severity
• • HF is unlikely if BNP <100 pg/ml or NT-proBNP <300 pg/ml
• CXR can support the diagnosis and assesses for complications
• • May show characteristic signs of HF e.g. cardiomegaly
  • Complications may be present e.g. pulmonary oedema, pleural effusion
• ECG + troponin helpful to exclude ACS
• • ECG can also exclude aF, LV hypertrophy, ongoing myocardial ischaemia or frequent ventricular ectopic beats
• D-dimer helpful to exclude PE or acute aortic dissection
• • PE or AA dissection is unlikely if value is normal
• Other tests are useful to screen for risk factors, causes or exacerbating factors of HF:
• • FBC (anaemia), U&Es, TFTs, fasting glucose, lipids, MSU (UTI)

Learning Objectives - Management

MEDICATIONS 

All patients with CHF should be prescribed a combination of the following regular meds:

• ACEi e.g. ramipril; use ARB only if intolerant to ACEi e.g. candesartan
• B-blocker e.g. metoprolol
• Aldosterone antagonist e.g. spironolactone
• SGLT2-inhibitor e.g. dapagliflozin

After 3 months, switch ACEi to ARNI e.g. sacubitril/valsartan (Entresto).

• Monitor frequently for hypotension, kidney impairment, and hyperkalaemia.
• Use diuretics (e.g. furosemide) only to treat fluid overload; reduce or cease once euvolaemia is achieved.

LIFESTYLE MODIFICATION

• Recommend patient cut down/quit smoking and alcohol intake 
• Restrict dietary salt intake 
• Restrict fluid intake to 1.5L/day
• Encourage light-moderate intensity exercise as tolerated

GENERAL ADVICE

• Strongly advise patient to adhere to medication 
• Poor compliance with medication is the most common cause for acute decompensated heart failure