Cardiac Failure - Presentation Outline

Format suggestion: Aim for ~20-25 slides total split evenly between two presenters (Person A covers the foundational science/diagnosis half; Person B covers management/primary care/follow-up half).

PERSON A - Foundations & Diagnosis

1. Introduction (2-3 slides)

• Epidemiology in Malaysia - HF is the leading cause of hospital admissions in Malaysian public hospitals; prevalence is rising as the population ages (CPG 2023, Section 1.1)
• Socio-economic burden on the Malaysian health system (CPG Section 1.2)
• Why family medicine matters here - HF is primarily managed at primary care level; seamless hospital-to-primary-care handover is a focus of the 2023 CPG

2. Definition & Classification (2 slides)

• Definition: HF is a clinical syndrome in which the heart fails to pump adequate blood to meet the body's metabolic demands at normal filling pressures (Textbook of Family Medicine 9e)
• Classification by LVEF (new in Malaysian CPG 2023 - classified by LVEF and clinical presentation, not just presentation alone):
  • HFrEF - LVEF <40%
  • HFmrEF - LVEF 40-49%
  • HFpEF - LVEF ≥50%
  • HFimpEF - previously reduced EF now improved
• NYHA Functional Classification (I-IV) - clinical severity
• ACC/AHA Stages A-D - includes prevention stages

3. Pathophysiology (2 slides)

• Neurohormonal model - RAAS activation, sympathetic nervous system activation, aldosterone escape, catecholamine toxicity
• LV remodeling: cardiac fibrosis, myocyte apoptosis, collagen deposition
• Key mediators: Angiotensin II, aldosterone, endothelin-1, inflammatory cytokines
• Tip: use a diagram of RAAS to show why drugs like ACEi/ARB/MRA/ARNI block specific steps
• (Textbook of Family Medicine 9e, p. 577-580)

4. Aetiology (1-2 slides)

• Common causes in Malaysia (CPG Section 5):
  • Ischaemic heart disease (most common)
  • Hypertension
  • Dilated cardiomyopathy
  • Valvular heart disease (rheumatic in younger patients - still relevant in Malaysia)
  • Diabetes mellitus
  • Thyroid disease, anaemia, alcohol
• Precipitating factors (FAILURE mnemonic): Forgotten medication, Arrhythmia, Infection/Ischaemia, Lifestyle, Uraemia/Renal failure, Embolism, Rheumatic/valvular problems

5. Clinical Presentation & Diagnosis (3 slides)

• Symptoms: dyspnoea (exertional, orthopnoea, PND), fatigue, ankle swelling
• Signs: raised JVP, S3 gallop, bilateral basal crepitations, peripheral oedema, displaced apex beat, hepatomegaly, ascites
• Framingham criteria (for clinical diagnosis)
• Investigations (CPG Section 6.2):
  • ECG - rarely normal in HF; look for LVH, AF, LBBB, Q waves
  • Chest X-ray - cardiomegaly, pulmonary oedema, Kerley B lines
  • Natriuretic peptides - BNP/NT-proBNP (CPG emphasises this for early diagnosis in primary care; key barrier in Malaysia is availability at KKs)
  • Echocardiogram - gold standard to confirm, classify HF and guide therapy
  • Lung ultrasound (newer tool)
  • Bloods: FBC, RFT, LFT, TFT, fasting glucose, lipids, urine dipstick

PERSON B - Management & Primary Care

6. Prevention of Heart Failure (1 slide)

• Stage A ("At Risk") - manage risk factors: HTN, DM, dyslipidaemia, obesity, smoking, alcohol (CPG Section 7.1)
• Stage B ("Pre-HF") - structural changes without symptoms; start ACEi/ARB in asymptomatic LV dysfunction (CPG Section 7.2)
• This is where family medicine has the greatest impact - identifying and aggressively treating Stage A/B

7. Non-Pharmacological Management (1-2 slides)

• Patient education - disease understanding, medication adherence, self-monitoring (weight daily, fluid restriction)
• Exercise training - cardiac rehabilitation is beneficial in stable HFrEF
• Diet: sodium restriction (<2g/day), fluid restriction if Na <130 mmol/L or symptomatic congestion
• Lifestyle: smoking cessation, alcohol restriction, weight management
• Psychosocial support - depression and anxiety are common in HF (CPG Sections 8.1-8.8)
• Avoid NSAIDs, thiazolidinediones, most CCBs (diltiazem, verapamil) in HFrEF

8. Pharmacological Management - HFrEF (3 slides)

• Loop diuretics (e.g. furosemide) for symptom relief only - do not reduce mortality
• Note Malaysian context: ARNI not available in government formulary; SGLT2i available in small quota at primary care, initially only for diabetics - CPG 2023 highlights this as a barrier

9. Pharmacological Management - HFpEF & HFmrEF (1 slide)

• HFpEF: no proven mortality-reducing drugs; SGLT2i now recommended (EMPEROR-Preserved trial); control rate in AF, treat underlying causes, diuretics for congestion
• HFmrEF: treat similar to HFrEF; consider all four pillars

10. Acute Heart Failure (Acute Decompensation) (1-2 slides)

• Recognition: acute pulmonary oedema, cardiogenic shock
• Initial management (LMNOP mnemonic):
  • L - Loop diuretic (IV furosemide)
  • M - Morphine (use with caution, now controversial)
  • N - Nitrates (if SBP >90mmHg)
  • O - Oxygen
  • P - Position (sit upright)
• When to call for help/transfer - haemodynamic instability, SpO2 not improving, need for NIV/intubation
• CPG 2023 Sections 9 & 10

11. Device Therapy & Referral Indications (1 slide)

• ICD - primary prevention of sudden cardiac death in HFrEF with LVEF ≤35% despite 3 months optimal medical therapy
• CRT (Cardiac Resynchronisation Therapy) - LVEF ≤35%, LBBB, QRS ≥150ms, symptomatic despite OMT
• When to refer from primary care to cardiology (CPG 2023):
  • Newly diagnosed HF for echocardiogram and initiation of therapy
  • Decompensation not responding to treatment
  • LVEF ≤35% (for ICD/CRT consideration)
  • Diagnostic uncertainty

12. HF in Primary Care - The Malaysian Context (1-2 slides)

• HF Clinic model - CPG 2023 proposes structured multidisciplinary HF clinics at tertiary level with step-down care to primary care (Klinik Kesihatan)
• Primary care physician's role:
  • Identify Stage A/B patients
  • Post-discharge follow-up within 7-14 days
  • Medication optimisation, monitoring renal function/electrolytes
  • Monitoring fluid status, weight charting
  • Patient and carer education
• Barriers at primary care: limited access to BNP/NT-proBNP, ARNI not in formulary, limited SGLT2i quota (CPG 2023 explicitly acknowledges these)

13. Monitoring & Prognosis (1 slide)

• Regular monitoring: BP, HR, weight, renal function, electrolytes (especially K+ on ACEi/MRA/SGLT2i)
• Red flags for decompensation: weight gain >2kg in 3 days, worsening oedema, dyspnoea at rest
• Prognosis: 5-year mortality ~50% after diagnosis; right heart failure, low Na, high creatinine = poor prognosis

14. Conclusion (1 slide)

• HF is a growing burden in Malaysia, manageable at primary care
• Early identification and treatment of risk factors (Person A's role)
• Optimising all four foundational medications = best survival benefit
• Family physician as coordinator of care between hospital and community

Quick Reference - Malaysian CPG 2023 Key Updates vs. 2019

Tips for the Presentation

• The Malaysian CPG 2023 (MOH full PDF) should be your primary reference; cite it explicitly
• In family medicine posting, emphasise prevention (Stages A/B), primary care role, and referral criteria - these are commonly examined
• Be prepared for questions on: why furosemide alone is not enough, why SGLT2i is now used even in non-diabetics, and the practicality of prescribing ARNI at KK level in Malaysia
• Use a clinical case vignette (e.g. 60-year-old Malay male, hypertensive, presents with SOB and bilateral ankle swelling) to thread the whole presentation together - it makes it more engaging and examiner-friendly