2. Heart Failure HF

Question 1

What is HF

Answer 1

Inability to sufficiently pump blood round the body

Question 2

HF

Tx

With explanation 1️⃣2️⃣3️⃣

Answer 2

0️⃣ Offer diuretics for congestive symptoms and fluid retention LOOP or THIAZIDE

1️⃣ACE/ARB + BB

ALT*
CI to ACE OR ARB: hydralazine + isosorbide (specialist)

If pts over 70 + mild-moderate stable HF: NEBIVOLOL

2️⃣ADD SPIRONOLACTONE
OR
EPLERENONE

In pts with LVSD after MI in mild- HF
ALT* (especially in Afro pts)

(Note: ARB plus ACE only 1st line when there is no other option available)

Replace ACE/ARB with:
Sacubtril (entresto) in pts LVEF <35%(who r taking low dose ACE OR ARB)

3️⃣ADD IVRABADINE <35% LVEF
♥️ bpm 75+
(Added to 1️⃣ and spironolactone/eplerenone

OR

DIGOXIN
(Added to SEVERE or worsening HF) to Improve symptoms, DOES NOT REDUCE MORTALITY)

Question 3

HR

Tx

Basic 1️⃣2️⃣3️⃣

Answer 3

0️⃣ Offer diuretics for congestive symptoms and fluid retention LOOP or THIAZIDE

1️⃣ ACE/ARB +BB (nebivolol >70)

ALT↪️ HYDRALAZINE + ISOSORBIDE

2️⃣ ADD SPRIONOLACTONE/ EPLERENONE

↪️ in Afro pts

ACE+ARB (entresto) (LVEF <35%)
SACUBTRIL
To replace ACE-ARB

3️⃣ ADD to 1️⃣
IVRABADINE

OR

DIGOXIN (improves symptoms not mortality)

Question 4

HR

FIRST LINE

Tx in fluid overload

Answer 4

ADD to Tx

LOOP diuretic (ok in severe HF/ Renal failure)

OR

ADD: THIAZIDES DIURETIC if : please

eGFR <30ml/min/1.73m2 or more

If 1 drug doesn’t work give both, still doesn’t work give:

METOLAZONE is added

Question 5

ACE
Licensed in HF
5

Answer 5

Ramipril 
Captopril
Enalapril
Lisionopril
Quinapril

Question 6

ARB licensed in HF

Answer 6

Candesartan

Valsartan

Question 7

BB

licences in HF

Answer 7

Bisoprolol
Carbvedilol

70+ (nebivolol)

Question 8

Positive inotrope

give few examples

Answer 8

Digoxin
Berberine
Calcium
Calcium sensitisers
Levosimendan
Catecholamines
Dopamine
Dobutamine
Dopexamine
Adrenaline (epinephrine)
Isoproterenol (isoprenaline)
Noradrenaline (norepinephrine)
Angiotensin II
Eicosanoids
Prostaglandins[10]
Phosphodiesterase inhibitors
Enoximone
Milrinone
Amrinone
Theophylline
Glucagon
Insulin

Question 9

Negative inotropic drugs

Give few examples

Answer 9

Beta blockers
Non-dihydropyridine Calcium channel blockers
Diltiazem
Verapamil
Class IA antiarrhythmics such as

Quinidine
Procainamide
Disopyramide
Class IC antiarrhythmics such as

Flecainide
Isovoacangine Voacristine

Question 10

What is an inotrope

Answer 10

Inotropic agents, or inotropes, are medicines that change the force of your heart’s contractions.

There are 2 kinds of inotropes: positive inotropes and negative inotropes.

Positive inotropes strengthen the force of the heartbeat.

Negative inotropes weaken the force of the heartbeat.

Question 11

If ARB used with ACE

Increased risk of?

Answer 11

Severe

Hyperkalaemia
Hypotension
Renal impairment

Question 12

If pts takes

ARB and ACE

Which supplement and which fruit to avoid ?

Answer 12

Potassium supplement or banana

Due to SE hyperkalamia

Question 13

Blood levels of

NT-proBNP

When to refer to specialist

<400ng/L

400-2000ng/L

> 2000ng/L

Answer 13

Unlikely 400 or less

Refer in 6 weeks 400-2000

Refer in 2 weeks or less 2000+

Question 14

HF

Symptoms

Answer 14

breathlessness after activity or at rest

feeling tired most of the time and finding exercise exhausting

swollen ankles and legs

Question 15

HF

what could be the cause?

Answer 15

cardiomyopathy, a disorder of the heart muscle that causes the heart to become weak.

a congenital heart defect.

a heart attack.

heart valve disease.

certain types of arrhythmias, or irregular heart rhythms.

high blood pressure.

emphysema, a disease of the lung.

diabetes.

Question 16

What drug class are

Spironolactone and Eplerenone

Answer 16

aldosterone antagonist

Question 17

Suspected HF sue to symptoms

What is the first thing to do?

Answer 17

Check

Perform ECG 
Consider chest X-ray, 
blood tests -> Measure NT-proBNP
urinalysis, 
peak flow or spirometry

Question 18

Renal function

At …………?

consider lower doses or slower titration of ACEI or ARBs, MRAs, sacubitril valsartan and digoxin.

Answer 18

eGFR 30 to 45 ml/min/1.73 m2

Question 19

HR

classes 1-4
most sever 4

Answer 19

class 1 – you don’t have any symptoms during normal physical activity

class 2 – you’re comfortable at rest, but normal physical activity triggers symptoms

class 3 – you’re comfortable at rest, but minor physical activity triggers symptoms

class 4 – you’re unable to carry out any physical activity without discomfort and may have symptoms even when resting