Chronic Heart Failure Flashcards
What are the lifestyle changes that a patient with chronic heart failure would benefit from making? (5)
Smoking cessation
Reducing alcohol consumption
Increasing physical exercise if appropriate
Weight control
Dietary changes
- increasing fruit and vegetable consumption
- reducing saturated fat intake
Why can a patient with Chronic heart failure with reduced ejection fraction NOT be given rate-limiting calcium channel blockers, except Amlodipine?
These drugs reduce cardiac contractility. Patients with heart failure and angina may safely be treated with Amlodipine.
Which type of diuretics are recommended for the relief of breathlessness and oedema in patients with fluid retention?
Loop diuretics such as:
- Furosemide
- Bumetanide
- Torasemide
… are usually the diuretics of choice
Thiazide diuretics may only be of benefit in patients with mild fluid retention and eGFR greater than 30 mL/minute/1.73m2
Which ACE inhibitors can be given for heart failure as first line treatments to reduce morbidity and mortality?
- Ramipril
- Captopril
- Enalapril maleate
- Lisinopril
- Quinapril
- Fosinopril sodium
Which beta-blockers licensed for heart failure should be given as first line treatment to reduce morbidity and mortality?
- Bisoprolol fumarate
- Carvedilol
- Nebivolol
If ACE inhibitors are not tolerated, which ARB drugs are licensed for heart failure?
- Candesartan cilexetil
- Losartan potassium
- Valsartan
If heart failure symptoms persist or worsen despite optimal first-line treatment, which aldosterone antagonist should be considered?
- Spironolactone
- Eplerenone
unless contraindicated due to e.g. hyperkalaemia or renal impairment.
What drugs can be considered if a patient cannot tolerate ARBs or ACEi ?
Hydralazine hydrochloride combined with a nitrate.
Should be prescribed under the advice of a heart failure specialist in patients who are intolerant of both ACE inhibitors and ARBs (in particular those of African or Caribbean origin with moderate to severe heart failure).
When initiating ACE i, ARBs and aldosterone agents, what drug monitoring needs to take place?
- Serum potassium and sodium,
- Renal function, and blood pressure
should be checked prior to starting treatment, 1-2 weeks after starting treatment, and at each dose increment.
When initiating beta blockers, what drug monitoring needs to take place?
Heart rate
Blood pressure
Symptom control
should be assessed at the start of the treatment and after each dose change
What are the indications and doses of Furosemide?
Oedema
- 40 mg PO OD
- 20-40 mg maintenance dose OD
- 20-50 mg IM/IV
- Increased in steps of 20 mg every 2 hrs if needed
Resistant Oedema
- 80-120 mg PO OD
- 20-50 mg IV/IM
- Increased in steps of 20 mg every 2 hrs if needed
Resistant Hypertension
- 40-80 mg PO OD
- 20-50 mg IM/IV
- Increased in steps of 20 mg every 2 hrs if needed
What are the contraindications of all loop diuretics?
Anuria;
Comatose and precomatose states associated with liver cirrhosis;
Renal failure due to nephrotoxic or hepatotoxic drugs;
Severe hypokalaemia;
Severe hyponatraemia
What are the cautions for all loop diuretics?
Can exacerbate diabetes (but hyperglycaemia less likely than with thiazides);
Can excacerbate gout;
Hypotension should be corrected before initiation of treatment;
Hypovolaemia should be corrected before initiation of treatment;
Urinary retention can occur in prostatic hyperplasia
Hypokalaemia
What are the common side effects of all loop diuretics?
Dizziness;
Electrolyte imbalance;
Fatigue;
Headache;
Metabolic alkalosis;
Muscle spasms;
Nausea
What are the indications and doses of Bumetanide?
Oedema
- 1 mg PO then 1 mg after 6-8 hrs if required
Oedema, severe cases
- 5 mg PO OD, increased in steps of 5 mg every 12-2 hrs, adjusted according to dose
Do not use to treat gestational hypertension because of the maternal hypovolaemia associated with this condition
What are the contraindications for all Angiotensin converting enzyme inhibitors?
Hereditary or idiopathic angioedema;
History of angioedema associated with prior ACE inhibitor therapy;
The combination of an ACE inhibitor with aliskiren is contra-indicated in patients with an eGFR less than 60 mL/minute/1.73 m2;
The combination of an ACE inhibitor with aliskiren is contra-indicated in patients with diabetes mellitus
What are the cautions for all Angiotensin converting enzyme inhibitors?
Concomitant diuretics; diabetes (may lower blood glucose;
Increased risk of hyperkalaemia);
Patients of black African or African-Caribbean origin (may respond less well to ACE inhibitors);
Peripheral vascular disease or generalised atherosclerosis (risk of clinically silent renovascular disease);
Primary aldosteronism (patients may respond less well to ACE inhibitors);
The risk of agranulocytosis is possibly increased in collagen vascular disease (blood counts recommended);
Use with care in patients with aortic or mitral valve stenosis (risk of hypotension);
Use with care in patients with hypertrophic cardiomyopathy
What are the common side effects for all Angiotensin converting enzyme inhibitors?
Alopecia;
angina pectoris;
angioedema (can be delayed; more common in black patients);
arrhythmias;
asthenia;
electrolyte imbalance;
hypotension;
palpitations;
paraesthesia;
renal impairment;
syncope;
taste altered;
What are the monitoring requirements for all ACE i?
Renal function and electrolytes should be checked before starting ACE inhibitors (or increasing the dose) and monitored during treatment, which should be more frequent if side effects are present
What are the indications and doses for the beta blocker bisoprolol fumerate?
Hypertension
- 5-10 mg PO OD, max 20 mg per day
Angina
- 5-10 mg PO OD, max 20 mg per day
Adjunct in heart failure
- 1.25 mg PO OD for 1 week, increased to 2.5 mg, then increased to 3.75 mg OD for 1 week
What are the contra-indications for Beta-blockers?
Asthma;
Cardiogenic shock;
Hypotension;
Marked bradycardia;
Metabolic acidosis;
Phaeochromocytoma (apart from specific use with alpha-blockers);
Prinzmetal’s angina;
Second-degree AV block;
Severe peripheral arterial disease;
Sick sinus syndrome;
Third-degree AV block;
Uncontrolled heart failure
What are the cautions for Beta-blockers?
Diabetes;
First-degree AV block;
History of obstructive airways disease (introduce cautiously);
Myasthenia gravis;
Portal hypertension (risk of deterioration in liver function);
Psoriasis;
Symptoms of hypoglycaemia may be masked;
Symptoms of thyrotoxicosis may be masked
What are the common side effects for all beta-blockers?
Bradycardia;
Confusion;
Depression;
Dyspnoea;
Erectile dysfunction;
Heart failure;
Paraesthesia;
Peripheral vascular disease;
Sleep disorders;
Syncope;
Visual impairment;
What can beta-blockers cause if given during pregnancy?
Intra-uterine growth restriction
Neonatal hypoglycaemia and bradycardia
The risk is greater in severe hypertension
What are the dose adjustments for beta-blockers for renal impairment?
Max. 10 mg daily if creatinine clearance less than 20 mL/minute
What can treatment cessation for all beta-blockers cause?
Avoid abrupt withdrawal especially in ischaemic heart disease. Sudden cessation of a beta-blocker can cause a rebound worsening of myocardial ischaemia and gradual reduction of dose is preferable when beta-blockers are to be stopped
