Chronic Heart Failure

Question 1

What are the lifestyle changes that a patient with chronic heart failure would benefit from making? (5)

Answer 1

Smoking cessation
Reducing alcohol consumption
Increasing physical exercise if appropriate
Weight control
Dietary changes
- increasing fruit and vegetable consumption
- reducing saturated fat intake

Question 2

Why can a patient with Chronic heart failure with reduced ejection fraction NOT be given rate-limiting calcium channel blockers, except Amlodipine?

Answer 2

These drugs reduce cardiac contractility. Patients with heart failure and angina may safely be treated with Amlodipine.

Question 3

Which type of diuretics are recommended for the relief of breathlessness and oedema in patients with fluid retention?

Answer 3

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

Question 4

Which ACE inhibitors can be given for heart failure as first line treatments to reduce morbidity and mortality?

Answer 4

• Ramipril
• Captopril
• Enalapril maleate
• Lisinopril
• Quinapril
• Fosinopril sodium

Question 5

Which beta-blockers licensed for heart failure should be given as first line treatment to reduce morbidity and mortality?

Answer 5

• Bisoprolol fumarate
• Carvedilol
• Nebivolol

Question 6

If ACE inhibitors are not tolerated, which ARB drugs are licensed for heart failure?

Answer 6

• Candesartan cilexetil
• Losartan potassium
• Valsartan

Question 7

If heart failure symptoms persist or worsen despite optimal first-line treatment, which aldosterone antagonist should be considered?

Answer 7

• Spironolactone
• Eplerenone

unless contraindicated due to e.g. hyperkalaemia or renal impairment.

Question 8

What drugs can be considered if a patient cannot tolerate ARBs or ACEi ?

Answer 8

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).

Question 9

When initiating ACE i, ARBs and aldosterone agents, what drug monitoring needs to take place?

Answer 9

• 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.

Question 10

When initiating beta blockers, what drug monitoring needs to take place?

Answer 10

Heart rate
Blood pressure
Symptom control

should be assessed at the start of the treatment and after each dose change

Question 11

What are the indications and doses of Furosemide?

Answer 11

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

Question 12

What are the contraindications of all loop diuretics?

Answer 12

Anuria;

Comatose and precomatose states associated with liver cirrhosis;

Renal failure due to nephrotoxic or hepatotoxic drugs;

Severe hypokalaemia;

Severe hyponatraemia

Question 13

What are the cautions for all loop diuretics?

Answer 13

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

Question 14

What are the common side effects of all loop diuretics?

Answer 14

Dizziness;

Electrolyte imbalance;

Fatigue;

Headache;

Metabolic alkalosis;

Muscle spasms;

Nausea

Question 15

What are the indications and doses of Bumetanide?

Answer 15

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

Question 16

What are the contraindications for all Angiotensin converting enzyme inhibitors?

Answer 16

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

Question 17

What are the cautions for all Angiotensin converting enzyme inhibitors?

Answer 17

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

Question 18

What are the common side effects for all Angiotensin converting enzyme inhibitors?

Answer 18

Alopecia;

angina pectoris;

angioedema (can be delayed; more common in black patients);

arrhythmias;

asthenia;

electrolyte imbalance;

hypotension;

palpitations;

paraesthesia;

renal impairment;

syncope;

taste altered;

Question 19

What are the monitoring requirements for all ACE i?

Answer 19

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

Question 20

What are the indications and doses for the beta blocker bisoprolol fumerate?

Answer 20

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

Question 21

What are the contra-indications for Beta-blockers?

Answer 21

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

Question 22

What are the cautions for Beta-blockers?

Answer 22

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

Question 23

What are the common side effects for all beta-blockers?

Answer 23

Bradycardia;

Confusion;

Depression;

Dyspnoea;

Erectile dysfunction;

Heart failure;

Paraesthesia;

Peripheral vascular disease;

Sleep disorders;

Syncope;

Visual impairment;

Question 24

What can beta-blockers cause if given during pregnancy?

Answer 24

Intra-uterine growth restriction

Neonatal hypoglycaemia and bradycardia

The risk is greater in severe hypertension

Question 25

What are the dose adjustments for beta-blockers for renal impairment?

Answer 25

Max. 10 mg daily if creatinine clearance less than 20 mL/minute

Question 26

What can treatment cessation for all beta-blockers cause?

Answer 26

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