Chronic Heart Failure Flashcards
HF
progressive clinical syndrome caused by structural or functional abnormalities of heart, resulting in reduced cardiac output
HF symptoms
~ shortness of breath
~ persistent coughing or wheezing
~ ankle swelling
~ reduced exercise tolerance, and fatigue
~ elevated JVP, pulmonary crackles and oedema
HF reduced ejection fraction
left ventricle loses its ability to contract normally & so presents with ejection fraction of less than 40%
HF preserved ejection fraction
left ventricle loses ability to relax normally so ejection fraction normal or only mildly reduced
if heart failure + reduced ejection fraction of less than 35%.
Implantable cardioverter defibrillators & cardiac resynchronisation therapy
Avoid what drugs in CHF with reduced ejection fraction
Rate-limiting CCB (verapamil, and diltiazem) &short-acting dihydropyridines (e.g. nifedipine, or nicardipine) as can reduce cardiac contrability
4 pillars of heart failure
- ACE or ARBs
- Diuretics
- Beta Blockers
- SGLT-2 inhibitors
Diuretics in HF
~ relief of breathlessness + oedema if fluid retention
~ Loop diuretics (furosemide, bumetanide, or torasemide) = diuretics of choice
~ Thiazide diuretics ONLY if mild fluid retention + eGFR >30
~ aware of hypotension, dehydration or renal impairment
ACE/ARBs/Beta blockers in CHF
~ ACE inhibitor (e.g. perindopril, ramipril, captopril, enalapril maleate, lisinopril, quinapril or fosinopril) + beta-blocker licensed for heart failure (e.g. bisoprolol fumarate, carvedilol, or nebivolol) = 1st line tx
~ if already taking beta-blocker for co-morbidities (e.g. angina or hypertension) & condition stable switched to one licensed for HF
~ ARB licensed for heart failure (e.g. candesartan, losartan, or valsartan) if ACE inhibitors not tolerated.
CHF add on therapy
If symptoms persist or worsen despite optimal 1st tx
~ mineralocorticoid receptor antagonist = spironolactone or eplerenone
~ AVOID in HYPER-KALAMIA, RENAL IMPAIRMENT
ACE inhibitors, ARBs & MRA monitoring requirements
serum K and Na, renal function, & BP checked prior to starting tx, 1-2 weeks after starting tx, & at each dose increment
~ Once target, or maximum tolerated dose achieved, monitored monthly for 3 months & then at least every 6 months, and if patient becomes acutely unwell
Beta blocker monitoring
~ HR
~ BP
~ Symptom control at start of tx and after each dose change
HF symptoms
- dyspnoea
- exercise intolerance/fatigue
- oedema (pulmonary or peripheral)
pulmonary = breathlessness
peripheral = swollen ankles, legs
HF tx steps
- ACE / ARBs
- Beta blockers
- Spironolactone (or eplerenone)
- Ivabradine or digoxin
ARBs licensed in HF
Candesartan, Valsartan
when can you use nebivolol in HF
Mild-moderate HF
in 70+
which beta blocker can you use in all grades of LVSD
Bisoprolol
Carvedilol
when would you add Eplerenone in HF
after acute MI with LSVD or mild heart failure
alternative to spironolactone in heart failure
~ Hydralazine + Isosorbide dinitrate (esp. African/Caribbean)
~ ARB (only given with ACE if no other option!)
~ sacubitril + valsartan (if LVEF <35%+ taking stable dose of ACE/ARB)
when would you add ivabradine in HF
added to standard therapy as 3rd step
if pt in sinus rhythm + HR >75 bpm
when would you add digoxin in HF ?
add as 3rd step
if worsening or severe HF as it doesn’t reduce mortality
if HF patient has fluid overload
add
~ loop diuretic
~ thiazide like diuretic in mild HF
when are thiazide diuretics ineffective
in eGFR <30
