Chronic heart failure

Question 1

general management

Answer 1

stop smoking
eat less salt
optimize weight and nutrition
treat the cause (eg dysrhythmias, valve disease)
treat exacerbating factors (anaemia, thyroid disease, infection, HTN)
avoid exacerbating factors eg NSAIDs (Na and water retention) and verapamil (negative inotrope)

Question 2

diuretics

Answer 2

reduce the risk of death and worsening of heart failure
loop diuretics eg furosemide to relieve Sx
if refractory oedema (ie does not respond to reduced dietary Na and loop diuretics), consider adding a thiazide eg metolazone

Question 3

ACE-i

Answer 3

consider in all those with left ventricular systolic dysfunction
improves Sx and prolongs life
if cough is a problem, and angiotensin receptor blocker (ARB) may be used instead

aldosterone is also responsible for the excretion of K, so monitor to ensure no hyperkalaemia

Question 4

B-blockers

Answer 4

decrease mortality in HF
these appear to be additional to those of ACE-i in patients with HF due to LV dysfunction
initiate after a diuretic and ACE-i
start low, go slow

Question 5

spironolactone

Answer 5

K sparing diuretic
decreases mortality by 30% when added to conventional therapy
use in those still symptomatic despite optimal therapy with diuretics, ACE-i and B-blockers
little risk of hyperkalaemia even when given with ACE-i

Question 6

digoxin

Answer 6

helps Sx even in those with sinus rhythm
consider if LV dysfunction and signs or Sx of HF whilst receiving standard therapy, or in patients with AF
monitor U&E and maintain K at 4-5mmol/L
digoxin toxicity can lead to arrhythmias and heart block

Question 7

vasodilators

Answer 7

the combination of hydralazine (SE drug induced lupus) and isosorbide dinitrate should be used if intolerant of ACE-i and ARBs as it reduces mortality
also reduces mortality when used for black patients with HF

Question 8

new york classification of heart failure

Answer 8

I. heart disease present, no undue dyspnoea from ordinary activity
II. comfortable at rest, dyspnoea on ordinary activities
III. less than ordinary activities cause dyspnoea, which is limiting
IV. dyspnoea present at rest, all activities cause discomfort

Question 9

BNP as a biomarker of HF

Answer 9

plasma BNP (B-type natriuretic peptide) reflects myocyte stretch
BNP is used to diagnose HF, and distinguishes HF from other causes of dyspnoea more accurately than LV ejection fraction
BNP is highest in decompensated HF, intermediate in LV dysfunction but no acute heart failure exacerbations and lowest if no HF or LV dysfunction

BNP>100ng/L = HF

Question 10

prognosis in HF

Answer 10

the higher the BNP, the higher the cardiovascular and all cause mortality
high BNP in HF is a;lso ass. w/ sudden death