Chronic heart failure

Question 1

What is the first line treatment for chronic heart failure?

Answer 1

ACEi and beta-blocker which is licensed for heart failure. Bisoprolol and carvedilol, nebivolol in stable mild to moderate heart failure in patients over 70 years.

Question 2

First line treatment for chonic heart failure is an ACEi and beta-blocker, which beta-blockers are licensed for stable mild to moderate heart failure? What about if the patient was >70?

Answer 2

ACEi and beta-blocker which is licensed for heart failure. Bisoprolol and carvedilol, nebivolol in stable mild to moderate heart failure in patients over 70 years.

Question 3

What should be monitored at initiation of and dose increase of an ACEi?

Answer 3

Urea
Creatinine
Electrolytes
eGFR

Question 4

What should be monitored at initiation of and dose increase of beta-blockers?

Answer 4

Heart rate
Blood pressure
Clinical status

Question 5

When is nebivolol licensed in heart failure?

Answer 5

For Adult 70 years and over
Initially 1.25 mg once daily for 1–2 weeks, then increased if tolerated to 2.5 mg once daily for 1–2 weeks, then increased if tolerated to 5 mg once daily for 1–2 weeks, then increased if tolerated to 10 mg once daily.

Question 6

What is the second line treatment for chronic heart failure? (3)

Answer 6

An aldosterone antagonist licensed for heart failure (spironolactone or eplerenone)
OR
An ARB licensed for heart failure (candersartan or valsartan - relatively high doses may be needed).
OR
Hydralazine in combination with a nitrate (esp if black or moderate to severe heart failure).

Question 7

Hydralazine in combination with a nitrate is an alternative first-line treatment for what patients?

Answer 7

Patients with heart failure due to left ventricular systolic who are intolerant of ACE inhibitors and ARBs.

Question 8

What is sacubitril?

Answer 8

Neprilysin inhibitor. Combination product of valsartan and sacubitril exists which may be of use for patients already stabilised on an ACE inhibitor or ARB for their heart failure who cannot tolerate beta-blockers.

Question 9

In patients with heart failure due to left ventricular systolic dysfunction who are taking aldosterone antagonists, what parameters must be monitored closely and why?

Answer 9

Serum K+ and creatinine levels in case of the development of hyperkalaemia or deterioration of renal function.

Question 10

When is digoxin used in the management of chronic heart failure?

Answer 10

Worsening or severe heart failure due to left ventricular systolic dysfunction despite first and second-line treatment

Question 11

What are the target levels of digoxin?

Answer 11

If you’re receiving treatment for heart failure, the normal level of digoxin is between 0.5 and 2.0 nanograms of medication per milliliter of blood (ng/ml). If you’re being treated for a heart arrhythmia, the normal level of the drug is between 1.5 and 2.5 ng/ml.

Question 12

What is the place of diuretics in heart failure management?

Answer 12

Routine relief of congestive symptoms and fluid retention - titrated up and down according to need following the initiation of subsequent heart failure therapies.

Question 13

What are the complications of heart failure? (5)

Answer 13

1. Cardiac cachexia - unintentional rapid weight loss (at least 7.5% of normal weight within 6 months).
2. Impaired kidney function.
3. Congestion, left-sided - lungs, right-sided - legs, feet and abdomen.
4. Arrhythmias
5. Angina and heart attacks

Question 14

When would calcium channel blockers be used in heart failure?

Answer 14

Amlodipine should be considered for the treatment of comorbid hypertension and/or angina in patients with heart failure.

BUT verapamil, diltiazem or short-acting dihydropyridine agents should be avoided.