Clinical Management of Heart Failure Flashcards
What is heart failure
- Heart cannot function resulting in raised BP inadequate cardiac output
- Usually caused by left ventricular MI
- survival after 5 yrs progressive
Acute heart failure
Sudden deterioration in HF which can lead to hospitalization
Chronic heart failure
- Established diagnosis of HF or gradual onset of symptoms
- HF with preserved EF
- HF with reduced EF
Ejection Fraction
- Blood pumped out of a filled ventricle when it contracts
- Normal EF aprox 50%
Three main features of Heart failure
- Fatigue
- Breathlessness
- Oedema
Fatigue when having heart failure
Decrease cardiac output causing impaired oxygen levels causing less oxygen reach muscle
Oedema
- Pulmonary or peripheral
- Mix of fluid retention increases pressure in heart and pulmonary muscles
Breathlessness
- Can occur on exertion
- Lying down causing abnormal pressure on diaphragm redistribute oedema on lungs
- Sleep with multiple pillows
Diagnosis of Heart failure
- Signs and symptoms
- Patient history
- Blood levels of NT-proBNP
- ECG check HF
- Exercise tolerance test
- Transthoracic echocardiography assess VF function
Role of NT-proBNP
- N-terminal pro-B-type natriuretic peptide is released in response to pressure changes
- <400ng/L less likely to be HF
- > 2,000ng/L very high levels
NT-proBNP levels exception
- Reduced by obesity and African background
- Levels high over 70
Grading severity
- New York Heart Association
- Based on symptoms dependent on quality of life
Treatment aims of heart failure
- Improve symptoms, functional capacity and quality of life
- Slow condition progression
- Prevent hospitalisation
- Reduce mortality
Managing Heart Failure with Preserved EF
- Preserved EF = EF over 40%
Loop diuretic
- Furosemide
- Titrated dose needed
- Relieve congestive symptoms and fluid retention
- To keep EF high and slow deterioration
Managing heart failure with reduced ejection fraction
- First line ACE inhibitor & Beta blocker
ACE inhibitor for ejection fraction
- ramipril
- decrease morbidity and mortality to improve symptoms
- Start with low dose and gradually increase to max tolerated dose
Beta blocker
- Bisoprolol
- Decrease morbidity and mortality improve symptoms
- Start with low dose and gradually
Mineralocorticoid Receptor Antagonists
- Spironolactone or eplerenone
- Decrease mortality and hospitalisation; improve symptoms
- Add in if still having symptoms despite ACEi and BB
ACE inhibitors side effects
- Dry persistent cough
- Dizzy and light headed
- Headache and diarrhea
- Increase sodium and potassium
Monitoring for ACE inhibitor
- Sodium, potassium and renal function
before starting - Blood pressure before and after each dose
Loop diuretics side effects
- Electrolyte imbalance
- Acute kidney injury
- Fatigue
Loop diuretics red flags
- Stop if causing low potassium levels
Mechanism of action for loop diuretics
- Blocks re-absorption of sodium, chloride and water from renal tubules
- Excretion of urine
Loop diuretics monitoring
- Monitor electrolytes
-Monitor renal function
Specialist Treatment Options
- Add to first line treatment
- Entresto, Digoxin, Ivabradine
SGLT2 Inhibitors
- Added if all Do not work
- Use dapagliflozin or empagliflozin to treat symptomatic HF
with reduced EF - Decrease risk of dying
SGLT-2
Inhibitors side effects
- Constipation
-Hypoglycemia when used with insulin
-Hypovolemia & high BP
Red flags
STOP if develop diabetic
ketoacidosis and do not re-start
Mechanism of SGLT2 inhibitor
- Reversibly inhibit sodium glucose co-transporter
- lower BP less strain on heart
Monitor for SGLT2 inhibitor
- Renal function and ketones
HF in reducing ejection fraction CKD
- Chronic kidney disease impair reserve available for kidney in response to congestion
HF secondary care
- IV diuretics by furosemide diuretic
- Monitor renal function
Lifestyle advice
- Regular exercise can be physically active
- Sleep time diuretic as urination symptoms
- Balance diet and alcohol reduction
Cardiac rehab program
- For stable HF exercise based training program
Co-morbidities with HF
- Diabetes mellitus
- Renal failure
- Hypertension
- Myocardial infarction
Optimal drug management doesn’t work
- Possible heart transplant
- Long waiting list risk of rejection
- Life long immunosuppressed
Palliative care
- HF continue to worsen aimed to optimise quality of life for life threatening condition
Symptom control
- Breathlessness - repeat dose opioid (Oromorph)
- Morphine
- Midazolam help anxiety and agitation
- Nausea and vomiting cyclizine
