CV: Heart failure Flashcards
What forms the basis of treatment for all patients with heart failure due to left ventricular systolic dysfunction?
An ACE inhibitor, titrated to a ‘target dose’ (or the maximum tolerated dose if lower), together with a beta-blocker.
In what patients might an angiotensin-II receptor antagonist be a useful alternative?
Patients who cannot tolerate ACEi due to side effects (cough etc). A relatively high dose of angiotensin-II receptor antagonist might be required to produce benefit.
When may candesartan cilexetil or valsartan be given as adjuncts to an ACEi in the treatment of heart failure?
Only under specialist supervision when other treatments are unavailable. This combination, together with an aldosterone antagonist or a potassium-sparing diuretic is not recommended.
The combination product valsartan with sacubitril exists, what role does it have in the treatment of heart failure?
It may be a suitable alternative for those patients already stablised on an ACEi or angiotensin-II receptor antagonist.
The beta-blockers bisoprolol fumarate and carvedilol are of value in what grade of heart failure? How does this compare with nebivolol?
Bisoprolol or carvedilol = any grade of stable heart failure. Nebivolol is licensed for stable mild to moderate heart failure in patients over 70 years.
What is the first line treatment choice of aldosterone antagonist to be added to an ACE inhibitor and a beta-blocker in patients with heart failure who continue to remain symptomatic?
Spironolactone - low doses reduce symptoms and mortality in these patients. If spironolactone cannot be used, eplerenone may be considered for the management of heart failure after an acute MI with evidence of left ventricular systolic dysfunction, or for chronic mild heart failure with left ventricular dysfunction.
Patients with heart failure who cannot tolerate an ACE inhibitor or an angiotensin-II receptor antagonist can be given what as treatment?
Isosorbide dinitrate with hydralazine hydrochloride - but this combination may be poorly tolerated.
When may the combination of isosorbide dinitrate and hydralazine hydrochloride in addition to standard therapy with an ACE inhibitor and a beta-blocker be considered?
In patiens who continue to remain symptomatic (particularly in patients of African or Caribbean origin who have moderate to severe heart failure).
Digoxin improves symptoms of heart failure and exercise tolerance and reduces hospitalisation due to acute exacerbations. What does it not reduce?
Mortality.
Digoxin in heart failure is reserved for when?
Patients with worsening or severe heart failure due to left ventricular systolic dysfunction who remain symptomatic despite treatment with an ACE inhibitor and a beta-blocker in combination with either an aldosterone antagonist, candesartan or isosorbide dinatrate with hydralazine hydrochloride.
Patients with fluid overload should also recieve what?
A loop or thiazide diuretic (with salt or fluid restriction where appropriate).
When would a thiazide diuretic not be used in patients with mild heart failure?
Thiazide diuretics are ineffective in patients with poor renal function (eGFR less than 30ml/minute/1.73m2).
If diuresis with a single diuretic is insufficient, a combination of what may be tried?
Loop and thiazide and even metolazone - but the resulting diuresis may be profound and care is needed to avoid potentially dangerous electrolyte disturbances.
