Heart failure Flashcards
Definition
Heart failure occurs when.
- the heart is unable to maintain sufficient cardiac output
- to meet the demands of the body.
In NZ 12,000 admissions/y (7,000 patients)
Costs 2% health budget
30% die within first year after admission to hospital
Causes
Condition predominantly of the elderly
NP Radiotherapy causes arrythmia
https://academic.oup.com/view-large/305162883
Cause & Examples of presentations
- Specific investigations
1. CAD
MI, Angina or “angina-equivalent” Arrhythmias
- Invasive coronary angiography
- CT coronary angiography
- Imaging stress tests (echo, nuclear, CMR)
2. Hypertension
HF with preserved systolic function
Malignant hypertension/acute pulmonary oedema
- 24 h ambulatory BP
- Plasma metanephrines, renal artery imaging
- Renin and aldosterone
3. Valve disease
Primary valve disease e.g., aortic stenosis
Secondary valve disease, e.g. functional regurgitation
Congenital valve disease
- Echo – transoesophageal/stress
4. Arrhythmias
Atrial tachyarrhythmias
Ventricular arrhythmias
Ambulatory ECG recording
- Electrophysiology study, if indicated
5. CMPs = cardiomyopathy
All Dilated Hypertrophic
Restrictive ARVC
Peripartum Takotsubo syndrome
Toxins: alcohol, cocaine, iron, copper
- CMR = cardiac magnetic resonance
- Genetic testing
- Right and left heart catheterization
- CMR, angiography
- Trace elements, toxicology, LFTs, GGT
Factors independently associated with a worsening prognosis
- Age > 70 years
- EF ≤ 30%
- Higher NYHA functional class
- Anaemia
- Renal impairment
- Hypotension
- Hyponatraemia
- High levels of BNP
- Co-morbidities including IHD, arrhythmias, diabetes, COPD, stroke
- Recurrent hospitalisation
The History
- Exposure to cardiotoxic agents
- Current and past alcohol consumption
- Smoking
- Collagen vascular disease
- HIV
- Thyroid disorder
- Phaeochromocytoma
- Obesity
Family History
- Atherosclerotic disease
- Sudden cardiac death
- Myopathy – Cardiomyopathy – Skeletal myopathy
- Conduction system disease
- Tachyarrhythmias
symptoms and sign typical of heart failure
Symptoms
- Orthopnea and PAD are more consistent symptoms of HF, due to fluid accumulation and/or poor cardiac output
- dyspnoea → exertional dyspnoea → dyspnoea at rest → orthopnoea → paroxysmal nocturnal dyspnoea
- lethargy/fatigue/weakness
- weight change: gain or loss
- dizzy spells/syncope
- palpitations
- ankle oedema
Signs
- – Elevated JVP
- – Deviated apex beat, S3
- – Basal inspiratory crackles
Differential diagnosis
- Respiratory
- Liver
- Thyroid disease
- Anaemia
- Obesity
- Physical deconditioning
- Angina
- Acute coronary syndrome
Heart Failure Assessment
Initial
- – Underlying cause?
- – Behaviours associated with worsening HF? (smoking, alcohol, illicit drugs)
- – Examination
- – wt, volume status
- – Na, K, urea, creatinine, urate, TFTs, lipids, glucose, Hb, MSU
- – ECG, CXR, echo
Tthe diagnosis algorithm of heart failure
Diagnosis is difficult Only 1/4 - 1/3 confirmed by cardiologist
Investigations
Apart from routine investigations,
Left ventricular function should be measured by:
- echocardiography (the most important test)
- or nuclear gated blood pool scanning
- to determine the ejection fraction,
- which is usually very low in heart failure.
B-type natriuretic peptide is a marker of the severity of CHF.
ifferentiate between systolic (commonest) and diastolic failure.
BNP
BNP is a good screening useful tool for diagnosis and
Ocasionally used to monitor Rx or when it is worsen
In NZ levels <35 is nromal
Use:
- SOB or oedema with uncertain diagnosis
- Ankle oedema of uncertain cause
Levels rise with:
- ↑LV filling pressure
- acute MI/ischaemia
- PE,
- CORD
- CRF
- ↑age: so it could be normal for age
- women
Level lower with obesity
NT proBNP
Acute HF unlikely
- NT-proBNP < 35.4pmol/L
Age stratified cutpoints (pmol/L)
Patient age HF unlikely HF likely
<50 35.4 – 53.1 >53.1
50-75 35.4 – 106.2 >106.2
>75 35.4 - 212.4 >212
Stages in the Development of Heart Failure
Stage A Groups at risk of HF with normal LV fn CAD, ↑BP, DM
Stage B asymptomatic LVH +/- LV impairment
Stage C Current or past symptoms + structural heart disease
Stage D Refractory HF
Treatment
Includes:
- appropriate pt education
- determination and Rx of the caus
- removal of any precipitating factors
- general non-pharmaceutical measures
- drug Rx.
Studies have shown the benefit of a multidisciplinary approach.
Keep ferritin >100:
- becasue it make HF worse
- Also iron absortion gets less in HF
- It is a good indication for FERINJECT
If EF impaired with treatment DO NOT reduce mdications dose due to high risk of relapse and death from HF
General non—pharmacological management
Refer for a rehabilitation program with interdisciplinary care
Physical activity:
- rest if symptoms severe;
- moderate activity when symptoms are absent or mild
Weight reduction, if pt obese
Salt restriction:
- advise no-added-salt diet (<2 g or 60–100 mmol/d)
Encourage no smoking and limited alcohol (1 SD/d)
Water restriction:
- water intake should be limited to ≤1.5 L/d in pts with advanced HF,
- esp. when the serum sodium falls below 130 mmol/L
Fluid aspiration if a pleural effusion or pericardial effusion is present
Heart Failure Ongoing Review
- Ability to perform daily activities
- Weight, volume status
- Diet, sodium intake, alcohol, drugs
- Monitor Na, K, creat/ eGFR, Hb
Prevention
Common
Approx 80% hospitalised > 65 years
Condition predominantly of the elderly
The emphasis on prevention is very important
- since the onset of HF is generally associated with a very poor prognosis.
Approx. 50% of pts with severe HF die within 2–3 yrs of diagnosis.
Drug therapy of systolic heart failure
Any identified underlying factor should be treated.
Initial drug therapy should consist of an ACE inhibitor and usually a diuretic.
- ACEI is the key drug; this optimises response and improves diuretic safety
Loop diuretics such as frusemide are
- preferred for acute episodes
- although other diuretics may be used for long-term maintenance therapy.
AF should be treated with digoxin.
Vasodilators are widely used and ACE inhibitors are currently the most favoured vasodilator.
Monitor and maintain potassium level in all pts.
ACE inhibitors, β-blockers and spironolactone have been shown to improve survival in CHF and in combination are the gold standard.
ACE inhibitors
Start low,
- go slow
- aim high
Dosage of ACE inhibitor:
- start with ¼ to ½ lowest recommended therapeutic dose
- and then adjust for the individual pt by gradually increasing it to the maintenance or max. dose.
Once-daily agents are preferred.
Use ARB (sartan) if cough with ACEI.
The first dose should be given at bedtime to prevent orthostatic hypotension ( due to diuresis )
Potassium-sparing diuretics or supplements should not be given with ACE inhibitors because of the danger of hyperkalaemia
Kidney function and potassium levels should be monitored in all patients
Angiooedema could take 2-3 days to settle
Titrate HF medications over two weeks
Some ACE inhibitors in common usage
Drug Initial daily dose Maintenance daily dose
Captopril 6.25 mg (o) nocte 25 mg (o) tds
Enalapril 2.5 mg (o) nocte 10 mg (o) bd
Fosinopril 5 mg (o) nocte 20 mg (o) nocte
Lisinopril 2.5 mg (o) nocte 5–20 mg (o) nocte
Perindopril 2 mg (o) nocte 4 mg (o) nocte
Quinapril 2.5 mg (o) nocte 20 mg (o) nocte
Ramipril 1.25 mg (o) nocte 5 mg (o) nocte
Trandolapril 0.5 mg (o) nocte 2–4 mg (o)/d
Diuretic
add this to the ACE inhibitor if congestion only
Loop diuretic preferred:
–frusemide 20–40 mg (o) once or twice daily or
- if wt increased by 1 kg, increase frusemide 1 mg
–ethacrynic acid 50 mg (o)/d or
–(thiazide type diuretic)
–hydrochlorothiazide 25–50 mg (o) daily (or other thiazide) or
–indapamide 1.5–2.5 mg (o) daily
Beta-blockers
Selective β-blockers prolong survival of pts with mild to moderate CHF taking ACE inhibitors.
Start with low doses (start low—go slow).
Beta-blockers approved to treat heart failure
Drug Initial daily dose Target dose
Bisoprolol 1.25 mg (o) 10 mg (o) daily
Carvedilol 3.125 mg (o) bd 25 mg (o) daily
Metoprolol ER 23.75 mg (o) 190 mg (o) daily
Nebivolol 1.25 mg (o) 10 mg (o) daily
Heart failure (unresponsive to first-line therapy)
Stepwise strategy:
ACE inhibitor plus
Frusemide 40–80 mg (o) bd plus
Selective β-blocker plus
Spironolactone 12.5–25 mg (o)/d (monitor potassium and KFTs)
Digoxin (if not already taking it)
- –0.5–0.75 mg (o) statim (depending on kidney function) then
- –0.5 mg (o) 4 h later then
- –0.5 mg the following day then
- –individualise maintenance plus
Consider sacubitril + valsartan (Entreso) if still symptomatic after first-line agents
Severe heart failure, management
- Seek specialist advice
- Hospital with bed rest
- ACE inhibitor (o) to max. tolerated dose
- Frusemide to max. 500 mg/d
- Selective β-blocker plus
- Spironolactone (low dose) 25 mg/d
If poorly controlled, consider adding:
- thiazide diuretic
- spironolactone—doses ↑ 100–200 mg/d
- a β-blocker
- digoxin
- heparin (if confined to bed)
If still uncontrolled, consider other vasodilators:
- isosorbide dinitrate and hydralazine
Consider cardiac transplantation for appropriate pts with:
- end-stage heart failure
- e.g. patients <50 yrs with no other major disease
Other surgical options include:
- heart valvular surgery
- CABG and
- surgical ventricular restoration (surgical reduction of an enlarged left ventricle).
Pitfalls in management
Excessive use of diuretics (most common treatment error)
Giving an excessive loading dose of ACE inhibitor
Failure to correct remedial causes or precipitating factors
Failure to measure left ventricular function
Failure to monitor electrolytes and kidney function
A stepwise pharmacological management approach to heart failure
Diastolic heart failure, Management
is based on treating the cause such as:
- hypertension
- ischaemia and
- diabetes.
The basic treatment is with:
- inotropic agents such as calcium antagonists (verapamil, diltiazem) and
- β-blockers.
If possible, avoid diuretics, digoxin, nitrates and nifedipine.
Acute severe heart failure, Treatment
(acute pulmonary oedema)
Keep in mind LMNOP—lasix, morphine, nitrates, O2, CPAP
Prop patient up
Oxygen (mask or intranasal) 6–8 L/min
Insert IV line
Glyceryl trinitrate 300–600 mcg sublingual or spray:
- can use IV nitrates in preference to morphine
- (if BP >100 mm Hg)
Frusemide 40 mg IV, ↑ 80 mg IV slowly as nec.
Morphine 1–2.5 mg/min IV slowly (↑ 5–10 mg), esp. if chest pain
CPAP (continuous positive airway pressure) or BiPAP
Give digoxin if rapid atrial fibrillation and pt not taking it.
Morphine is now less favoured.
Glyceryl trinitrate IV (in hospital) is preferred.
Continuous +ve airway pressure (CPAP) is effective.
Heart Failure Management Stage A
(high risk)
- BP < 140/85 (DM < 130/80) Optimal control → ↓ risk 50%
- Lipids LDL < 1.8, (DM < 1.5)
- DM (women 3x ↑risk)
- Metabolic syndrome (trials underway)
- Stop smoking, no illicit drugs, avoid Xs alcohol
- AF/ tachycardia – heart rate control Consider cardioversion
- Treat IHD
- Treat thyroid disease
- No evidence of benefit from nutritional supplements
- ACEI/ ARB may reduce risk
Heart Failure Management Stage B
asymptomatic LV dysfunction / LVH
• Remedy structural problem (if appropriate)
- – Coronary revascularisation
- – Valve surgery
- – Control atrial fibrillation
• Post MI
- – Beta blockers (metoprolol, carvedilol)
- – ACEI/ARB
• LV impairment
- – Beta-blockers, ACEI/ARB
- – Avoid digoxin unless AF
- – CCB may be harmful
• LVH
- –ACEI/ARB
- –Metoprolol/ Verapamil
• No evidence of benefit from nutritional supplements
Heart Failure Management Stage C
Current or Prior Symptoms of HF
In order
(In general wait at least 3/12 after Rx then repaet echo for the outcome in younger people)
• Diuretics
• ACEI/ARB
- Doses cilazapril 5mg, quinapril 20mg bd candesartan 32mg, losartan 50mg
- Consider ACEI + ARB if still symptomatic
• Beta-blockers – metoprolol CR 190mg, (avoid metoprolol tartrate) carvedilol 25mg bd
- Avoid or withdraw NSAIDs
- Review CCB, antiarrhythmic therapy
• Spironolactone – class III, IV. 12.5 – 25mg.
- Not if eGFR < 30, stop if K > 5.5
• Digoxin - ↓hospitalisation
Heart Failure Management Initiating Treatment
- Diuretic first for symptomatic relief
- ACEI – starting dose dependent on BP change to ARB if persistent cough
- Beta blocker – initiate after ACEI unless symptomatic ischaemia or arrhythmia
- Low BP
- – carvedilol 3.25mg bd or metoprolol ½ 23.75mg
- – double dose fortnightly as tolerated
- Late addition of spironolactone if full dose ACEI and beta – blocker and satisfactory renal function
- Add ARB (to ACEI) if still symptomati
Heart Failure Management Stage C
Symptomatic, normal LV systolic function
- Mainly elderly women with ↑BP, DM or both
- Often associated with AF or coronary disease
- Similar morbidity and mortality to abnormal LV function
- Aim for
- – BP control
- – Ventricular rate control with AF
- – Consider cardioversion to SR
- – Consider coronary disease and revascularisation
Heart Failure Management Stage C –
Symptomatic Adjuvant therapy
- Multidiscipline Team – GP, hospital nurse and cardiologist, patient and family
- Patient education and daily weigh at home
- Avoid NSAIDs, amphetamines/stimulants
- Exercise training
- Biventricular pacing for cardiac dyssynchrony
- AICD – automated implantable cardioverter – defibrillator
- AF/ tachycardia ablation
- Nutritional and hormonal supplementation is not recommended except omega 3 fatty acids
- Anticoagulation is not routinely recommended
Heart Failure Management Stage D
Refractory End-Stage
- Meticulous control of fluid retention
- Referral for cardiac transplantation in potentially eligible patients
- End-of-life/ hospice care
Therapeutic algorithm of Class I Therapy Indications for a patient with heart failure with reduced ejection fraction
ACE-I = angiotensin-converting enzyme inhibitor; ARNI = angiotensin receptor-neprilysin inhibitor; CRT-D = cardiac resynchronization therapy with defibrillator; CRT-P = cardiac resynchronization therapy pacemaker; ICD = implantable cardioverter-defibrillator; HFrEF = heart failure with reduced ejection fraction; MRA = mineralocorticoid receptor antagonist; QRS = Q, R, and S waves of an ECG; SR = sinus rhythm. aAs a replacement for ACE-I. bWhere appropriate. Class I=green. Class IIa=Yellow.
Neprilysin Inhibitor / ARB
Entresto (Sacubitril / Valsartan)
‒ Contraindicated with ACEI (because of the risk of angioedema)
- Withhold ACEI for 3/7 prior to starting
‒ Start with the lowest dose
‒ Needs Special Authority (NZ criteria)
- on optimal treatment
- EF < 35%
- NYHA Class II – IV
Neprilysin Inhibition Potentiates Actions of Endogenous Vasoactive Peptides That Counter Maladaptive Mechanisms in Heart Failure
PARADIGM-HF: Cardiovascular Death or Heart Failure Hospitalization (Primary Endpoint)
PARADIGM-HF: Cardiovascular Death
SGLT2 Inhibitors
Dapagliflozin, Empagliflozin, Sotagliflozin
- (SGLT1 and 2 inhibitor)
‒ Considered as the statins of 2022
‒ Increase renal excretion of glucose
- Lower blood glucose
- but it does not casue hypoglycaemia in non diabetic pts
- associated with UTI nad rare, life-threatening necrotizing genital infections
‒ HFrEF - 26% reduction in CV death or worsening heart failure
‒ Acute HF (DM2) 33% reduction CVD, hospitalizations for acute heart failure and urgent heart failure visits NNT = 4/1 year
‒ CKD – 44% reduction in adverse renal events ‒ Reduces events in HFpEF
- withraw for few days prior to GA due to ketaoacidosis
The most common side effects include:
- genital yeast infections
- flu-like symptoms
- a sudden urge to urinate.
EMPEROR Reduced Trial
Dapagliflozin in Patients with Chronic Kidney Disease
HF – Reduced ejection fraction Fonarow G C et al. J Am Heart Assoc 2012;1:16-26
‒ Cumulative reduction in the odds of death over 2 years compared with no treatment
treatments or combination of Rx that may cause harm in pts with symptomatic NYHA class II-IV heart failure
HFpEF Treatment
‒ Treat underlying cause
‒ AF rate control
‒ Antihypertensives
‒ Structural heart disease
‒ SGLT2 inhibitors reduces HF recurrences
Empagliflozin in heart failure with preserved ejection fraction
Heart Failure Management Adjuvant therapy
‒ Patient education and daily weigh at home
‒ Avoid NSAIDs, amphetamines/stimulants
‒ Exercise training
‒ Biventricular (CRT) pacing for cardiac dyssynchrony (LBBB)
‒ AICD
– automated implantable cardiac
– defibrillator LVEF < 35%
‒ AF/ tachycardia ablation
‒ Nutritional and hormonal supplementation is not recommended
‒ Anticoagulation is not routinely recommended
‒ Advance Care Plannin
