Heart Failure Flashcards
Heart failure ejection fractions
HFrEF <= 40%
HRmrEF 41-49%
HF-PEF >=50%
New York Heart Association (NYHA) classification of heart failure
I - no limitation on physical activity.
II - slight limitation on physical activity, symptoms on ordinary physical activity.
III - symptoms on less than ordinary physical activity, marked limitation
IV (end-stage) - cannot do any physical activity without symptoms or symptoms at rest
Incidence of heart failure in the UK
1 in 35 65-74y
1 in 15 75-84y
1 in 7 >= 85y
Prognosis in heart failure
50% die within 5y
30-40% of deaths are sudden cardiac death
End-stage - 6-12 months
NT Pro-BNP values and referral for assessment + Echo
> 2000 - seen within 2 weeks
400-2000 - seen within 6 weeks
< 400 - HF unlikely
What can raise NT Pro-BNP values?
What can reduce NT Pro-BNP values?
Raise: > 70y, LVH, MI, tachycardia, hypoxia, pulmonary HTN, PE, eGFR < 60, sepsis, COPD, DM, liver cirrhosis
Reduce: BMI > 35, ACEi/ARB, BB, spironolactone, Afro-Caribbean origin
Investigations for HF
1) NT Pro-BNP
2) ECG
3) Bloods: FBC, iron studies, LFT, U&E, TFT, HbA1c, lipids
Blood test indicators of a poor outcome in HF patients
Low Hb, raised PLT:lymophocyte, low lymphocytes
Medical management of HRrEF or HFmrEF
1) Loop diuretic if fluid overload
2) ACEi/ARB + BB
- start ACEi first if DM or fluid overload as BB can worsen symptoms
- do not start ACEi if suspect valve disease
- If K > 5 - specalist advice before starting ACEi
- can take a few weeks-months for improvement
If HFrEF or HFmrEF not well controlled on ACEi + BB, what medication can be added?
Spironolactone
If HFeEF or HFmrEF not well controlled on ACEI + BB + spironolactone what are the next steps?
Get advice and consider:
1) Replacing ACEi with socubitril valsartan if EF < 35%
2) SGLT-2 inhibitor (gliflozin)
3) Ivabradine if sinus rhythm + HR > 75 + EF < 35%
4) Hydralazine + nitrate if Afro-Caribbean
5) Digoxin if sedentary / AF
6) 6) cardiac resynchronisation therapy if wide QRS/BBB
Non-medical management of HF
1) Structured exercise rehabilitation programme (unless uncontrolled HTN/high energy pacing)
2) Annual flu and single pneumococcal vaccine
3) Dietician if BMI < 18.5 or weight loss advice if BMI > 30
Advice for HF patients
1) Monitor weight - if increases icy 2kg in 3 days for review
2) Aim for < 5g salt/day and do not use salt substitutes which can raise K (as may be on ACEi/MRA)
3) Follow mediterranean or DASH diet.
4) If NYHA III/IV do not exercise in water
Driving advice in HF
G1: continue if no distracting symptoms.
G2: disqualified if symptomatic - consider re-licensing if LVEF > 40%
Which HF patients should be referred to cardiology?
1) NYHA III/IV
2) LVEF <=35%
3) NT Pro-BNP > 2000 (2 weeks) or 400-2000 (6 weeks)
4) Valve disease
Diuretics: dosing, monitoring & what do if creatinine rises
Furosemide 20-40mg to 120mg max/day
Bumetanide 0.1-1mg to 5mg max/day
Monitoring:
1) Before starting check U&E + BP
2) Re-check at 1-2 weeks & at every dose increase
Creatinine rises by > 20%/eGFR falls by > 15% - recheck U&E in 2 weeks.
Creatinine rises by 30-50%/eGFR > 30 - recheck U&E in 1 week
Creatinine rises by > 50%/eGFR < 25 - stop
What vaccinations should be offered?
Annual flu
Pneumococcal:
- once
- every 5 years if asplenia, splenic dysfunction or CKD
Suspected HF with previous MI
Do not do BNP
Urgent referral, echo and specialist assessment due to poor prognosis
Which BBs to offer in HF?
Carvedilol or bisoprolol - reduce mortality
