HEART FAILURE

Question 1

What is heart failure?

Answer 1

• Progressive condition
• Causes reduced cardiac output

Question 2

How are chronic heart failures defined?

Answer 2

1. Preserved ejection fraction
   - left ventricle loses its ability to RELAX normally
   - therefore the ejection fraction is normal or only mildly reduced
2. Reduced ejection fraction
   - left ventricle loses its ability to CONTRACT normally
   - therefore presents with an ejection fraction of less than 40%

Question 3

Heart failure symptoms

Answer 3

• SOB
• persistent coughing/ wheezing
• ankle swelling
• reduced exercise tolerance
• fatigue

Question 4

Risk factors

Answer 4

• male
• age
• diabetic
• smokers

Question 5

Chronic heart failure - non drug treatment

Answer 5

smoking cessation
reducing alcohol consumption
increasing PA
salt intake of less than 6g/day

Question 6

1st line treatment

Answer 6

1. ACEi + BB (bisop/ carvedilol)
   - initiated at low dose and slowly titrated up to max tolerated dose
   - Give ARB if ACEi not tolerated
   - Give hydralazine + nitrate if both ACEi ad BB not tolerated
2. ACEi + BB + aldosterone antagonist (spironolactone)

Question 7

ACEi for HF

Answer 7

e.g. perindopril, ramipril, captopril, enalapril maleate, lisinopril, quinapril or fosinopril sodium

Question 8

BB for HF

Answer 8

bisoprolol
carvedilol
nebivolol

Question 9

ARB for HF

Answer 9

candesartan
losartan
valsartan

Question 10

If heart failure symptoms persist or worsen despite optimal first-line treatment

Answer 10

add an aldosterone antagonist
spironolactone/ eplerenone

Question 11

When would you not add an aldosterone antagonist?

Answer 11

unless contraindicated (e.g. due to hyperkalaemia or renal impairment).

Question 12

If pt is already on BB

Answer 12

Patients who are already taking a beta-blocker for co-morbidities (e.g. angina or hypertension) and whose condition is stable should be switched to a beta-blocker licensed for heart failure.

Question 13

Hydralazine hydrochloride combined with a nitrate

Answer 13

• can be considered under the advice of a heart failure specialist in patients who are intolerant of both ACE inhibitors and ARBs
• in particular those of African or Caribbean origin with moderate to severe heart failure

Question 14

If symptoms persist despite optimal treatment

Answer 14

add amiodarone, digoxin, sacubitril with valsartan, ivabradine, empagliflozin, or dapagliflozin.

digoxin for pt in sinus rhythm in worsening or severe HF

Question 15

Diuretics are recommended

Answer 15

for the relief of breathlessness and oedema in patients with fluid retention.

Question 16

Loop diuretics

Answer 16

furosemide, bumetanide, or torasemide

Question 17

Patient experienced acute coronary syndromes are prescribe dual antiplatelet

Answer 17

aspirin + cloidogrel/ prasugrel/ ticagrelor.
an ACEi, BB and statin

Question 18

What are the monitoring requirements for standard treatment in heart failure?

Answer 18

• Serum K+
• Serum Na+
• Renal function
• Blood pressure
• Measured before and 1-2 weeks after starting treatment (at a each dose increment)
• Once stabilised on treatment, monitor MONTHLY for 3 months, then every 6 months

Question 19

How often should patients with heart failure weigh themselves?

Answer 19

• DAILY at same time
• Report any weight gain of
  1.5-2kg (gained in 2 days) to
  GP or specialist (sign of oedema)

Question 20

What vaccinations should be offered to patients with heart failure?

Answer 20

Annual vaccination against:
- Influenza
- Pneumococcal disease

Question 21

Which Diabetic drugs have recently been granted license for the treatment of chronic heart failure?

Answer 21

• Dapagliflozin
• More recently: Empagliflozin
• Both are SGLT2 inhibitors
• They have been shown to reduce mortality and hospitalizations in heart failure patients

Question 22

When would SGL2 inhibitors be given in heart failure?

Answer 22

Add on therapy to standard treatment, e.g.:
1. ACE-I (or ARB) + BB + SGL2
inhibitor
Or
2. ACE-I (or ARB) + BB +
Aldosterone antagonist + SGL2
inhibitor

OR WITH SACUBITRIL/ VALSARTAN + BB combo
3. Sacubitril/valsartan + BB + SGL2 inhibitor
or
4. Sacubitril/valsartan + BB + Aldosterone antagonist + SGL2
inhibitor