Heart Failure Flashcards
What is HeartFailure?
- It is the inability of the heart to pump sufficient around the body, meeting its needs.
- Heart failure is a progressive clinical syndrome, caused by structural or functional abnormalities of the heart - resulting in reduced cardiac output.
The TWO types:
1) Acute heart failure (AHF) - symptoms come on suddenly
2) Chronic heart Failure (CHF) - symptoms have been on going
What are the symptoms of heart Failure?
- Shortness of breath (pulmonary oedema)
- Persistent coughing or wheezing
- Ankle swelling
- Reduced exercise tolerance
- Fatigue
- Sometimes pulmonary crackles
- Chest pains (if they have angina)
- Palpitations(if they have arrhythmia)
RISKS
The risk of heart failure is greater in Men, diabetic patients and increases with age.
What are the causes of heart Failure:
- CHD (Coronary heart disease) - this is the most common cause, especially after a heart attach(myocardial infarction)
- Cardiomyopathy - disease of the heart muscle
- Disease of the heart valve
- Arrhythmia
- Meds that damage the heart - excess alcohol, cocaine, chemo therapies
- Non heart conditions- Hypo and hyperthyroidism and severe anaemia
How is heart Failure diagnosed?
- Physical examination: Faster than normal pulse , enlarged heart, signs of fluid retention(eg swollen ankles ,enlarged liver, crackles in lungs
- Blood tests: Measure B-type natriuretic peptide BNP or NT-proBNP (increase when a patient has heart failure)
- Ecgs, X-rays, blood and urine tests
Aims of the treatment:
- Reduce mortality
- Relive the symptoms
- Improve exercise tolerance
- Reduce acute exacerbations.
Non drug treatment
involves changing life style, encouraging smoking cessation, reducing alcohol consumption, weight loss and restricting the amount of salt used in their diets.
Calcium channel blockers and heart failure:
- Avoid these(verapamil, diltiazem) and short acting dihydropyridines(eg.Nifedipine and nicardipine) - reduce cardiac contractility
- Patients with angina and heart failure can safely use amlodipine
FIRST LINE
First line therapy: ACE- inhibitor(/ ARB but only if tolerant to ACEi) + A Beta Blocker (bisoprolol,carvedilol,nebivolol- do not withhold BB treatment for age,diabetes,COPD PVD,erectile dysfunction)
(Perindopril,ramipril,catopril,enalapril,lisinopril,quinapril,fosinril)
Arbs - candesartan,Valsartan,losartan- considered if ace not tolerated
- One drug should be started off at a time, clinical judgment is used when determining which One to start off with first - Beta Blockers licensed for HF in the UK : bisoprolol, carvedilol, nebivolol - ACE-inhibitors and Beta blockers have no effect on mortality in Heart failure with preserved ejection fraction
LOOP DIURETICS
Whilst loop diuretics play an important role in managing and reducing fluid overload, there is no evidence of long term reduction in mortality:
1) Add on a loop diuretic like furosemide
2) Or a Thiazide diuretic in mild cases of heart failure.Thiazides are ineffective in renal failure where eGFR is less than 30ml/min
Second line therapy: Aldosterone antagonist
- These can be referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and Eplerenone
- Both Ace inhibitors (which patients are likely to already be on) and aldosterone antagonists both cause hyperkalemia - therefore potassium should be monitored.
There’s an increasing role for SGLT-2-inhibitors in the management of heart failure with a reduced ejection fraction
- These reduce glucose reabsorption and increase urinary glucose excretion. Examples include Canagliflozin, Dapagliflozin and Empagliflozin.
- Evidence has shown that SGLT-2 inhibitors reduce hospitalisation, secondary to heart failure and cardiovascular death
Third line therapy
Ivabradine, Sacubitril-Valsartan, digoxin, hydralazine+nitrate and empagliflozin and dapagliflozin too
- Third line treatment is initiated by a specialist
Ivabradine
- Criteria = sinus rhythm more than 75 bpm and left ventricular fraction is less than 35%
Sacubitrl- Valsartan( and taking stable dose of ACEi/ARB)
- Criteria = left ventricular fraction more than 35%
Digoxin
- Digoxin has shown to also not been shown reduce mortality in patients with heart failure but can improve symptoms due to its inotropic properties
- It is strongly indicated if there is a co-existent Atrial fibrillation
Hydralazine + nitrate(commonly isorbide dinitrate)
- this may be particularly indicated in Afro- Caribbean patients
Cardiac resynchronisation therapy
- indications include a widened QRS (eg. Left bundle branch block) complex on ecg
Other treatments:
- Offer annual influenza vaccine
- Offer one-off pneumococcal vaccine
- Adults usually require just one dose but those with asplenia(absence of spleen), splenic dysfunction of CKD need a booster every 5 years
Fluid overload:
- Add a loop diuretic
- Add on a Thiazide diuretic in mild heart failure
- These relive breathlessness and oedema in patients with fluid retention
- Loop diuretics are usually the ones of choice (furosemide, bumetanide,torasemide)
Thiazide diuretics only benefit mild fluid retention and eGFR > 30ml/min/1.72m2
