heart failure Flashcards
Define HF
Progressive clinical syndrome characterised by structural or functional abnormalities of the heart that produces raised intracardiac pressure and/or reduced cardiac output at rest and/or at exercise
3 main categories
- reduced EF
- mildly reduced EF
- preserved EF
symptoms of HF
- persistent cough/wheeze
- SOB
- ankle swelling
- reduced exercise tolerance
- fatigue
3 signs of HF
- pulmonary oedema
- basal crepitations (pulmonary cackles)
- elevated jugular venous pressure
Risk factors for HF
- CAD
- MI
- Hypertension
- AF
- DM
- FHx HF or sudden cardiac death <40
- Male
- Smoker
- Elderly
most common cause of HF
CAD
HF often co-exists with other comorbidities e.g
- CHD
- CKD
- AF
- Hypertension
- Dyslipidaemia
- Obesity
- Diabetes mellitus
- COPD
most common cause of HF in Afro/Afro-Caribbean
more likely to develop HF secondary to hypertension
relationship between comorbids and HF prognosis
worse prognosis of HF if pt has comorbidities
Complications of HF
- CKD
- AF
- depression
- cachexia (weakness and wasting of body)
- sexual dysfunction
- sudden cardiac death
Pregnant women/given birth within 6 months and suspected to have HF
- arrange emergency admission or
- seek immediate specialist advice
what to do if HF is suspected clinically
- admission if pt has severe symptoms
- measure natriuretic peptide level (NT-pro-BNP)
- 12-lead ECG in all people
- consider other tests to evaluate for other factors and exclude other conditions
serum natriuretic peptide levels
- normal: HF unlikely
- > 2k ng/l (235pmol/l) - urgent referral for specialist assessment and transthoracic ECG within 2 weeks
- 400-2k ng/L (47-236) refer for above within 6 weeks
does level of natrueitic peptide indicate type of HF
No - does not differentiate between different types (e.g. if reduced, preserved EF etc)
name 2 markers that are strong RF and prognostic markers of poor outcomes in pt with suspected HF
- anaemia
- high platelet: lymphocyte % (low lymphocyte count)
what to do in pt with HF due to valve disease
refer for specialist assessment and give advice regarding follow up
natriuretic peptide levels may be reduced by
- BMI >35
- drugs e.g. diuretics, ACEi, ARB, BB, MRA (e.g. spironolactone)
- afro-caribbean
natriuretic peptide levels may be elevated by
- > 70
- LV hypertrophy, MI, tachycardia
- RV overload
- hypoxia
- pulmonary hypertension
- pulmonary embolism
- CKD (eGFR <60)
- sepsis
- COPD
- DM
- liver cirrhosis
differential diagnosis - conditions causing breathlessness
- COPD
- Asthma
- PE
- Lung cancer
- Anxiety
differential diagnosis - conditions causing peripheral oedema
- Prolonged inactivity or venous insufficiency causing dependent oedema
- Nephrotic syndrome
- Drugs e.g. DHP-CCBs, NSAIDs
- Hypoalbuminemia (from renal or hepatic disease)
- Pelvic tumour
differential diagnosis - other conditions
- obesity
- severe anaemia or thyroid disease
- bilateral renal artery stenosis
define HF with reduced ejection fraction
LV loses its ability to contract normally and therefore presents with ejection fraction of less than 40%
HF with preserved ejection fraction
LV loses its ability to relax normally and therefore the ejection fraction is normal or only mildly reduced
what is the New York Heart Association (NYHA) functional classification tool used for
Used to define the progression of chronic HF according to severity of symptoms and limitations to physical activity
HF is considered to be stable or chronic when
Symptoms remain unchanged for at least one month despite optimal treatment
lifestyle treatment in pt with HF to reduce risk progression and associated comorbidities
- smoking cessation
- reduced alcohol
- increase exercise if appropriate
- weight control
- increase fruit and veg
- reduce saturated fats
- salt intake <6g daily
Use of salt substituted containing potassium in pt with HF
AVOID to reduce risk of hyperkalaemia
non-drug treatment options in pt with HF and REF <40%
Implantable cardioverter defibrillators and cardiac resynchronisation therapy
Which vaccines are recommended in pt with HF?
- Pneumococcal
- Annual influenza
A patient who is on atenolol 100mg BD for angina has been diagnosed with HF. would you change the medication?
Change BB to one licensed for use in HF: bisop, carved, nevibolol
Review of meds when a pt is diagnosed with HF
- stop drugs which may cause or worsen HF e.g. RLCCB and SA DHP CCBs as these reduce cardiac contractility
- except amlodipine - pt with HF and angina can be treated with this
drug treatment for CHF with REF
- 1st line: ACEi + BB (bisop, carved, nebivolol)
- If ACEi not tolerated, ARB (cande, losart, valsart)
- Preferred initial treatment may be with ACEi if pt has DM or signs of fluid overload and BB can make symptoms of HF worse
- do not offer ACE I if clinical suspicion of haemodynamically significant valve disease
- If symptoms persist, + MRA (spirono, eplerenone)
- Intolerant of ACEi + ARB: specialist advice on. hydralazine + nitrate (esp for Afro/Caribbean)
- If symptoms persist, speak to specialist re amiodarone, digoxin, entresto, ivabradine, empag, dapagliflozi
Drug treatment for chronic HF with reduced ejection fraction - fluid overload
- Offer loop diuretic (toras, furos, bumet) for relief of breathlessness and oedema
- Thiazides may only be of benefit in pt with mild fluid retention and eGFR >30
- titrate does according to clinical response and adjust as needed
- if symptoms persist, seek advice from HF specialist
Monitoring drug treatment - ACEi, ARBs, MRAs
- imitation: check serum K + Na, renal function, BP before
- then check 1-2 weeks after starting
- and at each dose increment
- once stable, monitor monthly for 3 months, then at least every 6 months, and when pt is acutely unwell
monitoring drug treatment - BB
on initiation and after each dose change: HR, BP, symptom control
Treatment of CHF with preserved EF
- review and stop any drugs that cause/worsen HF e.g. CCBs
- managed under care of HF specialist
- low to medium dose loop diuretic for fluid retention - up to 80mg furosemide or equivalent
- if pt fails to respond, seek advice from specialist - may consider empag or dapag
Summarise what management of people with HF with mildly reduced ejection fraction includes
Offer diuretic if symptoms f fluid overload
Consider offering an ACEi, BB ( + MRA if symptoms persist)
additional management for all pt with HF
- is antupalatelet drug indicated e.g. clopidogrel?
- is a statin indicated?
- screen for anxiety and depression
- offer annual flu vaccine and once only pneumococcal vaccine
- assess nutritional status (BMI) and refer as needed
- childbearing age: contraception & pregnancy advice
monitoring weight
- Advise pt to check weight e.g. daily, weekly, or fortnightly, depending on clinical judgement.
- Weigh at same time of day (e.g. after waking and voiding but before dressing or eating).
- Advise what to do if there is sudden and sustained weight gain (e.g. > 2 kg in 3 days).
- Options include seeking medical advice, increasing the diuretic dose, reducing fluid intake, or a combination of actions.
- The pt should understand that deterioration can occur without weight gain.
maintaining fluid balance
- Severe symptomatic heart failure: restrict fluid intake
- e.g. to <1.5–2 L / day to relieve symptoms
- or consider a weight-based fluid restriction e.g 30 mL/kg body weight, or 35 mL/kg body weight over 85 kg
- Restriction of hypotonic fluids may improve hyponatraemia.
- Fluid intake should not be excessively restricted to reduce the risk of dehydration.
- People should seek medical advice if they feel thirsty, light headed, or dizzy, as this may be a sign of hypotension or hypovolaemia
what to do if acutely unwell (e.g. diarrhoea and vomiting)
- If stale HF and taking ACEI, ARB, diuretic or MRA: maintain fluid intake and stop drugs until recover & eating and drinking normally
- Sick day rules
- Be aware of risk of AKI if pt unwell or dehydrated
- If severe of uncontrolled HF or symptoms of diarrhoea and vomiting persist, seek medical advice re meds and checking renal function & electrolytes
nutritional status advice
- If the BMI is under 18.5 kg/m2, consider referring the person for dietetic advice.
- If the BMI is over 30 kg/m2, give advice on maintaining a healthy weight.
Driving - DVLA
- Group 1 entitlement (cars, motorcycles): can continue as long as no symptoms that distract drivers attention, DVLA don’t need to be notified
- Group 2 entitlement (lorries, buses): disqualified from driving if symptomatic. re licensing may be permitted if LVEF is at least 40% and there is no disqualifying condition
What to do if a patient had syncope or pre syncope (unless clearly due to postural hypotension)
Refer to a cardiologist as this may be due to ventricular tachycardia, particularly in people who have a reduced ejection fraction (HF-REF).
examples of loop diuretics and dosages
- Furosemide 20-40mg daily
- Bumetanide 0.5-1.0 mg daily
- Torasemide 5-10mg daily
when is use of digoxin in pt with HF given and why?
- for pt in sinus rhythm as ADD ON THERAPY in worsening symptoms severe HF despite optimal treatment
- although it doesn’t reduce mortality, it may decrease symptoms and hospitalisations due to acute exacerbations
- routine monitoring of serum levels not recommended in pt with HF
which 2 conditions affects the management of HF in pt with these conditions?
AF
CKD
patients should be advised to weigh themselves daily and report a weight gain of ….
report weight gain of more than 1.5-2 kg in 2 days to HF specialist or GP
advice for pt with dilutional hyponatraemia (aka water intoxication)
only restrict fluid intake
implantable cardioversion defibrillators and cardiac resynchronisation therapy are treatment options in..
pt with HF and REF of less than 35%
anticoagulation should be considered for pt in sinus rhythm with HF if…
Hx thromboembolism, LV aneurysm or intracardiac thrombus
advanced HF
- breathlessness common symptom
- may even occur with optimal management and in absence of clinical pulmonary oedema
- long-term oxygen therapy not recommended but may be considered if there are comorbidities that would benefit from it e.g. COPD
which drug should you initiate first in HF : BB or ACEi? and when would you introduce the other?
- use clinical judgement
- only initiate other drug once pt is stable on existing treatment
- initiate at low dose and slowly titrate up to max - in pt with CKD, lower doses and slower titration should be considered
CCBs should be avoided in heart failure because they reduce cardiac contractility and so can worsen symptoms. The exception is this drug, which can be used cautiously in stable HF
amlodipine
