Heart failure Flashcards
three main underlying causes of heart failure
coronary artery disease
diabetes mellitus
hypertension
heart failure may also be called
congestive heart failure CHF
congestive cardiac failure CCF
pathogenesis of heart failure
pressure or volume overload increases the work on the myocardium
this is initially compensated by cardiac hypertrophy
chronic overload leads to decompensation where the cardiomyocytes lose their contractility
stroke volume and output is reduced
classification by ejection fraction
HFrEF (reduced): <40%, (previously called systolic failure)
HFmrEF (mildly reduced): 40-49%
FHpEF(preserved): >50%, ( previously called diastolic failure)
symptoms at presentaton
dyspnoea
cough
fatigue
poor exercise tolerance
ankle swelling
signs at presentation
tachycardia
additional heart sounds/murmurs
elevated jugular venous pressure
tachypnoea
bilateral lung base crackles
enlarged liver
peripheral oedema
ECG might show
acute or previous ischaemia, arrhythmia and other abnormalities that may suggest causative or exacerbating aetiologies such as IHD
laboritory tests
FBC, UECs, LFTs, troponin, BSL
consider serum BNP or NT-proBNP when diagnosis unclear
imaging
CXR - classic findings include alveolar oedema, Kerley B lines, cardiomegaly, upper lobe diversion and pleural effusion
echocardiography - can differentiate between HFrEF and HFpEF, s well s highlight other abnormalities or causative factors
may also consider stress testing or cardiac MRI
differential diagnosis
for shortness of breath:
- COPD, sleep apnoea
for peripheral oedema:
- venous insufficiency, thrombosis
- CKD and/or nephrotic syndrome
- cirrhosis
- calcium-channel blockers
specific treatments for underlying causes
lower blood pressure
revascularisation or drug therapy for coronary artery disease
manage diabetes
arrythmias
excess alcohol intake
use of recreational stimulant drugs
cardaic amyloidosis, haemochromatosis, thalassaemia, chemotherapy toxicity)
valvular heart ddisease
hyperthyroidism
chronic lung disease
pulmonary embolism
pericardial effusion
drug therapy for HFrEF
all patients with HfrEF should be started on
ACEI/ARB
beta blocker
aldosterone antagonist
SGLT2
Loop diuretic can be dded to therapy at any stage to control symptoms of congestion
when should you add the beta blocker
for patients with clinical signs of congestion (eg. breathlessness, peripheral oedema) defer starting the beta blocker until the patient is euvolaemic
how long does starting all the medications take
start all 4 classes of drugs within 2-4 weeks of diagnosis
increase doses of ACEI and BB every 2-4 weeks up to the maximum tolerated dose
start all 4 drugs before starting up titration
optimisation of therapy may take 2-3 months
first line choices for ACEI/ARB
either an ACE or sacubitril+valsartan (non-pbs)
ARBs are second line
starting the patient on a beta blocker
can initially worsen the symptoms
do not start during acute decompensation or if the patient has congestion
start with low dose and increase gradually
monitor symptoms and measure weight daily
what should you monitor during dog optimisation period
symptoms, fluid status, kidney function, electrolyte concentrations
beta blocker examples
bisoprolol
nebivolol
metoprolol succinate
aldosterone antagonist examples
eg. eplerenone or spironolactone
SGLT2 inhibitor examples
dapagliflozin
empagliflozin
hyperkalaemia risk
in patients with kidney impairment
the combnation of aldosterone antagonist and renin-angiotensin system inhibitor cn cause life threatening hyperkalaemia
a small rise in serum potassium (within normal range) may occur and may be transient
starting an SGLT2
eg. dapagliflozin or empagliflozin
when to start a loop diuretic
can be used in patients with heart failure to reduce signs and symptoms of congestion
eg. furosemide or bumetanide
how to treat patients with HFpEF
SGLT2 inhibitor eg. empagliflozin and dapagliflozin
this is the only routine drug that should be prescribed for all patients with HFpEF
what else might you prescribe for someone with HFpEF
drugs for their comorbidities/underlying causes
eg. blood pressure reducing medication, beta blockers for afib or fast resting ventricualr rate or coexisting coronary artery disease
lifestyle advice for HF
drug management to support adherance
fluid management advice
sodium restriction advice
- no added salt diet, excessive salt intake can precipitate or worsen heart failure
regular assessment for depression
- depression is a common comorbidity
obesity management advice
dietitian input
physical activity support
drug management advice to support adherance might include
- when and why dose adjustments are needed
- adverse events
- regurlalry updated drug list should be supplied to care team
- do not use NSAIDs or pseudoephidrine
fluid mangement advice might include
- use daily weight charts as an indictor of fluid retention
- use fluid management program
- limit fluid intake to 1.5L per day
- manage night time symptoms with recliner or extra pillows
complications of HF
pleural effusion
acute decompensation of CHF
sudden cardiac death
acute renal failure
chronic renal insufficiency
anaemia
What common issues are encountered in heart failure management when drug therapy is initiated?
Asymptomatic fall in blood pressure or rise in serum creatinine (up to 30%) or serum potassium (within normal range)
These changes may be transient and should be evaluated in the clinical context.
What should be considered if a patient on combination therapy has symptomatic hypotension?
Change timing of doses (eg. split into morning and night), review volume status, stop treatments that reduce blood pressure but do not improve outcomes in HFrEF
Examples of such treatments include those for prostate enlargement and calcium channel blockers.
What is the preferred approach if a patient remains symptomatic with hypotension without congestion?
Reduce the dose of renin-angiotensin system inhibitor (or other vasodilators) and loop diuretic in preference to reducing beta blocker dose
This is unless the heart rate is less than 50 beats/minute.
What action should be taken if kidney function continues to deteriorate without signs of congestion?
Initially reduce or withhold the loop diuretic
cease any NSAIDs
Review the patient’s volume status and medical therapy.
What should be considered for patients with hyperkalaemia?
Ensure no potassium supplement is taken, review diet, decrease dose of renin-angiotensin system inhibitor or mineralocorticoid receptor antagonist
Withhold mineralocorticoid receptor antagonist if serum potassium is greater than 5 mmol/L.
What is the association between iron deficiency and heart failure?
patients with heart failure are at increased risk of developing iron deficiency
Iron deficiency with or without anaemia in heart failure is associated with increased mortality
What benefits does intravenous iron therapy provide to patients with HFrEF and iron deficiency?
Improves symptoms, exercise tolerance, quality of life, and may reduce hospitalisation
This is applicable for patients with or without anaemia.
consider investigations to identify cause of iron deficiency if appropriate
