Heart Failure Flashcards
How should the cause of heart failure be investigated?
Bloods: FBC, UandEs, glucose, lipids, TFTs, cardiac enzymes
CXR - support evidence for HF, excludes other diagnoses
Urinalysis
Lung function tests
What is the NYHA classification if heart failure severity?
Class 1 - no symptoms on ordinary physical activity
Class 2 - slight limitation of physical activity by symptoms
Class 3 - less than ordinary activity leads to symptoms
Class 4 - inability to carry out any activity without symptoms
How should diagnoses be confirmed in a patient either previous Mi?
Patient should be referred for cardiologist assessment and Doppler echocardiography within two weeks
To assess: Overall systolic function Diastolic function LV wall thickness Valvular disease Estimation of pulmonary artery systolic pressure
How should diagnosis of heart failure be confirmed if no previous MI?
Measure BNP and NTproBNP
BNP >400 - refer for Echo in 2 weeks
BNP 100-400 - refer for echo in 6 wks
BNP <100 - heart failure unlikely
What patient advice should be given in heart failure
Smoking cessation Weight loss Reduce salt intake Avoid excessive dehydration Monitor fluid retention by weighing self - if unexpected weight gain >3kg in three days, seek advice! Reduce alcohol Exercise (unless class 4) Oxygen required for plane travel if class 3 May have sexual problems Flu and pneumococcal jabs
What are the two main types of heart failure?
Heart failure due to left ventricular systolic dysfunction
Heart failure with preserved left ventricular ejection fraction
What is the management of heart failure with preserved ejection fraction?
Manage comorbid conditions such as:
Hypertension
IHD
DM
Consider specialist referral
What is the treatment of heart failure due to left ventricular systolic dysfunction?
1st line:
Offer ACEI and beta blocker
2nd line: Consider adding AT2 antagonist Consider aldosterone antagonist Consider diuretic for fluid retention Consider digoxin
Which patients with heart failure should receive ACEI?
All patients with LVEF of 40% or less
Which patients with HF shod receive beta blockers?
Patients with symptomatic HF and LVEF <40%
All patients on diuretics and ACEI, even if asymptomatic
What are contraindications for ACEI?
Angioedema RAS Hyperkalaemia Renal impairment Aortic stenosis
How should ACEis be used
Check UandEs prrior to treatment and 1-2 weeks after
Recheck UandEs at 1, 3, 6 months after achieving maintenance dose
Start ramipril 2.5mg and titrate dose up if no problems
If renal function worsens, eliminate nephrotoxic drugs such as NSAIDs, can reduce dose or stop ACEI if creatinine rises
How should diuretics be used?
Loop diuretics eg furosemide, bumetanide provide symptomatic relief
Start low and titrate upwards based on clinical response
Side effects: hypokalaemia hypovolaemic Uraemia Circulatory collapse
What beta blockers might be used in HF?
Bisoprolol
Carvedilol
Metoprolol
Nebivolol
What are the contraindications to beta blockers?
Asthma
2nd/3rd degree heart block
Sick sinus syndrome
Bradycardia
How should beta blockers be used in HF?
Initiate at low dose, increase every 2-3 weeks
Monitor BP and HR with dose increases
Do not abruptly stop - increases risk of MI/arrhythmia
How should at2 antagonists be used in HF?
Eg candesartan, valsartan
Indications: if intolerant of ACEI
Contraindications:
not with ACEI and beta blockers in HF inadequate renal function
Must monitor renal function and UandEs
When should spironolactone be used in HF?
In all patients without renal dysfunction or hyperkalaemia
What type of drugs are spironolactone and eplerenone?
Mineralocorticoid/aldosterone receptor antagonists
How should spironolactone be monitored?
Monitor renal function and UandEs at one week and four weeks
Monitor monthly for first three months
What are the side effects of spironolactone?
GI disturbances
Hyperkalaemia
Breast tenderness or enlargement
How should digoxin be monitored?
Monitor UandEs
Maintain potassium at 4-5 mmol
Do not monitor routinely, but it may be necessary
Which patients with HF should have warfarin?
If comorbid atrial fibrillation or thromboembolism
Which patients with HF should have aspirin?
If HF with comorbid coronary heart disease
When are calcium channel blockers indicated in HF?
HF with hypertension/angina
Amlodipine NOT verapamil or diltiazem
When should implantable cardioverter defibrillators be considered in HF?
In patients with serious ventricular arrhythmia, eg survived VT/Vfib
In those who have LVEF <40% but expected survival with good functional status of over a year
In patients with familial cardiac conditions with high risk - QT syndrome, HOCM, brugada
What are the options for post discharge management of HF?
Clinic based service:
In hospital outpatient department
Often nurse led
Home based service:
Programme with self-help manual and facilitator support
For low to moderate risk patients
How should patients with HF be monitored?
Monitor at least 6 monthly Assess: Functional capacity Fluid status Cardiac rhythm Cognitive status Nutritional status Review drug treatment - side effects, need for changes Serum urea, electrolytes, creatinine, eGFR
When is cardiac desynchronisation therapy used in HF?
For patients with mild (NYHA 2) symptoms as well as those more severely symptomatic
May be considered when: Sinus rhythm LVEF <30% QRS is prolonged ECG shows LBBB
How many patients with HF die within four years of diagnosis?
50%
