Heart failure

Question 1

What is Heart failure?

Answer 1

A complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation.

Question 2

What are the main causes of Heart failure?

Answer 2

Hypertensive Heart Disease
Ischaemic heart Disease
Cardiomyopathy
Valvular Heart Disease RHD

Question 3

What are the clinical syndromes of acute heart failure?

Answer 3

modified from the European Society of Cardiology

1. Acute decompensated Heart failure - mild features of heart failure e.g. dyspnoea
2. Hypertensive AHF - high blood pressure, preserved left ventricular function, pulmonary edema on chest xray
3. Acute Pulmonary edema - tachypnoea, orthopnea, pulmonary crackles, oxygen saturation <90%, pulmonary edema on chest Xray
4. Cardiogenic shock - Systolic blood pressure <90%, mean arterial pressure drop >30mmHg, Urine output <0.5ml/kg/hr, Heart rate >60bpm
5. High Output Heart failure - Warm peripheries, pulmonary congestion, blood pressure may be low e.g. septic shock
6. Right Heart failure - low cardiac output, elevated jugular venous pressure, hepatomegaly, hypotension

Question 4

What are the clinical syndromes of Heart failure

Answer 4

1. Left ventricular systolic dysfunction LVSD or Heart failure and a reduced ejection fraction HFREF
2. Diastolic Heart Failure consisting of signs and symptoms of Heart failure with preserved left ventricular ejection fraction HFPEF
3. Right ventricular systolic dysfunction RVSD

Question 5

How to treat Heart Failure

Answer 5

1. Symptomatic relief with Diuretic
2. ACEI and B-blocker + Symptom relief if ACEI contraindicated, use ARA the lorsatans
3. If there is no response, add spiranolactone
4. if still symptomatic add on to B-blocker with Heart rate >70 on optimal doses of B-blockers + Ivabradin (Funny current inhibition)
5. Sarcubitrol/valsartan but remove ACEI that you were using
6. in Blacks, Hydralazine/Isosorbide dinitrate (The A-HeFT trial)
7. Use Digoxin at first when AFib but add on if the rest have failed.

Question 6

What studies should you know

Answer 6

1. RALES study Spiranolactone
2. COMET study Carvedilol/Metoprolol
3. DIG study Digoxin
4. Val HeFT and ELITE II and CHARM

Question 7

What are the Classes of Drugs used in Chronic Heart Failure?

Answer 7

1. Diuretics
2. Angiotensin-converting enzyme Inhibitors (CONSENSUS, SOLVD)
3. Angiotensin II receptor antagonists (CHARM-candesartan, Val HeFT and ELITE II)
4. Beta blockers (CIBIS, CIBIS II, MERIT-HF, COMET) Bisoprolol and Carvedilol. Nibivolol (SENIORS)
5. Aldosterone antagonists (RALES, EPHESUS)
6. Cardiac Glycosides (DIG, ROCKET AF)
7. Vasodilators and Nitrates (A-HeFT)
8. Inotropic and Vassopressor agents used in AHF and severe haemodynamic compromise
9. Othere medications (SCD-HeFT-amiodarone showed no benefit compared to placebo in patients with impaired left ventricular function and mild to moderate heart failure)

Question 8

What are the treatment modalities in Heart Failure?

Answer 8

1. Lifestyle
   - Education
   - Dietary modification (no large meals, if necessary weight reduction, salt restriction, fluid restriction in severe heart failure, weigh daily, omega 3 polyunsaturated fatty acids reduce mortality and hospital admission)
   - Smoking
   - Physical activity, exercise training and rehabilitation
   - Vaccination
   - Air travel
   - Sexual Activity (patients on nitrates not to take phosphodiesterase type 5 inhibitors e.g. sildenafil, as they may produce profound hypotension)
   - Driving
   - Monitoring
   - Multi disciplinary approach (cardiologist, heart failure nurse, dietician, pharmacist, occupational therapist, physiotherapist and palliative care adviser.
2. Drug - refer to the above
3. Device
   - Cardiac Resynchronization Therapy CRT
   - Implantable Cardioverter-Defribillator ICD
4. Surgery