Heart failure

Question 1

List the aims of chronic heart failure treatment

Answer 1

1) Relieve symptoms
2) Improve exercise tolerance
3) Reduce incidence of acute exacerbations
4) Reduce mortality

Question 2

Which two drugs form the basis of treatment for all patients with heart failure due to left ventricular systolic dysfunction?

Answer 2

An ACE inhibitor together with a B-Blocker

Question 3

Why might an ARB be given to patients instead of an ACEi in heart failure?

Answer 3

Due to side effects such as cough.

↳ But a relatively high dose of ARB might be required to produce benefit

Question 4

1) Which two B-blockers are of value in any grade of stable heart failure due to left ventricular systolic dysfunction?
2) How should B-blockers be initiated in heart failure?

Answer 4

1) Bisoprolol and carvedilol
2) Very low dose and titrated very slowly over weeks or months. symptoms may deteriorate initially calling for adjustment of concomitant therapy.
↳ Treatment should be started by those experienced in management of heart failure

Question 5

Nebivolol can also be used in mild to moderate heart failure. Which patients would be licensed to receive this drug?

Answer 5

Patients over 70 years of age

Question 6

What other medication can be added on to therapy in patients who remain symptomatic with ACEi + B-blocker

Answer 6

Aldosterone antagonist spironolactone. Low dose of this drug reduce symptoms and mortality in these patients
↳(initially 25mg OD, adjusted to 50mg OD according to response. Take with or after food or meal)

Question 7

If spironolactone is not suitable or tolerated, which other aldosterone antagonist would be a suitable alternative?

Answer 7

Eplereonone (Initially 25mg OD then increased to 50mg OD within 4 weeks of initial treatment)
↳ (note due to interactions: max 25mg OD when used with amiodarone, and inhibitors of CYP34A)

Question 8

What are the monitoring requirements for aldosterone antagonists (spironolactone and epleronone) in heart failure?

Answer 8

Close monitoring of the following, especially following change in clinical condition or treatment:
1) sCr
2) eGFR
3) Potassium (severe hyperkalaemia with ACE + ARB’s , avoid potassium supplements)
↳high risk of hyperkalaemia in renal impairment

Question 9

What combination of drugs may be considered in patients who cannot tolerate an ACEi or ARB?

Answer 9

Isosorbide dinitrate in combination with Hydralazine but this combination is poorly tolerated

Question 10

Who would the following combination of drugs be considered in: Isosorbide dinitrate + Hydralazine in addition to standard therapy with ACEi and B-blocker?

Answer 10

Patients who continue to remain symptomatic e.g. patients of African or Caribbean origin who have moderate to severe heart failure

Question 11

1) Outline the benefits of using digoxin in heart failure

2) Which patients is digoxin reserved for use in?

Answer 11

1) Improves symptoms of heart failure and exercise tolerance and reduces hospitalization due to acute exacerbations
↳ BUT does not reduce mortality
2) Reserved for patients with worsening or severe heart failure who remain symptomatic despite treatment with ACEi + B-Blocker with either aldosterone agonist, candesartan or isosorbide + hydra

Question 12

How should patients with fluid overload be managed in heart failure?

Answer 12

Loop or thiazide diuretic ( with salt or fluid restriction where appropriate)

Question 13

Explain when a loop diuretic may be chosen over a thiazide diuretic in heart failure

Answer 13

Thiazide diuretics may be of benefit in patients with mild heart failure and good renal function BUT they are ineffective in patients with poor renal function (eGFR below 30ml/min) and so a loop diuretic is preferred.

Question 14

What could be considered if diuresis with a single duretic is insufficient in heart failure?

Answer 14

1) Can try a combination of loop + thiazide

2) Addition of metolazone can be considered but careful to avoid potentially dangerous electrolyte disturbances

Question 15

1) Outline the MoA of aldosterone antagonists

2) How do spironolactone and epleronone differ with regards to their indications

Answer 15

1) Aldosterone antagonists inhibit the action of aldosterone by competitively binding to the aldosterone receptor. This increases Na+ and water excretion and potassium retention
2) spironolactone is used for all indications, whereas eplerenone is used for heart failure only

Question 16

1) outline the important adverse effects of aldosterone antagonists
2) why might there be adherance issues with patients taking spironolactone and why is this not a problem with eplerenone?

Answer 16

1) Hyperkalaemia which can lead to muscle weakness, arrhythmias and even cardiac arrest
2) Spironolactone can cause gynaecomastia (reversable) . Eplereone is less likely to cause endocrine side effects.
↳ ( aldosterone antagonists can also cause liver impairment and jaundice and are a cause of stevens-Johnson syndrome)
↳ aldosterone antagonists may also cause impotence

Question 17

who are aldosterone antagonists contraindicated in?

Answer 17

1) severe renal impairment
2) hyperkalaemia
3) Addisons disease (aldosterone deficient)
4) can cross placenta so avoid in pregnant and also BF

Question 18

why is spironolactone usually prescribed in combination with a loop or thiazide diuretic?

Answer 18

1) spironolactone is a relatively weak diuretic that takes several days to start having an effect
2) when prescribed with loop or thiazide it counteracts potassium wasting and potentiates diuretic effect