Heart Failure

Question 1

What is heart failure?

Answer 1

It essentially means that the heart has reduced cardiac output and therefore is unable to pump enough blood to meet metabolic demand

Question 2

What are the four different types of HF?

Answer 2

1. HF with reduced ejection fraction
2. HF with preserved ejection fraction
3. HF with mid-range ejection fraction
4. Pt experiences symptoms of HF due to causes other than pump failure such as vascular problems, arrhythmias of excessive IV fluid administration.

Question 3

When is HF classed as having reduced ejection fractions?

Answer 3

Here the ejection fraction (the amount of blood pumped with each contraction) is <40%. It can be left, right or bi.

Question 4

When is HF classed as having preserved ejection fraction?

Answer 4

Here the ejection fraction is >50%. It is also known as diastolic HF.

Question 5

When is HF classed as being mid range?

Answer 5

When the ejection fraction is between 40-50%

Question 6

What are the signs and symptoms of HF?

Answer 6

signs: lung crepitations, raise JVP, displaced apex beat, 3rd heart sound, hepatomegaly/ascites, pulmonary oedema on CXR, left ventricular hypertrophy on the ECG.

Symptoms: SOB on exertion, reduced exercise intolerance, fatigue, oedema (especially ankles), night cough, orthopnoea, paroxysmal nocturnal dyspnoea, weight gain, decrease appetite.

Question 7

What tests can we consider to confirm HF?

Answer 7

BNP (brain naturetic peptide) Usually this is low in our blood but if he heart has to work harder i.e in HF then it will be higher.

Echocardiogram - Provides information on the structure and function of the heart.

Question 8

What is the most common type of HF?

Answer 8

LVSD

reduced ejection fraction. This is what evidence is mainly based on so other forms are mainly treated symptomatically.

Question 9

What compensatory symptoms are activated when cardiac output is reduced in HF?

Answer 9

• RAAS
• sympathetic

Activation of these lease to vasoconstriction, sodium and water retention, increased contractility, increased HR and increased BP. These in turn all exacerbate HF symptoms and can cause cardia remodelling.

Question 10

What are the main stay initial treatment for HF?

Answer 10

Ace inhibitor (ramipril)
Beta block - BCN (bisoprolol, carvedilol, nebivolol)

Both should be titrated together and get to the most tolerated dose.

Question 11

What additional treatments can be used in HF?

Answer 11

• mineralocorticoid receptor antagonist (MRA’s) eg spironolactone and eplerenone
• hydrazine + nitrate
• digoxin
• ivabradine
• ARB - licensed for HF - candesartan, valsartan, losartan.
• Sacubitril/valsartan - ARB + neprilysin inhibitor to promote natural peptides which help balance fluid within the body.

Question 12

should diuretics be used in everyone with HF?

Answer 12

No only patients who are symptomatic with fluid overload.

Question 13

What medicines can exacerbate HF?

Answer 13

NSAIDS

Question 14

what vaccines should pt have if they have HF?

Answer 14

annual flu

one of pneumococcal

Question 15

what dietary advice can we give

Answer 15

reduce salt intake

reduce alcoholol.

Question 16

Always best to know the cause of HF so we can treat

Answer 16

eg arrhythmia - we will need to control this
valve - may need to be replaced
may just be a general decline in HF
For patients with reduced ventricular function this can result in cariogenic shock.

Question 17

Main treatments in acute HF management are

Answer 17

• oxygen to improve sats
• loop diuretics to reduce oedema. These are often given IV (controlled rate to reduce the chance of ototoxicity)
• Dobutamine - used to treat potentially reversible cariogenic shock in level 2 care setting - short term use only
• IV nitrated - only recommended if HF is associated with ischema
• intra-aortic balloon bump

Question 18

When are nitrates recommended in HF

Answer 18

if it is associated with ischema

Question 19

Which long-term treatments for patients with HF with reduced ejection fraction have been shown the reduce mortality?

Answer 19

bisoprolol, ramipril, spironolatone.

Question 20

Entresto (sacubitril/valsartan) facts…

Answer 20

may lower BP

concomitant use with aliskiren should be avoided.

Question 21

Can patients develop AKI due to HF?

Answer 21

Yes

Question 22

Can dopamine be used in any care setting to manage cariogenic shock?

Answer 22

No usually level 2 and above

Question 23

Should all patients with HF be given oxygen?

Answer 23

No only patients who are hypoxic. Can develop free radicals and cause more damage to cardiac muscle

Question 24

When are IV nitrates recommended?

Answer 24

when patients have schema

Question 25

Which drugs may worsen HF?

Answer 25

pioglitazone
verapamil
bisoprolol (mainstay of treatment but they can worsen symptoms initially so patients are counselled that they may feel worse before they feel better)
NSAIDS

Question 26

Usual rate of IV furosemide

Answer 26

4mg/min

Question 27

Symptoms of HF

Answer 27

Oedema
Nocturnal dysnooea
Reduced exercise tolerance
Decrease appetite
Cough

Question 28

Expected daily weight to use in HF with oedema

Answer 28

1kg

Question 29

Will patients with sacral oedema have problems absorbing oral furosemide ?

Answer 29

Yes

Question 30

Can nsaids be used in HF?

Answer 30

No

Question 31

Wash our period for entreso

Answer 31

36 hours

Usually 48 hours in practice

Question 32

Can we use verapamil and diltizaem in HF?

Answer 32

No they have negative ionotropic effects so we want to avoid them !