Heart Failure

Question 1

Heart failure Definition:

Answer 1

Heart muscle is too weak, so heart cannot pump blood effectively around the rest of the body. So, the rest of the body does not receive the oxygen and supply of blood that it requires to meet its tasks

Question 2

Treatment of HF

Answer 2

• The treatment of chronic HF aims to relieve symptoms, improve exercise tolerance, reduce the incidence of acute exacerbations and reduce mortality.
  STEP 1:
• An ACE inhibitor (perindopril, ramipril, captopril, lisinopril, fosinopril) titrated to a ‘target dose’ together with a beta-blocker (Bisoprolol or Carvedilol) form the basis of treatment for all patients with heart failure due to left ventricular systolic dysfunction.
• Nebivolol (b-blocker) can be used for mild-moderate HF in >70’s.
• ARB (candesartan, losartan, valsartan) may be a useful alternative for patients who, because of side effects e.g. cough cannot tolerate ACE inhibitors. A relatively high dose may be needed to produce benefit.
• Candesartan or valsartan may be given as adjuncts to ACE inhibitors when other treatments are unsuitable
• If ACE-i and ARB not tolerated consider hydralazine and isosorbide dinitrate under specialist use

STEP 2:

• Add spinolactone or eplerenone
• Amiodarone
• The combination of valsartan with sacubitril (Entresto), which is an angiotensin-II receptor blocker + Neprilysin inhibitor is a suitable alternative for patients stabilised on an ACE inhibitor or Angiotensin-II receptor antagonist.
• Ivabradine

STEP 3:
- Add digoxin in worsening or sever HF (however, digoxin doesn’t reduce mortality)

• ACE/ARB/Spironolactone/Aldosterone antagonist –> Monitor serum K+ and Na+ , renal function, and BP prior to starting treatment, 1-2 weeks after starting treatment, and at each dose increment.

Question 3

HF - If patients remain symptomatic despite taking an ACE inhibitor and Beta-blocker, then

Answer 3

Spironolactone (aldosterone antagonist) can be added… this drug reduces symptoms + mortality. If spironolactone can’t be used, then Eplerenone can be used for HF after an acute MI or chronic HF.

Question 4

HF - Patients who cannot tolerate an ACE inhibitor/Angiotensin-II receptor antagonist or in whom they are

Answer 4

Isosorbide dinitrate + Hydralazine hydrochloride but it is poorly tolerated. This combination may be considered in addition to standard therapy with an ACEI + Beta-blocker in patients who continue to remain asymptomatic, particularly in Afro-Caribbean’s

Question 5

HF - Which drug improves symptoms of heart failure and exercise tolerance and reduces hospitalisations

Answer 5

Digoxin improves symptoms of heart failure and exercise tolerance and reduces hospitalisations due to exacerbations BUT NOT MORTALITY. It is reserved for those with worsening/severe HF who remain symptomatic despite the above treatments.

Question 6

HF - Patients with fluid overload should receive either a

Answer 6

Loop/Thiazide diuretic (with salt/fluid restriction).
A thiazide diuretic may be of benefit in patients with mild heart failure + good renal function, however they are ineffective in patients with poor renal function (eGFR <30mL/min/1.73m2) and a loop is preferred.
 If diuresis with a single diuretic is insufficient then… a combination of loop + thiazide may be tried.

Question 7

Non-drug treatment of HF:

Answer 7

• smoking cessation
• increasing physical exercise
• weight control
• dietary changes (reduce sat. fat, more fruit and veg)
• encourage patients to weigh themselves daily and to report any weight gain >1.5-2 kg in 2 days to their GP
• salt intake <6g per day

Question 8

Treatment of fluid overload in HF

Answer 8

• Diuretics (remove water) are recommended for the relief of breathlessness and oedema in patients with fluid retention.
• Loop diuretics such as furosemide, bumetanide or torasemide are usually preferred
• Thiazide diurectics may only be of benefit in paients with mild fluid retention and eGFR >30ml/min/1.73m2