Heart Failure Flashcards
What is heart failure?
The heart is unable to optimally maintain circulation of blood
What should be measured in order to diagnose heart failure?
- N-terminal pro-B-type natriuretic peptide (NT-proBNP)
- refer people with suspected heart failure and an NT-proBNP level above 2,000 ng/litre
(236 pmol/litre) urgently, to have specialist assessment and transthoracic
echocardiography within 2 weeks. - Refer people with suspected heart failure and an NT-proBNP level between 400
and 2,000 ng/litre (47 to 236 pmol/litre) to have specialist assessment and
transthoracic echocardiography within 6 weeks - below 400 means less likely to be heart failure
What can reduce levels of serum natriuretic peptides?
- obesity, African or African–Caribbean family origin, or treatment with diuretics,
angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin II receptor
blockers (ARBs) or mineralocorticoid receptor antagonists (MRAs)
What other diagnostic tests should be carried out to evaluate alternative diagnosis etc?
- transthoracic echocardiography to exclude important valve disease
- ECG
- Chest xray
- blood tests (FBC)
- urinalysis
- peak flow or spirometry
What is the first line treatment in heart failure?
ACE inhibitor and Beta blocker
What should initial ACE dosing be?
Start at low dose and titrate upwards in short intervals (e.g. every 2 weeks) until target or maximum tolerated dose is reached
What should be monitored with ACE inhibitors and ARBs and MRAs?
- Measure serum sodium and potassium, and assess renal function, before and 1
to 2 weeks after starting an ACE inhibitor, and after each dose increment. - measure BP
- Once the target or maximum tolerated dose of an ACE inhibitor is reached,
monitor treatment monthly for 3 months and then at least every 6 months, and
at any time the person becomes acutely unwell
What can be given as an alternative if ACE inhibitors are not tolerated?
- Consider ARB for people who have heart failure with reduced ejection fraction and intolerable
side effects with ACE inhibitors
What can be offered in addition to an ACE inhibitor (or ARB) and a beta blocker?
- A mineralocorticoid receptor antagonist (MRA) is offered to
people who have heart failure with reduced ejection fraction if they continue to
have symptoms of heart failure
e.g. aldosterone antagonist - spironolactone
When is Ivabradine offered?
Offered in treating chronic heart failure in people;
- with New York Heart Association (NYHA) class II to IV stable chronic heart failure with
systolic dysfunction and
- who are in sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and
- who are given ivabradine in combination with standard therapy including beta-blocker
therapy, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists,
or when beta-blocker therapy is contraindicated or not tolerated and
- with a left ventricular ejection fraction of 35% or less.
- only given after 4 weeks of current treatment with ACE +BB etc
When is Sacubitril valsartan recommended?
- with New York Heart Association (NYHA) class II to IV symptoms and
- with a left ventricular ejection fraction of 35% or less and
- who are already taking a stable dose of angiotensin-converting enzyme (ACE)
inhibitors or ARBs
*BLACK TRIANGLE DRUG
When should hydralazine in combination with nitrate be considered?
Seek specialist advice and consider offering hydralazine in combination with
nitrate (especially if the person is of African or Caribbean family origin and has moderate to severe heart failure [NYHA class III/IV] with reduced ejection
fraction)
When is digoxin recommended?
Digoxin is recommended for worsening or severe heart failure with reduced
ejection fraction despite first-line treatment for heart failure. Seek specialist
advice before initiating
What monitoring requirements are there for digoxin?
Routine monitoring of serum digoxin concentrations is not recommended. A
digoxin concentration measured within 8 to 12 hours of the last dose may be
useful to confirm a clinical impression of toxicity or non-adherence
What treatment is given in heart failure with reduced ejection fraction in people with CKD?
- treat with ACE inhibitors/ARBs + BBs etc as before
- but if the person’s eGFR is 45ml/min/1.73 m^2 or below, consider lower doses and/or slower titration of dose ACE inhibitors or ARBs, MRAs and digoxin.
- For people who have heart failure with reduced ejection fraction and chronic
kidney disease with an eGFR below 30 ml/min/1.73 m, the specialist heart
failure MDT should consider liaising with a renal physician
