Heart failure algorithm

Question 1

x

Answer 1

x

Question 2

x

Answer 2

x

Question 3

x

Answer 3

x

Question 4

x

Answer 4

x

Question 5

x

Answer 5

x

Question 6

The first-line treatment for all patients is ?

Answer 6

an ACE-inhibitor and a beta-blocker

one drug should be started at a time

====
furosemide not prevent reduce the mortality but alleviate the symptoms

Question 7

beta-blockers licensed to treat heart failure in the UK include

Answer 7

bisoprolol, carvedilol, and nebivolol

Question 8

The standard second-line treatment

Answer 8

aldosterone antagonist

spironolactone and eplerenone

Question 9

when starting second line treatment what are the cautions to be aware of ?

Answer 9

ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalemia

Question 10

Third-line treatment should be initiated by a specialist. Options include?

Answer 10

(SGLT 2 inhibitors have increasing using gliflozosin - // SGLT-2 INHIBITORS - WITH A REDUCED EJECTION FRACTION // )

ivabradine,

sacubitril-valsartan,

hydralazine in combination with nitrate,

digoxin

cardiac resynchronisation therapy

Question 11

when should ivabradine be considered in heart failure ?

Answer 11

sinus rhythm >75/min
LVEF <35%

NO RESPONSE ACEi , beta blocker and aldosterone antagonist therapy

Question 12

criteria for sacubitril-valsartan

Answer 12

left ventricular fraction < 35%

//SYMPTOMATIC ON ACE INHIBITORS OR ARBS

SHOULD BE INITIATED FOLLOWING ACEI OR ARB WASH-OUT PERIOD//

Question 13

criteria for hydralazine in combination with nitrate

Answer 13

// PARTICULARLY INDICATED IN AFRO-CARIBBEAN PATIENTS //

Question 14

criteria for cardiac resynchronisation therapy

Answer 14

include a widened QRS (e.g. left bundle branch block) complex on ECG

// IMPROVED SYMPTOMS AND REDUCED HOSPITALISATION IN NYHA CLASS III PATIENTS //

Question 15

Other treatments

Answer 15

offer annual influenza vaccine

offer one-off pneumococcal vaccine

Question 16

one-off pneumococcal vaccine where adults usually require just one dose but who needs a booster every 5 years

Answer 16

asplenia, splenic dysfunction or chronic kidney disease

Question 17

when is digoxin indicated ?

Answer 17

Not been proven to reduce mortality in patients with heart failure.

It may however improve symptoms due to its inotropic properties
it is strongly indicated if there is coexistent atrial fibrillation

Question 18

Mechanism of action of neprilysin inhibitor, sacubitril, in combination with the angiotensin II receptor blocker, valsartan

Answer 18

Prevents degradation of ANP and BNP

Question 19

Digoxin mechanism of action ?

Answer 19

inhibits Na+-K- ATPase pump in myocardial cells resulting in a transient increase of intracellular sodium, which in turn promotes calcium influx via the sodium-calcium exchange pump leading to increased contractility

Question 20

digoxin should not be administered with ?

Answer 20

hypokalemia, it becomes easier for digoxin to bind to ATPase, leading to toxicity. Furosemide and other diuretics can lower potassium levels, resulting in digoxin toxicity