Heart Failure and therapeutics Flashcards
What is the definition of heart failure?
- Failure of the heart to pump blood at a rate sufficient to meet the metabolic requirements of the tissues
- Caused by an abnormality of any aspect of cardiac function and with adequate filling pressure
What is heart failure characterised by?
Typical haemodynamic changes (e.g. systemic vasoconstriction) and neurohumoral activation
What are the common causes of heart failure in the UK?
- Corornary artery disease
- Hypertension
- Idiopathic as in unknown
- Toxins (alcohol, chemotherapy)
- Genetic
What are the causes of heart failure which are less common in the UK
- Valve disease
- Infections (virus, Chaga’s)
- Congenital heart disease
- Metabolic (haemochromatosis, amyloid, thyroid disease)
- Pericardial disease (e.g. TB)
What are the 4 types of heart failure?
- HF-REF (systolic HF)
- HF-PEF (diastolic HF)
- Chronic (congestive)
- Acute (decompensated)
Describe the typical presentation of HF-REF
- Younger
- Male
- Coronary aetiology
Describe the typical presentation of HF-PEF
- Older
- More often female
- Hypertensive aetiology
What is the breif overall pathology-physiology of heart failure?
- Myocardial injury results in left ventricular systolic dysfunction
- This results in perceived reduction in circulating volume and pressure
- Resulting in neurohumoral activation (SNS, RAAS, ET and AVP, Natriuretic peptides etc. )
- This leads to systemic vasoconstriction and the renal retention of sodium and water which then leads to further left ventricular systolic dysfunction and the cycle continues
What are the symptoms of heart failure?
- Dyspnoea and cough
- Ankle swelling (also legs and abdomen)
- Fatigue/tiredness
What are the signs of heart failure?
- Peripheral oedema (ankles, legs, sacrum and abdomen)
- Elevated JVP
- Third heart sound
- Displaced apex beat
- Pulmonary oedema (lung crackles)
- Pleural effusion
What are the symptoms in NYHA class I
No symptoms and no limitation in ordinary physical activity i.e. they don’t get short of breath from walking
What are the symptoms in NYHA class II?
Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity
What are the symptoms in class III NYHA?
Marked limitation in activity due to symptoms, even during less than ordinary activity e.g. walking short distances
Comfortable only at rest
What are the symptoms in class IV heart failure?
Severe limitations. Experience symptoms even while at rest. Mostly bed bound patients
What investigations should be carried out in all heart failure patients?
- ECG
- Chest X ray
- Echocardiogram (chamber size, systolic and diastolic function, valves)
- Blood chemistry (U+Es, Creatinine, urea, LFTs, urate)
- Haematology (Hb, RDW)
- Natriuretic peptides (BNP, NT-proBNP)
What is the diagnostic algorithm for heart failure?
- Suspected heart failure: risk factors/ symptoms and signs/ abnormal ECG
- Carry out NT-proBNP or BNP. If NT-proBNP is equal to or higher than 125 pg/mL or BNP is equal to or greater than 35pg/mL then carry out echocardiography
- If abnormal findings then heart failure is confirmed, carry on to find the HF phenotype
How can you define the heart failure phenotype?
- LVEF measurement
- If =/<40% it is HFREF (reduced ejection fraction)
- If 41-49% then HFMREF (mildly reduced)
- If =/>50% then HFPEF (preserved)
What is the treatment of HFrEF?
- ACEi or ARNI
- Beta blocker
- MRA
- Dapagliflozin or empagliflozin
- Loop diuretic for fluid retention
What medications should be given to all HF patients as stated in the ESC HFA guidelines?
- ACEi or APRN
- Beta blocker
- MRA (aldosterone receptor antagonist)
- SGLT2i
What is the effect of angiotensin II on the blood vessels?
- Vasoconstriction
- smooth muscle cell hypertrophy
- Superoxide generation
- endothelial secretion
- Monocyte activation
- inflammatory cytokines
- Reduced fibrinolysis
What is the effect of angiotensin II in the kidney?
- Sodium and water retention
- Efferent arteriolar vasoconstriction
- Glomerular and interstitial fibrosis
What is the effect of angiotensin II on the heart?
- cellular hypertrophy
- myocyte apoptosis
- Myocardial fibrosis
- Inflammatory cytokines
- Coronary vasoconstriction
- Positive inotropy (strengthened heart contractions)
- Proarrhythmia
What is the effect of angiotensin II on the adrenal gland?
Aldosterone secretion
What is the effect of angiotensin II on the brain?
- Vasopressin secretion
* Sympathetic activation
Describe the action of the ARNI LCZ696
ARNI= Angiotensin receptor Neprilysin Inhibition
•It combines valsartan and sacubitril
•Valsartan is a AT1 antagonist, Redding vasoconstriction, sodium/water retention and fibrosis/hypertrophy
•Sacubitril is a neprilysin antagonist. Neprilysin degrades natriuretic peptides. Sacubitril results in increased NTPs resulting in vasodilation, natriuresis, diuresis and inhibition of pathologic growth/fibrosis
Give two examples of SGLT2is
- Dapagliflozin
* Empagliflozin
Give two examples of SGLT2is
- Dapagliflozin
* Empagliflozin
What are the devices that can be used in heart failure?
•ICD- implantable cardioverted defibrillator
What are the devices that can be used in heart failure?
•ICD- implantable cardioverted defibrillator
Describe biventricular/multi site pacing (or cardiac resynchronization therapy)
- 3 leads
- One in the right atrium
- One in the right ventricle
- Lead through the coronary sinus to the left ventricle (this makes it different to a normal pace maker)
Who qualifies for CRT-D and CRT-P?
- Anyone with a QRS over 150ms, CRT-P for class IV, option of either for class III
- QRS 120-149 and LBBB NYHA class II-IV, CRT-p if class IV, option of either in class III
- QRS 120-149 no LBBB, NYHA class IV CRT-P
What can be used to inhibit the sinus node?
Ivabradine (slows the rate)
What can Ivabradine be used to treat?
Systolic heart failure
What drugs can be used in African Americans with heart failure?
Hydralazine and isosorbide dinitrate
What drugs have the best evidence base for the treatment of heart failure with a midly reduced ejection fraction?
Diuretics
Describe the management of acute heart failure
- Aqua Natriuresis: Ultrafiltration
- Arterial vasodilation: nitrates/dobutamine/nitroprusside
- Venodilation: nitrates/morphine
- Natriuresis: Furosemide
- Increased inotropy: Dobutamine, dopamine, milrinone
- Preload reduction: bilevel or continuous positive airway pressure
