Heart Failure and Treatment Flashcards
What are the DEFINING FEATURES of HEART FAILURE (HF)?
1) Dyspnoea, Fatigue or Oedema due to Cardiac Dysfunction
2) At Rest or On Exertion
3) Accompanying Neurohormonal Activation
What are the SALIENT EPIDEMIOLOGICAL FEATURES of HF?
1) Approx. 40-60,000 Patients with HF/Left Ventricular Systolic Dysfunction (LVSD) in Scotland
2) > Prevalence and Incidence With Age (>74 years)
3) Financial Burden on NHS
4) > Inpatient Stay and > Re-Admissions
What are the SYMPTOMS of HF?
1) Dyspnoea
2) Fatigue
3) Oedema
4) < Exercise Tolerance
What are some of the SIGNS of HF?
1) Tachycardia
2) Distended JVP
3) Chest Crepitations
4) Displaced Apex Beat
5) 3rd Heart Sound
6) Oedema
Why is it DIFFICULT to DIAGNOSE HF based on clinical SIGNS ALONE?
Non-Specific Signs
*Objective Evidence of Cardiac Dysfunction Necessary
What is the DIAGNOSTIC CRITERIA for a HF diagnosis?
1) Symptoms or Signs of HF AND 2) Objective Evidence of Cardiac Dysfunction AND (in some cases) 3) Response to Therapy
What are the MAIN INVESTIGATIONS for CARDIAC DYSFUNCTION in HF?
1) Echocardiography
2) ECG
3) FBC - Mainly U and Es and Brain Natriuretic Peptide (BNP)
Why is a TEST of BNP levels in the blood SIGNIFICANT in HF?
- > BNP in HF
1) Highly Sensitive Test
2) < BNP Excludes HF
What are some of the CARDIAC PRECIPITANTS of HF?
1) LVSD
2) Valvular Disease
3) Pericardial Constriction or Effusion
4) Myocardial Ischaemia or MI
5) Arrhythmias
6) Restrictive Cardiomyopathy
7) RVF
Why should LV EJECTION FRACTION (LVEF) NOT be CALCULATED via ECHO?
- Very Difficult to Accurately Quantify
i. e. Due to Quality of Images; Experience of Operator, etc
What is considered a NORMAL LVEF?
50-80%
What is considered a MILD LVEF?
40-50%
What is considered a MODERATE LVEF?
30-40%
What is considered a SEVERE LVEF?
< 30%
What are some of the OTHER INVESTIGATIONS of CARDIAC DYSFUNCTION in HF?
1) Radionuclide Ventriculography (RNVG/MUGA)
2) Left Ventriculography
3) Cardiac MRI
What are the TYPES of HF?
1) Systolic HF/HFrEF (< EF and Fluid Back Up in Lungs)
2) Diastolic HF/HFpEF (LVH and < Compliance; < EDV)
What is the PROGNOSIS for patients with HF?
Poor Prognosis
1 Year Survival Rate for HF Worse than Several Cancers
What are the some of the RISK FACTORS for HF?
1) Hypertension
2) Coronary Artery Disease
3) Alcoholism
4) Previous MI
5) Valvular Disease
6) Diabetes
7) Congenital Heart Defects
8) OSAD
9) Obesity
10) Smoking
11) > Age
What are the MAIN GOALS of HF MANAGEMENT?
Improve Symptoms
Improve Survival
What are the MAINSTAY TREATMENTS for alleviating SYMPTOMS in HF?
Loop Diuretics, i.e. Furosemide
What are some of the SIDE EFFECTS of DIURETICS?
1) Dehydration
2) Hypotension
3) Hypokalaemia
4) Hyponatraemia (< Na+)
5) Gout
What FACTORS must be CONTROLLED to < MORTALITY in HF?
1) Sympathetic Activation
- Beta Receptor Blockade
2) RAAS Activation
- Angiotensin Blockade
- Aldosterone Blockade
3) Neurohormonal Activation
- > Levels of ANP/BNP
What CLASSES of DRUGS are IMPORTANT in < ACTIVATION of RAAS during HF and attenuating symptoms and mortality?
1) ACEIs, i.e. Ramipril or Enalapril
2) ARBs, i.e. Losartan or Valsartan
What are some of the SIDE EFFECTS of ACEIs?
1) Initial Hypotension
2) Cough
3) Angioedema
4) Renal Impairment/Failure
5) Hyperkalemia
ARBs are considered not as effective as ACEIs in treating HF; when is it BENEFICIAL to use ARBs instead of ACEIs?
If the Patient is Intolerant of ACEIs
What is an ALTERNATIVE to ACEIs/ARBs which both < RAAS activation and enhances neurohormonal activation?
Angiotensin Receptor Neprilysin Inhibitor (ARNI), i.e. Valsartan-Sacubitril
What are the ADVANTAGES and DISADVANTAGES of ARNIs?
Advantage: > Effectiveness in < Morbidity and Mortality from HF, in Comparison to ACEI/ARBs
Disadvantages: > Cost
What OTHER DRUGS can be used in COMBINATION with ACEIs to < mortality and improve symptoms in HF?
1) K+ Sparing Diuretic - Spironolactone
2) Beta-Blockers, i.e. Carvedilol or Bisoprolol
What are the STRENGTHS and WEAKNESSES of BETA-BLOCKER use in patients with HF ( < LVEF)?
Strength
< Morbidity and Mortality by 30% in Mild/Moderate and Severe HF
Weakness
Potentially Hazardous
- Start Low Dose
- Use in Combination with Diuretics and ACEI
- Only Use if Patient is Stable
What TWO DRUGS can be used in the treatment of HF, but have a NARROW THERAPEUTIC INDEX and must be MONITORED closely?
1) Digoxin
2) Warfarin
Other than symptomatic and clinical relief, what else MUST BE MONITORED in patients being treated for HF?
Weight (due to Diuretic use and subsequent fluid loss)
*Daily Weight Assessment
