Heart Failure: Diagnosis & Management

Question 1

How should you investigate heart failure?

Answer 1

Previous MI - Arrange echocardiogram & specialist assessment within 2 weeks

No previous MI

• Measure serum natriuretic peptides (BNP)
• If levels are ‘high’ arrange echocardiogram & urgent referral within 2 weeks.
• If levels are ‘raised’ arrange echocardiogram and routine referral within 6 weeks

Question 2

what are the 2 types of BNP?

Answer 2

BNP and NTproBNP

Question 3

What levels of BNP are high, raised and normal

Answer 3

Question 4

What can increase BNP levels?

Answer 4

• Left ventricular hypertrophy
• Ischaemia
• Tachycardia
• Right ventricular overload
• Hypoxaemia (including pulmonary embolism)
• GFR < 60 ml/min
• Sepsis
• COPD
• Diabetes
• Age > 70
• Liver cirrhosis

Question 5

What can decrease BNP levels?

Answer 5

• Obesity
• Diuretics
• ACE inhibitors
• Beta-blockers
• Angiotensin 2 receptor blockers
• Aldosterone antagonists

Question 6

What drugs (and in what trials) are shown to reduce mortality in heart failure?

Answer 6

• ACE inhibitors (SAVE, SOLVD, CONSENSUS)
• Spironolactone (RALES)
• Beta-blockers (CIBIS)
• Hydralazine with nitrates (VHEFT-1)

Question 7

What is the first line treatment in HF with LV dysfunction?

Answer 7

1. ACE-i - titrate to dose “start low and uptitrate slow (every 2 weeks)”
   
   • Use A2RB if intolerant to ACEi
2. Beta-Blocker in ALL LV dysfunction.
   
   • Ensure no heart block or asthma.

Question 8

What is second line treatment in HF with LV dysfunction?

Answer 8

Only following specialist advice.

• Aldosterone antagonists (Spironolactone, Eplerenone)
• Hydralazine in combination with a nitrate.
• Digoxin (does not reduce mortality but may improve symptoms due to ionotropic properties)

Question 9

If someone is symptomatic with HF, what can you give and how?

Answer 9

• Start with loop diuretic
• Monitor U&Es.
• When stable reduce dose or switch to thiazide diuretic.

Question 10

What should you offer EVERY patient who has HF?

Answer 10

Lifestyle advise.

Question 11

Which drugs haven’t been shown to reduce mortality in heart failure?

Answer 11

Furosemide

Digoxin

Question 12

So….to repeat & in summary, what should your drug management strategy be for HF?

Answer 12

• First-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
• Second-line treatment is now either:
  
  • Aldosterone antagonist
  • Angiotensin II receptor blocker
  • Hydralazine in combination with a nitrate
• Third-line Treatment: if symptoms persist:
  
  • Cardiac resynchronisation therapy
  • Digoxin should be considered
• Diuretics should be given for fluid overload

Question 13

What vaccinations should be offered to patients with HF?

Answer 13

Offer annual influenza vaccine

Offer one-off** pneumococcal vaccine