Heart Failure (HF) Flashcards
What is it?
BNF - HF is a progressive clinical syndrome caused by structural or functional abnormalities of the heart, which = reduced cardiac output.
ACUTE = Sudden onset
Chronic = Symptoms Happen over time.
(Acute admitted to hospital ASAP CHF tested outside hospital)
Risk greater in smokers, obese, men, diabetics and increases with age.
HF can be either reduced or preserved ejection fraction (EF):
- Reduced - left ventricle can’t contract proper (EF<40%)
- Preserved - Left ventricle can’t relax proper so EF is normal or minimum reduction.
NYHA:
Class I - No limitation during normal physical activity.
Class II - Slight limitation on moderate exertion e.g., walking/climbing stairs.
Class III - Marked limitation. Symptoms occur on minimal exertion e.g. walking on the flat.
Class IV - Breathlessness at rest.
HF causes
CHD, HTN, Cardiomyopathy, Disease of heart valves, Arrhythmias, Meds that damage heart (Excess alcohol, cocaine etc), Non heart conditions (Thyroid issues, severe anaemia {reduced CO}).
Often Comorbidities
Signs/Symptoms/ Diagnosis
Signs and Symptoms:
ALL: SOB, Persistent coughing/wheezing, ankle swelling, reduced exercise tolerance, fatigue, Chest pain, Palpitations.
Pulmonary congestion: SOB, basal crackles, frothy sputum, PND, orthopnoea (pillows).
Peripheral congestion: Pitting ankle oedema, raised JVP, hepatomegaly, ascites, bowel oedema, anorexia.
Reduced perfusion: Fatigue, confusion/slowness of thought, pallor, renal failure, tachycardia, cold hands &feet.
Also: 3rd/4th Heart sounds, displaced apex beat, murmurs, cardiomegaly.
Diagnosis
Investigations done -
* Systems review/physical examination and routine observations (BP, JVP, pulse, heart sounds)
* Chest X-ray
* Echocardiography
* ECGs
* Blood (Blood gas analysis, U&Es inc. creatinine, LFTs, FBC, TFTs.
* Natriuretic peptides - If have HF =
levels of ANP and BNP are elevated due to myocardial wall stress
Non-Pharmacological Treatment
Exercise, smoking cessation, alcohol reduction, diet (K+ - restrict), Restrict salt in diet (<6g/day)
Salt and fluid only restricted if they are high.
Report weight gain of 1.5 to 2 kg in 2 days to Dr
Implantable cardioverter defibrillators and cardiac resynchronisation therapy are treatment options recommended PPL with HF and reduced EF <35%
CHF with reduced EF - Pharmacological treatment (BNF)
MNEMONIC - BANDAIDS
CCBs
AVOID rate limiting CCBs - (V/D) and Short acting dihydropyridines (Nifedipine, Nicardipine) BC they reduce cardiac contractility.
PTs with HF and angina can use Amlodipine.
MAIN Treatments
ACEi/ARB + Beta Blockers
(Drug must be Licensed for HF)
Patient already on B-Blocker for another condition if condition is stable should switch to B-Blocker used for HF.
Clinical judgement to see which drug to start 1st. Start next drug when PT is stable.
MUST start at low dose and titrated to MAX tolerated.
- ADD Aldosterone antagonist if symptoms persist
ALT Hydralazine + Nitrate if ACEi/ARB intolerant patients/ ADD IF Symptoms persist (esp. in Afro-Caribbean).
ADJUNCT
HF symptoms persist/worsen despite optimal 1st line: ADD
- Aldosterone antagonist (Spironolactone or Eplerenone) unless contraindicated.
- ALT/symptoms continue Specialist advice:
+ 1/more of: - Amiodarone,
- Digoxin (HF with sinus rhythm),
- Sacubitril with valsartan (Replaces ACEi/ARB if EF<35%),
- Ivabradine (in sinus rhythm & HR>75 & EF<35%),
- Empagliflozin or Dapagliflozin 10mg (T2DM, HF, CKD other uses)
In SINUS RYTHMN PTs recommended to ADD Digoxin.
Hx of thromboembolism use ANTICOAGULATION.
DIURETICs
- Apart from aldosterone antagonists (above) other diuretics for HF are:
For relief of SOB and oedema in PTs with fluid retention.
Usual 1st line - Loop diuretics (Furosemide, Bumetanide, Torasemide).
- Thiazide only beneficial if have mild fluid retention and eGFR>30. (eg Indapamide, Bendroflumethiazide, Chlortalidone, Hydrochlorothiazide)
Diuretic doses to be titrated and adjusted for HF this reduces risk of dehydration, renal impairment or hypotension.
Licenced drugs for HF
ACEi/ARB: Many ACEi (perindopril, ramipril, captopril, enalapril, lisinopril, quinapril or fosinopril),
ARB: eg Candesartan, Valsartan, losartan
B-Blocker: (eg NBC- Nebivolol, bisoprolol, Carvedilol) - DONT withhold due to age, diabetes, COPD, PVD, ED - Benefit outweighs risk.
CCB: ONLY amlodipine if have HF and angina
Diuretics: Loop for SOB and oedema with fluid retention. Thiazides only for mild fluid retention and eGFR >30.
MRA/K+ sparing: Spironolactone, Eplerenone,
Digoxin, Hydralazine, Nitrates, Sacubitril + valsartan, Ivabradine
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NOTE: List not exhaustive just some examples
Pharmacological treatment - CHF with Preserved EF (BNF)
MANAGED UNDER specialist.
FLUID RETENTION RELIEF:
Low/Medium dose Loop diuretic.
Monitoring
Starting ACEi/ARB/Aldosterone antagonist BEFORE/1-2 weeks after/ After each dose increase check:
Serum K+ and Na+, Renal function, BP
Once target/MAX tolerated achieved Monitor monthly for 3 months THEN evert 6 months and IF patient becomes unwell.
Starting B-blocker check:
HR, BP, symptoms control.
PPL with CKD - LOWER doses and SLOWER titration of ACEi/ARB/Aldosterone antagonist and digoxin considered.
Other key points
STOP ALL drugs which worsen HF (NSAIDs retain Na+, CCB except amlodipine if applies)
When giving ACEi/ARB + B-Blocker
- ACEi first IF PT has diabetes or fluid overload.
- B-Blocker first if has angina
Hydralazine + Nitrate if unable to take ACEi/ARB esp. afro-Caribbean.
Digoxin can be extra beneficial if PT also has AF or other arrhythmias.
Dapagliflozin/Empagliflozin - 10mg for HF
