Heart Failure [pharmaceutical treatment, heart transplant, implantable devices like ICD, CRT, LVAD]; Toxic heart deteriorations, Primary Heart tumours

Question 1

Pharmacological treatments for Heart failure

Answer 1

HFrEF:
ACC/AHA Stage B [prevent symptomatic HF]:
- Beta Blocker
- + ACEi/ARB

ACC/AHA Stage C and D [Reduce morbidity, mortality, hospitalizations]: One agent from each drug class
- Diuretics [Loop or Thiazide]
- ACEi/ARBs/ARNIs
- Beta Blockers [ONLY Bisprolol/Carvedilo/Metoprolol succinate]
- SGLT2 inhibitors [reversibly inhibits sodium-dependent glucose transporter - diuresis]
- Aldosterone Antagonists [Spironolactone/Eplerenone]

Additional therapy for considerations:
- Funny sodium channel inhibitor
- Digoxin [especially if A.fib also present]

HFpEF:
First Line:
- SGLT2 inhibitors for all patients
- Loop Diuretics for congestion symptoms

Second line:
- Spironolactone
- ARBs/ARNI

ARNI = Angiotensin receptor-neprilysin Inhibitors

Question 2

Non-pharmacotherapies for Heart Failure

Answer 2

Automatic Implantable Cardioverter Defibrillators [AICD]:
- Performs cardiac rhythm monitoring
- Delivers electric shock to myocardium
- Transvenous AICD: Defibrillator, Synchronized cardioversion, antibrady and tachy pacing
- Subcutaneous AICD: Defibrillator only
- Give to HF patients at risk of Ventricular Fibrillation or Tachycardia | Give to HF patients with < 35% EF with ischemic/non-ischemic cardiomyopathy

Cardiac Resynchronization Therapy [CRT]:
- Cardiac rhythm monitoring
- Biventricular pacing
- Leads implanted in RA, RV and Coronary sinus
- CRT-Pacemaker: Biventricular pacemaker only
- CRT-Defibrillator: Biventricular pacemaker + AICD
- Give to HF patients with Systolic dysfunction [Class III, IV NYHA], < 35% EF, LBBB and Wide QRS complexes
- DO NOT give to Narrow QRS complex HF patients

Left Ventricular Assist Devices [LVAD]:
- Mainly used as a bridge to pacemaker implantation [before] and an alternative to pacemakers [when pacemaker placement not possible]
- R-VAD | L-VAD | BIVAD
- Give to patients with severe ventricular dysfunction, severe HF [< 25% EF] or intractable arrhythmias | Life long Heparin/Warfarin therapy

Heart Transplant is the only proper ‘cure’ for advanced and very severe HF. Considered for Advanced HF patients with no improvement on Pharmaco and non-Pharmaco therapies