Heart Failure - treatment

Question 1

What is chronic heart failure characterised by?

Answer 1

Progressive cardiac dysfunction 
Breathlessness 
Tiredness 
Neurohormonal disturbance 
Sudden death

Question 2

What is heart failure?

Answer 2

The state in which the heart is unable to pump blood at a rate commensurate with the requirements of the tissues or can do so only from high pressures

Question 3

What are the two types of heart failure?

Answer 3

Systolic heart failure (HFrEF)

Diastolic heart failure (HFpEF)

Question 4

What is systolic heart failure?

Answer 4

Decreased pumping function of the heart, which results in back up in the lungs and heart failure

Question 5

What is diastolic heart failure?

Answer 5

A thickened and stiff heart that does not fill with blood properly which results in fluid backup in the lungs and heart failure

Question 6

What are the risk factors for heart failure?

Answer 6

Coronary artery disease 
Hypertension 
Valvular heart disease 
Alcoholism 
Infection 
Diabetes 
Congenital heart defects 
Obesity 
Age 
Smoking 
High or low hematocrit level 
Obstructive sleep apnea

Question 7

What is the number one risk for heart failure?

Answer 7

Hypertension

Question 8

What is the pathological progression of cardiovascular disease?

Answer 8

Myocardial injury
Pathological remodelling
Low ejection fraction
Death

Question 9

How does systolic dysfunction cause heart failure?

Answer 9

The heart can no longer pump out blood properly
As circulatory volume increases, the heart dilates, force of contraction weakens and cardiac output drops
Decreased cardiac output activates the RAAS further
This continuous to happen: RAAS activated, circulatory volume increases and cardiac performance decreases
Dilation of the heart causes hypertrophy of cardiac myocytes and then fibrosis

Question 10

What are the two reasons for heart failure?

Answer 10

Sustained hypertension

Myocardial damage

Question 11

What happens during heart failure?

Answer 11

Cardiac output falls
This is registered as decreased circulatory volume
Vasoconstrictor systems activate
RAAS activates

Question 12

What does the RAAS do?

Answer 12

Retains salt and water

Peripheral vasoconstriction

Question 13

What does the RAAS cause the release of?

Answer 13

Angiotensin II

Aldosterone

Question 14

What does activation of the sympathetic system release?

Answer 14

Noradrenaline

Adrenaline

Question 15

What does activation of the sympathetic system do?

Answer 15

Vasoconstriction
Renin release
Myocyte hypertrophy

Question 16

What do atrial and brain natriuretic peptides do?

Answer 16

Vasodilation

Sodium excretion in the urine

Question 17

How is salt and water excretion and vasodilation achieved?

Answer 17

Natriuretic peptide system

EDRF

Question 18

What is the result of heart failure?

Answer 18

Heart that can’t pump blood sufficiently
Retention of salt and water resulting in pulmonary oedema
Myocyte death and fibrosis

Question 19

What are the goals of heart failure management?

Answer 19

Improve symptoms

Improve survival

Question 20

What medication is used to improve symptoms?

Answer 20

Diuretics

Digoxin

Question 21

What medication is used to improve symptoms and survival?

Answer 21

ACE inhibitors/ARBs
Spironolactone
Valsartan-sacubitral

Question 22

What medication is used to improve survival?

Answer 22

Beta blockers

Ivabradine

Question 23

What is the treatment regime followed for heart failure?

Answer 23

Symptomatic treatment
Inhibition of detrimental neurohormonal adaptations
Enhancement of beneficial neurohormonal adaptations
Enhancement of cardiac function

Question 24

What is involved in symptomatic treatment?

Answer 24

Loop diuretics
Mainstay of symptomatic treatment
Furosemide or Bumetanide

Question 25

What is involved in blocking detrimental hormonal changes?

Answer 25

Sympathetic activation using beta blockers such as Carvedilol, Bisoprolol and Metoprolol

Question 26

How are the effects of angiotensin II blocked?

Answer 26

ACE inhibitors such as Ramipril | Angiotensin antagonists such as Valsartan and Losartan

Question 27

How are the effects of aldosterone blocked?

Answer 27

Spironolactone

Question 28

How are the beneficial hormonal changes enhanced?

Answer 28

Natriuretic peptide system - ANP/BNP | Neprolysin prevents metabolism and enhances ANP/BNP action

Question 29

How is cardiac function enhanced?

Answer 29

Positive inotropes - improve hearts ability to pump such as Digoxin Vasodilators - nitrovasodilators reduce preload and afterload and atrial dilators have been shown to improve cardiac function too

Question 30

Nam some nitrovasodilators

Answer 30

Isosorbide mono | Dinitrate

Question 31

Name an atrial dilator

Answer 31

Hydralazine

Question 32

What do loop diuretics do?

Answer 32

Remove excess salt and water

Question 33

What are the adverse drug reactions for loop diuretics?

Answer 33

``` Dehydration Hypotension Hypokalaemia Hyponatraemia Gout Impaired glucose tolerance Diabetes ```

Question 34

What should frusemide not be used with?

Answer 34

``` Amino glycosides Lithium NSAIDs Antihypertensives Vancomycin ```

Question 35

What do ACE inhibitors do?

Answer 35

Prevent conversion of angiotensin I into angiotensin II | Reduce preload and after load to the heart

Question 36

What do ACE inhibitors reduce in post MI patients?

Answer 36

Morbidity Mortality Onset of heart failure

Question 37

What are the adverse drug reactions of ACE inhibitors?

Answer 37

``` First dose hypotension Cough Angioedema Renal impairment Renal failure Hyperkalaemia ```

Question 38

What drugs should not be used with ACE inhibitors?

Answer 38

NSAIDs Potassium supplements Potassium sparing diuretics

Question 39

What do ARBs do?

Answer 39

Selectively block the angiotensin II, AT1 receptors

Question 40

When are ARBs used?

Answer 40

In ACE inhibitor intolerant patients

Question 41

What are the roles of the AT1 receptor?

Answer 41

``` Vasoconstriction Vascular proliferation Aldosterone secretion Cardiac myocyte proliferation Increased sympathetic tone ```

Question 42

What are the roles of AT2?

Answer 42

Vasodilation Antiproliferation Apoptosis

Question 43

What is Valsartan-Sacubitril?

Answer 43

Combined valsartan, ARB and Neprilysin

Question 44

What does Valsartan-Sacubitril do?

Answer 44

Blocks AT1 receptors | Stops breakdown of ANP and BNP

Question 45

How should aldosterone antagonists be used?

Answer 45

In combination with ACE inhibitors if possible

Question 46

What do beta blockers do?

Answer 46

Block the action of the sympathetic system

Question 47

When should beta blockers be used?

Answer 47

When the patient has been selected by a specialist after they have been stabilised

Question 48

What does Digoxin do?

Answer 48

Increases the availability of calcium in the myocytes

Question 49

What negative effects can digoxin have?

Answer 49

Arrhythmias Nausea Confusion

Question 50

What is monitored to see how the patient is reacting to heart failure management?

Answer 50

Symptomatic relief Clinical relief Weight Patient education

Question 51

What is monitored in symptomatic relief?

Answer 51

Shortness of breath Tiredness Lethargy

Question 52

What is monitored in clinical relief?

Answer 52

Peripheral oedema Ascites Weight