Heart Failure (with reduced systolic function)

Question 1

What is LVSD?

Answer 1

Left ventricular systolic dysfunction

Question 2

Aetiology and pathophysiology of LVSD

Answer 2

-Coronary Heart Disease/myocardial infarction (scarring, loss of contraction, dilation)
-Hypertension (pressure overload)
-Dilated Cardiomyopathy (genetic/alcohol/viral)
-Valvular Heart disease

Question 3

Symptoms of LVSD

Answer 3

-Dyspnoea/breathlessness (on exertion/ PND)
-Fatigue
-Ankle swelling (oedema)
-Palpitations

Question 4

Clinical signs of LVSD

Answer 4

-Ankle oedema
-Elevated Jugular Venous Pressure (JVP)
-Basal Lung Crepitation
-Pleural effusions (typically bilateral, small)

Question 5

Investigations of LVSD

Answer 5

-Routine bloods- U&E (kidney), FBC (anaemia), Glucose (diabetes), TFT’s (hypo)
-Chest X-ray (enlargement of heart shadow, pulmonary oedema, effusions)
-ECG (AF, LBBB, Q waves)
-Plasma natriuretic peptide (negative predictive value)
-Echocardiogram (exclude structural / valvular HD)

Question 6

Drug Treatment of LVSD

Answer 6

-Loop diuretics (e.g Furosemide 40-80mg /bumetanide 1-2mg daily)
-ACE inhibitors (e.g. ramipril 2.5-10mg, enalapril 5-20mg daily)
-Beta blockers (e.g. bisoprolol 2.5-10mg, carvedilol 3.125-10mg daily)
-Mineralocorticoid antagonists (e.g. spironolactone 25-50mg daily, inhibit renin-angiotensin-aldosterone system))

Question 7

Advanced treatments of LVSD

Answer 7

-Sacubitril-Valsartan (ARNI- Angiotensin receptor antagonist, neutral endopeptidase inhibitor) = instead of ACEi
(49/51 mg - 97/103 mg twice daily)
-Cardiac Resynchronisation therapy (CRT- LBBB)
-Internal Cardioverter defibrillator (ICD- ventricular arrythmias)

Question 8

Ongoing and long-term care of LVSD

Answer 8

-Up titration of ACE and BB gradually over 6-12 weeks at 1-2 weekly intervals
-2-4 weekly monitoring of BP, heart rate and blood chemistry (HF nurse team)
-Once optimized on medications, review 6-12 monthly checking BP and renal function by GP
-Self-management – daily weights, dietary salt and fluid restriction (1.5-2L per day), self adjustment of diuretics for weight gain of 1-2kg of 3 consecutive days
-Remain physically active using mild – moderate aerobic exercise (walking or jogging)
-Prognosis is limited particularly in the elderly (>75) with 10-20% annual mortality even with treatment