HF Management Flashcards
Define chronic heart failure
The definition of chronic heart failure has evolved over time.
As per European Task Force on Heart Failure - “A syndrome in which the patients should have the following features:
- symptoms of heart failure, typically breathlessness or fatigue, either at rest or during exertion, or ankle swelling
- objective evidence of cardiac dysfunction at rest”
European definition reflcts changed thinking about heart failure
List some symptoms and signs of chronic heart failure*
NO CHEST PAIN
Symptoms and signs
#### Symptoms
More typical symptoms include:
- dyspnoea (usually with exertion)
- orthopnoea
- paroxysmal nocturnal dyspnoea
- fatigue
Less typical symptoms include: ^[good for Hx taking]
- nocturnal cough
- wheeze
- abdominal bloating
- anorexia
- confusion in elderly
- depression
- palpitations
- dizziness
- syncope
- bendopnoea
Signs
More typical signs include:
- elevated JVP
- hepatojugular reflux
- third heart sound
- laterally displaced apex beat
Less specific signs include: ^[good for Hx taking]
- weight gain (> 2 kg/wk)
- weight loss in advanced HF
- peripheral oedema
- pulmonary crackles
- pleural effusions
- cardiac murmur
- tachycardia and tachypnoea
- Cheyne-Stokes respiration ^[cycles of apnoea and hyperventilation]
- ascites
List clinical risk factors for congestive heart failure
Clinical risk factors for CHF
- advanced age (> 60 years)
- low physical activity (and generally an increased BMI)
- cigarette smoking ^[also risk for CAD i.e. may be a contributor]
- overweight ^[also risk for CAD i.e. may be a contributor]
- hypertension ^[also risk for CAD i.e. may be a contributor]
- diabetes, due to constant hyperglycaemia ^[also risk for CAD i.e. may be a contributor]
- valvular heart disease
- coronary artery disease
- LV hypertrophy
- family history of cardiomyopathy
- atrial fibrillation ^[common presentation of heart failure]
Describe the stages of heart failure
Stages of heart failure
- Stage A: at-risk: patients at risk without current or previous symptoms or signs, and without structural or functional heart disease, or abnormal biomarkers
- Stage B: pre-heart failure: without symptoms or signs but evidence of one of: structural heart disease, increased filling pressures, risk factors AND increased natriuretic peptides/persistently elevated cTn in the absence of competing diagnoses
- Stage C: symptomatic heart failure: current or previous
- Stage D: advanced heart failure: marked symptoms that interfere with daily life and with recurrent hospitalisations despite attempts to optimise GDMT
Note: may need to update
Note 2, for people with HF:
- 50% with EF > 50%
- 35% with EF < 40
- 15% with EF <25-30%
List a range of therapies to reduce CHF, with inclusion criteria
- diuretics
- SGLT2i
- ARNi
- MRA
- ARB
-
- diuretics
- ACEi or ARB
- beta blockers
- aldosterone antagonists
Describe three non-pharmacological management approaches for CHF
- Principle of prevention: if you can reduced CAD, you can reduce heart failure
- Treat comorbidities to improve quality of life
- MDT: very beneficial
- Similarly, good treatment of hypertension can prevent heart failure
- Even asymptomatic patients will benefit from ACEIs and diuretics
Non-pharmacological management of CHF
* 8-12 week HF management program for patients with high-risk
features (↓ mortality and rehospitalisation)
* Multidisciplinary telemonitoring where management program not
possible
* Nurse-led medication titration for HFREF patients (nurses have ability
to recognise deteriorating patients)
* Risk factor modification e.g. alcohol/smoking cessation, diet
Describe differences in management of HF-pEF and HF-rEF
Management of HFpEF:
## Goals
- control symptoms
- improve QOL
- prevent hospitalisation and mortality
Strategies
- identification of comorbidities
## Treatment
- diuresis to relieve symptoms of congestion
- follow guideline driven indications for comorbidities e.g. HTN, AF, CAD, DM
- revascularisation/valvular surgery as appropriate
Management of HFrEF:
Goals
- control symptoms
- patient education
- prevent hospitalisation and mortality
Drugs
- diuretics for fluid retention
- ACEI or ARB
- beta blockers
- aldosterone antagonists
Drugs for use in selected patients
- hydralazine/isosorbide dinitrate
- ACEI and ARB
- digoxin
and CRT, ICD, and revasc/valvular surgery in selected patients, as appropriate
Describe three first line pharmacological agents to treat symptomatic HF-rEF
Lines of treatment for HF-rEF/pillars of management:
- ACEI or ARB, decrease activity of RAAS
- beta blockers, to reduce sympathetic activity, has lusitropic effect, but may reduce EF further. Use beta blockers once euvolumeic
- minerlocorticoud receptor antagonist or MRA,to reduce rase acticiy
- diuretics, which “always help”, drastically reduces congestion
- empagliflozin - SGLT2 or the “fourth pillar”. Increases glucose excretion, increasing diuresis. It also changes ATPase in myocytes, thus improving heart failure
Typically, diuretics and ACEIs are used first.
Describe indications and contraindications for cardiac transplantation
Indications:
Definite
- persistent class 4 symptoms
- VO2 max <10 kml/kg/min
- severe ischaemia not amenable to revasc.
- recurrent uncontrollable ventricular arrhythmias
Probable
- NYHA class 3
- VO2 max <14
- recurrent unstable angina with poor LV function
Inadequate
- LVEF <20% without significant smptoms
- past history of class 3/4 symptoms
- VO2 max>14 , without other indication
Contraindications:
- over 65 y
- active infection
- untreated malignancy/malignancy in remission and under 5y follow up
- fixed high pulmonary pressures
- current substance abuse
- DM with severe or progressive end-ogan damage
- morbid obesity
- unhealed peptic ulceration
- averse psychosocial factors limiting compliance with therapy
- coexisting systemic illness, likely to limit survival
- recent pulmonary embolism
Describe ATTR and red flags*
- acquired wild type TTR amyloidosis seen mainly in older white men
- characterised by restrictive thick walled cardiomyopathy
- diastolic dysfunction
- normal systolic function
- cardiac failure
- and also characterised by carpal tunnel syndrome
Red flags
- HFpEF: over 60
- Intolerance to standard HF therapies i.e. ACEIs, ARBs and beta blockers
- Discordance- between QRS voltage and LV wall thickness
- Diagnosis- of carpal tunnel/lumbar spinal stenosis
- Echo- showing increased LV wall thickness
- Nervous system - ANS dysfunction, including GI complaints or unexplained weight loss
Describe some diagnostic tools for heart failure
- Heart failure diagnostic criteria
- HFREF:
- Symptoms ± signs of HF
- LVEF <50%
- HFPEF:
- Symptoms ± signs of HF
- LVEF >50%
- Additional evidence:
- Structural heart disease (e.g. LVH, LA
enlargement in response to ↑ L pressure) - Diastolic dysfunction with ↑ filling pressure
determined by cardiac catheterisation, echo,
elevated BNP, etc.) - initial assessment: EUC, LFTs, FBC, ECG, CXR
- Echo
- BNP if uncertain, >400 rule in
- scores: H2FPEF
