Treatment

Question 1

What treatment would you give for HFrEF?

Answer 1

ABAL

• A – ACEi (ramipril 10mg o.d.)
• B – Beta blocker (bisoprolol 10mg o.d.)
• A – Aldosterone antagonist (spironolactone or eplerenone when symptoms not controlled with A or B)
• L – Loop diuretics (furosemide 40mg o.d.)

ACEi and Beta blcoker together as 1st line

Question 2

What would you do if the original doses of an ACEi and Beta-blocker are not working to relieve symptoms?

Answer 2

Titrate the doses up

Question 3

How do ACEi relive HF symptoms?

Answer 3

• Inhibits vasoconstriction, so lowers arterial constriction and increases venous capacity
• Decreases Na+ and water retention

Question 4

Which Beta-blockers are licensed for HF?

Answer 4

• Bisoprolol
• Carvedilol
• Nebivolol
• Metoprolol (modified release)

Question 5

When would you give an ARB?

Answer 5

Used as an alternative to ACEi, for example of the patient develops a cough

Question 6

When would you give a MRA/aldosterone receptor antagonist?

Answer 6

• In addition to ACEi (or ARB) and beta-blocker, if symptoms continue
• Used in severe LV dysfunction (EF <35%)

Question 7

What devices can be implanted if EF<35%?

Answer 7

Cardiac resynchronisation therapy (CRT)
- Improves synchronicity between LV and RV and within LV

Implantable cardiac defibrillators (ICD)
• Attempting to overdrive pace VT
• Deliver electrical shock to cardiovert VT/VF

Question 8

How do you treat HFpEF?

Answer 8

• Diuretics
• Treatment of co-morbidities
• Offer personalised exercise-based cardiac rehabilitation programme unless condition is unstable

Question 9

When is 3rd line treatment use of ivabradine indicated?

Answer 9

Sinus rhythm >75

EF <35%

Question 10

When is 3rd line treatment use of sacubitril-valsartan indicated?

Answer 10

EF <35%

Symptomatic on ACE-i and ARBs

Question 11

When is 3rd line treatment use of digoxin indicated?

Answer 11

AF

Question 12

When is 3rd line treatment use of hydralazine and nitrate indicated?

Answer 12

African-Caribbean patients

Question 13

What are the side effects of loop diuretics?

Answer 13

• Hypotension
• Hypotranaemia
• Hypokalaemia
• Hypomagnesaemia
• Hypochloraemic alkalosis
• Hypocalcaemia
• Ototoxicity
• Renal impairment (dehydration and direct toxic effect)
• Hyperglycaemia
• Gout