Treatment Of Chronic Heart Failure

Question 0

Non-pharmacological interventions

Answer 0

Risk factor modification (smoking, drinking, weight)
Limiting sodium and water intake
Limiting travel to high altitudes or humid environments
Regular influenza/pneumococcal vaccines

Question 1

Treatments of chronic heart failure

Answer 1

Non-pharmacological methods
Drug treatments
Assistive devices

Question 2

Describe the NYHA classes of breathlessness

Answer 2

Class 1 - No limitation
Class 2 - Symptoms on normal exercise
Class 3 - Symptoms on slight exercise
Class 4 - Symptoms at rest

Question 3

First line treatment of left ventricle systolic dysfunction

Answer 3

ACE inhibitors and Beta-blockers

Question 4

Second line treatment for left ventricular systolic dysfunction

Answer 4

Aldosterone Anagonist if NYHA III - IV or recent MI
ARB if NYHA II - III
Hydrazine in combination with a nitrate if black and NYHA III - IV

Question 5

Ivabradine

Answer 5

Inhibits the funny ion channel (not kidding!!) in the SAN and AVN (mixed Na+/K+ channel)
5-7.5mg BD

Question 6

Cardiac rehabilitation

Answer 6

Effective for stable patients if supervised group based programme incorporating educational and psychological elements

Question 7

ACE inhibitors in HF

Answer 7

First line treatment in HF-REF with or without symptoms
If congested start ACEi and diuretic
Must check renal function as dose is titrated to effected dose

Question 8

Efficacy of ACEis in HF

Answer 8

20-25% reduction in mortality and hospitalisation

Question 9

Complications of ACEis in HF

Answer 9

Decreasing renal function - discontinue if creat increases by >50% or >200 or potassium >6
Hypotension - ignore if asymptomatic, if problematic stop other vasodilators and reduce diuretics first
Cough - exclude significant pulmonary cause and shift to ARBs if troublesome

Question 10

Beta-blockers in HF

Answer 10

Symptomatic and prognostic benefit for patient of all backgrounds NYHA II - III
Carvedilol, Nebivolol, Bisoprolol, Metoprolol

Question 11

Cardioselective Beta-blockers

Answer 11

Metoprolol, Bisoprolol and Nebivolol

Safe in COPD and mild to moderate PVD

Question 12

Vasodilating Beta- blockers

Answer 12

Nebivolol and Carvedilol

Question 13

Beta-blocker dosing

Answer 13

If problematic switch to double doses at two week intervals
Small doses still give benefit, don’t increase dose if patient becomes bradycardic
Symptomatic improvement takes 3-6 months

Question 14

When should diuretics be used in HF?

Answer 14

Only if patient shows signs of fluid overload
If patient dose not respond used twice daily IV infusions

Bumetanide gives a possible advantage if signs of right sided HF

Question 15

When should Aldosterone receptor Antagonists (Spirolactone) be added?

Answer 15

All patients with NYHA II-IV symptoms as it improves symptoms and rate of survival
In all cases of HF post MI
Spirolactone found to give 30% relative risk reduction in patients with NYHA III-IV symptoms

Question 16

Possible complications of Aldosterone receptor antagonists

Answer 16

Risk of a hyperkalaemic renal failure - check regularly and reduce/stop if K above 5.5 or creatinine >200

Risk of GI upsets/bleeds

Question 17

Angiotensin II receptor blockers (ARBs, Losartan) should be used when

Answer 17

When patients are ACEi intolerant due to cough, similar in efficacy and risk reduction
Can be used in combination with ACEi in symptomatic patients

Question 18

Digoxin

Answer 18

In patients suffering AF with any level of HF
Greatest effect from combination of digoxin and beta-blocker
Reduces admissions in severe HF, but does not reduce mortality

Question 19

Digoxin interacts with

Answer 19

Verapamil, Amiodarone, Propafenone, Erythromycin, Omeprazole, Tetracycline

Question 20

Hydralazine and nitrates are used

Answer 20

In patients who are intolerant of ACEi and ARBs due to cough or renal impairment
Reduces mortality
Has additional benefit in black populations, is possible that combination prevents nitrate tolerance

Question 21

Use of anti thrombotic agents in HF

Answer 21

Little evidence
Warfarin in patients with AF
Avoid aspirin unless evidence of vascular disesae

Question 22

Calcium channel blockers in HF

Answer 22

Avoid Diltiazem and Verapamil

Felodipine and Amlodipine have little/no effect

Question 23

Nesiritide

Answer 23

Is a recombinant ANP which works the renin-angiotensin system
Was initially believed to be helpful but no evidence is helpful
Possibly harmful

Question 24

What are vaptans?

Answer 24

Vasopressin receptor antagonists which are promising drugs in development

Question 25

Endothelin antagonists

Answer 25

Are useful in pulmonary hypertension but not in standard HF

Question 26

Statins

Answer 26

Like aspirin Aee useful if there is an underlying ischeamic cause but not otherwise

Question 27

The treatment of diastolic HF

Answer 27

Largely the same as systolic dysfunction
Evidence base for Nebivolol and candesartan (ARBs)
Don’t over-diurese and avoid tachycardia
Focus treatment on hypertension

Question 28

Devices used to treat chronic HF

Answer 28

CRT pacemaker

CRT defibrillator

Question 29

Cardiac resynchronisation therapy (CRT) pacemaker

Answer 29

Used in HF patients with evidence of desynchrony

36% reduction in mortality above maximal medical therapy

Question 30

Cardiac resynchronisation therapy (CRT) defibrillator

Answer 30

Same as a pacemaker but used in patients at risk of SVT/VT/VF and is able to shock the patient if these rhythms occur

Question 31

Ranolazine

Answer 31

Used in angina
Inhibits late Na+ current
No haemodynamic effects or bradycardia