Treatment Of Chronic Heart Failure Flashcards
Non-pharmacological interventions
Risk factor modification (smoking, drinking, weight)
Limiting sodium and water intake
Limiting travel to high altitudes or humid environments
Regular influenza/pneumococcal vaccines
Treatments of chronic heart failure
Non-pharmacological methods
Drug treatments
Assistive devices
Describe the NYHA classes of breathlessness
Class 1 - No limitation
Class 2 - Symptoms on normal exercise
Class 3 - Symptoms on slight exercise
Class 4 - Symptoms at rest
First line treatment of left ventricle systolic dysfunction
ACE inhibitors and Beta-blockers
Second line treatment for left ventricular systolic dysfunction
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
Ivabradine
Inhibits the funny ion channel (not kidding!!) in the SAN and AVN (mixed Na+/K+ channel)
5-7.5mg BD
Cardiac rehabilitation
Effective for stable patients if supervised group based programme incorporating educational and psychological elements
ACE inhibitors in HF
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
Efficacy of ACEis in HF
20-25% reduction in mortality and hospitalisation
Complications of ACEis in HF
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
Beta-blockers in HF
Symptomatic and prognostic benefit for patient of all backgrounds NYHA II - III
Carvedilol, Nebivolol, Bisoprolol, Metoprolol
Cardioselective Beta-blockers
Metoprolol, Bisoprolol and Nebivolol
Safe in COPD and mild to moderate PVD
Vasodilating Beta- blockers
Nebivolol and Carvedilol
Beta-blocker dosing
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
When should diuretics be used in HF?
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
When should Aldosterone receptor Antagonists (Spirolactone) be added?
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
Possible complications of Aldosterone receptor antagonists
Risk of a hyperkalaemic renal failure - check regularly and reduce/stop if K above 5.5 or creatinine >200
Risk of GI upsets/bleeds
Angiotensin II receptor blockers (ARBs, Losartan) should be used when
When patients are ACEi intolerant due to cough, similar in efficacy and risk reduction
Can be used in combination with ACEi in symptomatic patients
Digoxin
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
Digoxin interacts with
Verapamil, Amiodarone, Propafenone, Erythromycin, Omeprazole, Tetracycline
Hydralazine and nitrates are used
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
Use of anti thrombotic agents in HF
Little evidence
Warfarin in patients with AF
Avoid aspirin unless evidence of vascular disesae
Calcium channel blockers in HF
Avoid Diltiazem and Verapamil
Felodipine and Amlodipine have little/no effect
Nesiritide
Is a recombinant ANP which works the renin-angiotensin system
Was initially believed to be helpful but no evidence is helpful
Possibly harmful
What are vaptans?
Vasopressin receptor antagonists which are promising drugs in development
Endothelin antagonists
Are useful in pulmonary hypertension but not in standard HF
Statins
Like aspirin Aee useful if there is an underlying ischeamic cause but not otherwise
The treatment of diastolic HF
Largely the same as systolic dysfunction
Evidence base for Nebivolol and candesartan (ARBs)
Don’t over-diurese and avoid tachycardia
Focus treatment on hypertension
Devices used to treat chronic HF
CRT pacemaker
CRT defibrillator
Cardiac resynchronisation therapy (CRT) pacemaker
Used in HF patients with evidence of desynchrony
36% reduction in mortality above maximal medical therapy
Cardiac resynchronisation therapy (CRT) defibrillator
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
Ranolazine
Used in angina
Inhibits late Na+ current
No haemodynamic effects or bradycardia
