Treatment of Heart Failure Flashcards
What is usually dealt with in the management of Heart Failure?
The Left Ventricle Systolic Dysfunction associated with a LV ejection fraction of less than 45%
What is the ejection fraction of a healthy person?
(55-60%)
What happens if someone has LV dysfunction but a preserved LV ejection fraction?
The treatment for this is not clearly defined.
A preserved LV ejection is >50%
What are the aims of treatment?
Reduction in symptoms such as fatigue, oedema, dyspnoea (laboured breathing)
Reduction in the number of acute states with the progression of the disease
Decreased mortality and the rate at which it occurs.
What is the purpose of pharmacological treatment?
Counteract the neurohormonal response due to lower the CO
What is the class of drugs affecting the Sympathetic nervous system?
Beta Blockers - beta adrenoreceptors antagonist work to slower the heart rate and casue vasodilation (opposite to Noradrenaline)
What class of drugs affect the Renin-Angiotensin- Aldosterone system? (3)
ACE inhibitors
ARB (angiotensin receptor antagonist)
Aldosterone antagonist
What is the guidelines on ACE inhibitors?
Suitable to all grades of LV dysfunction. A low initial dose is required to reduce the risk of sudden fall in BP
Upward tritration over 2-3 weeks
When would a thiazide-like drug be added?
If oedema was an accompynying symptom of the Heart Failure
We know that cough is a common symptom of ACE. What should be excluded as a cause of the cough in HF patients?
Possible pulmonary oedema
Give examples of ACE inhibitors
Lisinopril, Ramipril, Veramipril
What are the guidelines on ARBs?
These are not 1st line treatment, but are used if an ACE isn’t tolerated. It has the same effect as ACE inhibitors but is more expensive.
What are the guidelines on Beta BLockers?
These are part of the 1st line treatment and are recommended for ALL pateints with stable heart failure unless the drugs are contraindicated or not tolerated.
The lowest dose possible should be used from the beginning.
WHat are the benefits of Beta Blockers?
They blunt the effect of the Noradrenaline released in response to the sympathetic nervous system, especially the effect on the heart rate
What does a slower HR caused by the beta blockers result in?
Slower HR = Longer diastolic filling pressure = better ventricular filling = more effective CO.
What is the other possible mecahnism of action of Beta blockers?
MAy also stabilise the electrical conduction reducing arrhythmias
What is the last minor effect of Beta bLockers?
They have a small blunting effect on the RAASystem
What is possible with the low initial dose?
What should happen after symptoms improve?
A short period of worsening symptoms - fatigue, poor excercise tolerance etc, but this will wear off.
After these symptoms improve, the dose should be totrated to the maximum tolerated dose over 8 weeks
Give some examples of Aldosterone receptor antagonist drugs and when are these used?
Spironolactane, Eplerenone. These are used as adjunctive therapy along with the ACE inhibitors or a Beta Blocker.
What is the suitable dose of Aldosterone receptor antagonist drugs?
Lowest dose possible = 25mg
What care should be taken with Aldosterone receptor antagonist drugs and ACE or ARB?
Be aware of Hyperkalaemia
What are the additional possible HF therapies?
Loop or Thiazide like diuretics
Digoxin
Ivabradine
Hydralazine/nitrate combination
Loop or Thiazide like diuretics: when and why?
May be added if patients are still symptomatic on 1st line therapy, and also If oedema was an accompynying symptom of the Heart Failure
Digoxin: Why and who?
Can produce some symptomatic benefit in patients with sinus rhythm but will have no mortality benefit
Ivabradine: WHen and Why?
the symptomatic management of stable heart-related chest pain and heart failure not fully managed by beta blockers. It blocks Funny Current which slows the progression of HF, but not much evidence
Hydralazine/nitrate: WHy? Why?
Used to balance venodilation and arteriodilation to reduce preload and afterload to increase Caridac Output. Especially usefull for African/Carribean patients where ACE inhibitors aren’t as beneficial.
WHat is Acute Decompensated HF?
Rapidly worsening symptoms with respiratory distress
What is the treatment?
MEdical emergancy:
IV opiates (morphine) to reduce anxiety
High Oxygen flow to aid breathlessnes
IV loop diuretic to reduce pulmonary oedema
IV nitrate to venodilate, increase Caridac output.
IV sympathomometic Inotrope.
