Treatment of Heart Failure

Question 1

What are the aims of treatment for heart failure with reduced ejection fraction?

Answer 1

• Relieve symptoms,
• Improve exercise tolerance,
• Reduce incidence of acute exacerbation and,
• Reduce mortality if possible

Question 2

What are the strategies for treatment?

Answer 2

• Increase cardiac contractility,
• Decrease preload and afterload in order to decrease cardiac demand
• Inhibit RAAS
• Prevent inappropriate increase in HR,
• Mobilise oedematous fluid

Question 3

What are some non-pharmacological treatments of heart failure?

Answer 3

• Lifestyle factors,
• Device therapy such as pacing, Cardiac resynchronisation therapy, implantable cardiac defibrillators, coronary revascularisation or heart transplant.

Question 4

What are the main drugs used in the treatment of chronic heart failure?

Answer 4

ABBA waterloo.

• Ace inhibitors or ARBs
• Beta Blockers
• Aldosterone receptor antagonists
• Loop diuretics (WATERloo)

Question 5

What is the first step in the treatment of chronic heart failure?

Answer 5

DAB
- Diuretics if fluid retention,
- ACE inhibitors/ARBs
- Beta Blockers. 
The combination of A + B reduces mortality and improves quality of life

Question 6

Why are diuretics not used on their own?

Answer 6

They trigger the renin aldosterone activating system (RAAS) which can make the condition worse.

Question 7

Describe the regimes of loop diuretics

Answer 7

• Used if there are clinical signs of congestion.
• Aim is to achieve dry weight on lowest diuretic dose. This can be achieved with patient self management via:
• Daily weights, if gets to high or too low then alter dose.
• Symptom review, if they get dyspnoea, peripheral oedema.
• Look at thirst level and dizziness.

Question 8

What are the common side effects of loop diuretics? name two examples of drug.

Answer 8

Furosemide and Bumetanide.

• Electrolyte disturbances,
• Hypotension
• Renal impairment,
• Hypovolaemia
• Nocturia if dose taken late in day,
• Acute gout with high doses

Question 9

What are the functions of ACEI or ARBs?

Answer 9

Reduces salt and water retention, reduces vasoconstriction, reduces vascular resistance, reduces afterload, improves tissue perfusion, reduces ventricular remodelling and hypertrophy

Question 10

What drugs are used in patients of African/Caribbean ethnicity?

Answer 10

Hydralazine which is a vascular muscle relaxant and nitrates (usually isosorbide mononitrate).

Question 11

What are the common side effects of ACEI and ARBs?

Answer 11

Dizziness, 
Headaches,
Hyperkalaemia risk, 
Renal impairment
- Teratogenic (shouldn't be given to pregnant women)
Specific to ACEI - Dry cough. 
Specific to ARBs - back/leg pain

Question 12

Recognise how the apparently paradoxical use of beta blockers is of benefit

Answer 12

It can cause a slow heart rate meaning the cardiac output could be decreased however this allows the ventricles to fill more during diastole and reduce renin release.

Question 13

What are the beta blocker side effects?

Answer 13

• Contra-indication in bradycardia or heart block,
• Fatigue,
• Shortness of breath
• Dizziness, cold peripheries, reduced libido, insomnia

Question 14

What is the step two of treating chronic heart failure

Answer 14

• Adding aldosterone antagonist (spirnolactone) if they are still experiencing symptoms. Only low doses are used, but it reduces symptoms and mortality.

Question 15

What are the common side effects of aldosterone receptor antagonists?

Answer 15

• Hyperkalaemia
• Hyponatremia
• Hypotension
• Gynaecomastia with spironolactone
• Renal impairment

Question 16

Describe the management of heart failure drug adverse effects

Answer 16

Flexible dosing for DABs, Review BP and if has bradycardia then may need to stop beta-blockers or review rate controlling drugs

Question 17

Describe the 3rd or 4th step in the management of chronic failure

Answer 17

• Sucubitril (Neprilysin inhibitor) + Valsartan combination or Ivabradine

Question 18

What are the other options if patient still remains symptomatic?

Answer 18

If there is persistent sodium/water retention - use additional diuretics like thiazides.
Co-excising angina - Oral nitrates or amlodipine

Question 19

Describe the effects of digoxin

Answer 19

In AF - increases vagal efferent activity to heart to decrease SAN firing rate and decrease conduction velocity in AVN
In heart failure - Increases the force of myocardial contraction. Inhibits the Na/K-ATPase and indirectly increases calcium levels.

Question 20

What are the digoxin side-effects/toxicity?

Answer 20

• Narrow theraputic window,
• Dizziness
• Conduction abnormalities
• Blurred or yellow vision.

Question 21

What is the first line treatment of Acute Heart Failure?

Answer 21

LMNOP.
Loop diuretics (IV) - causes vasodilation, diuresis and reduced preload.
IV opioids (Morphine) - Reduce anxiety, vasodilates, reduced sympathetic drive.
IV or sublingual Nitrates - reduces preload and afterload and vasodilation.
Oxygen,
Positioning - keep patient upright.

Question 22

What is the second line treatment for acute heart failure

Answer 22

Ionotropes (beta agonists) which increase contractility which will increase SV and increase CO so increase clearance of pooled blood in ventricles. As CO increases baroreceptor sense increase in MABP so decrease sympathetic drive, to decrease HR and TPR

Question 23

Where are ionotropes used?

Answer 23

In intensive care units and coronary care units only

Question 24

Name examples on ionotropes and their function.

Answer 24

Beta agonists such as Dobutamine (maintains BP in cardiogenic shock), Dopamine (increases renal perfusion at low, at high it increases BP)
Isoprenaline - Bradycardia/heart block emergencies.
Adrenaline.

Vasopressors - Noradrenaline, causes vasoconstriction, increase BP and used in septic shock