Week 4 - Chronic Heart Failure Treatments

Question 1

What is the aim of treatment?

Answer 1

• improve status and functional capacity of patient,
• QoL,
• prevent hospital admission
• reduce mortality

Question 2

What are the neuro-hormonal antagonists we use?

Answer 2

ACE inhibitors, ARB’s, ARNI
b blockers
MRA - mineralcorticoid receptor antagonist

Question 3

What is a loop diuretic example and its role?

Answer 3

furosemide. inhibits ion transporters at loop of henle to reduce salt and water retention. works at low GFR’s

Question 4

What are issues with loop diuretics?

Answer 4

• patient may become resistant by other transport mechanisms being activated
• oedema in gut may prevent drug absorption
• oedema may continue

Question 5

How do you overcome loop diuretic resistance? Whats an issue?

Answer 5

furosemide with thiazides.

pee a lot. risk dehydration, hypotension, hyponatraemia, hypokalaemia

Question 6

What ACE inhibitors are used?

Answer 6

ramipril, enalapril, lisinopril

Question 7

What is the benefit and negatives of ACE inhibitors in HF patients?

Answer 7

• used first line. reduces mortality
• many ADR’s and drug-drug interractions

Question 8

What is ARB’s and when is it used?

Answer 8

candesartan. angiotensin II receptor blockers. in ACE resistance or cough as a side effect.

Question 9

What is an ARNI?

Answer 9

Valsartan-sacubitral
angiotensin II receptor blocker and neprilysin inhibitor combined. prevents breakdown of ANP and BNP.

Question 10

When would ARNI be used?

Answer 10

• NYHA class II-IV symptoms
• In patients with EF 35% or less.
• those already taking ACE/ARB

Question 11

What is the action of sacubitral?

Answer 11

inhibits neprilysin. that prevents the breakdown of ANP and BNP.

Question 12

What 4 benefits do ANP and BNP provide in heart failure?

Answer 12

vasodilation, diuretics, natriuretics, and inhibit RAAS

Question 13

What is a large benefit and a negative in ARNI?

Answer 13

significantly decrease hospitalisation and mortality rates more than ACE and ARB

in high doses may cause hypotension

Question 14

What is a MRA?

Answer 14

mineralcorticosteroid receptor antagonist. diuretic.
block receptors that bind aldosterone, therefore causing Na+ loss and sparing K+, in distal tubule.

Question 15

When is MRA used and what is its benefit?

Answer 15

in patients with symptoms despite other treatment - ACE/ARB/ARNI and B blockers

reduced hospitalisation and mortality significantly

Question 16

What are 2 MRA’s?

Answer 16

spironolactone and Eplerenone

Question 17

What beta blockers do we use and on who/not?

Answer 17

• carvedilol and bisoprolol.
• use only on stable patients. can cause deterioration in patients with fluid overload

Question 18

Whats the positive of beta blockers?

Answer 18

decrease mortality by 30% in mild, moderate and severe HF.

Question 19

What is the mechanism and use of ivabridine?

Answer 19

• not neurohormonal. blocks Na+ receptor in SA node to slow down HR.
• use in patients with sinus rhythm only
• dont use in patients with HR <70bpm or atrial fibrillarion
• significantly reduce hospitalisation and mortality

Question 20

What is the use of positive inotropes?

Answer 20

• digoxin we use only. reduces hospitalisation but not mortality.
• toxicity isn’t uncommon. nausea and confusion (in elderly)

Question 21

How many drugs may a patient expect to be on following chronic heart failure?

Answer 21

many. combination theraoy shows greatest reduction in mortality and hospitalisation

Question 22

What is the therapeuric regime?

Answer 22

• ACE. if resistant, ARB. if resistant, ARNI.
• B Blockers and ivabradine
• MRA
• MAYBE digoxin and warfarin

Question 23

How do we monitor the benefit of treatment?

Answer 23

• symptoms,
• clinical relief
• weight for oedema and water retention

Question 24

Which drug shouldnt be given with ACE inhibitors?

Answer 24

• naproxen - NSAID. Reduces blood pressure lowering effect of ACE
• can cause acute kidney injury

Question 25

What is a common side effect of ACE ? what do you give instead if they have this?

Answer 25

cough. give ARB instead - Candesartan