Wk 13: Heart failure (management)

Question 1

What is the inpatient management of a patient with decompensated HF?

Answer 1

10 days:

• Bed rest
• LMWH
• Daily weights
• Fluid restrictions: 1.5L/day
• Daily U+Es during IV
• IV diuretics
• Catheter

Question 2

Which drug is first given for a patient with HF?

Answer 2

Diuretic

Question 3

What are diuretics used for?

Answer 3

• For: dyspnoea, ankle + pulmonary oedema
• Red fluid retention

Question 4

What are the monitoring requirements of diuretics?

Answer 4

• Electrolyte + renal function
• Cation: dehydration + renal dysfunction

Question 5

Which diuretics are used for HF?

Answer 5

Loop:
- Furosemide, bumetanide, torsemide

• Oral/ IV if severely congested
• No improvement: Add bendroflumethiazide/metolazone (renal impairment)

Question 6

Which medication are used to manage HF?

Answer 6

• ACEI/ARNI
• Bblocker
• MRA
• SGLT2

Question 7

How are ACEI initiated?

Answer 7

• Start when limited fluid retention/back to baseline weight
• Start low + titrate
• Baseline U+Es >1/2 wks >3 months
• Inc dose every 2 wks
• Once max, add Bblocker

Question 8

What is the alt to ACE?

Answer 8

Valsartan/sacubitril

• Angiotensin receptor neprilysin inhibitor
• Neprilysin degrades vasoactive peptides
• Don’t start til 48hrs after discontinuing ACE (red angioedema)

Question 9

What are MRAs (aldosterone antagonist) used for?

Answer 9

• Severe symptomatic HF
• Post MI HF

Question 10

What is the mechanism of action of MRAs?

Answer 10

• Prevent remodelling + fibrosis
• Prevent sudden cardiac death
• Improve hemodynamics

Question 11

What are the 2 MRAs available for HF?

Answer 11

• Spironolactone
• Eplerenone

Question 12

What are the complications of MRAs?

Answer 12

Hyperkalaemia + worsening renal function

Question 13

What is spironolactone?

Answer 13

• Non-selective inhibitor of aldosterone
• Initial 25mg daily
• Inc 50mg/dec 12.5mg daily
• Baseline U+Es, recehck 1wk
• S/e: hyperkalaemia, di + gynaecomastia

Question 14

What is epleronone?

Answer 14

• Selective aldosterone antagonist
• Selective tf less gynaecomastia
• Initial dose: 25mg daily, inc 50mg OD w/in 4 wks
• S/e:

Question 15

What are the monitoring requirements of ACEi, B Blockers + MRA?

Answer 15

• Sodium, K + renal at baseline + 7-14 days after dose increments
• BP before + after dose increments

Question 16

Which SGLT2 inhibitors are used for HF?

Answer 16

• Dapagliflozin + Empagliflozin
• 10mg OD

Question 17

What are the counselling points for SGLT2 inhibitors?

Answer 17

• Genitourinary infections
• DKA
• Sick day rules: w/hold if vom/di

Question 18

When is digoxin used?

Answer 18

• AF + any degree HF
• Max therapy + worsening HF due to LVSD

Question 19

When is ivabradine used?

Answer 19

• Chronic HF
• Selective + specific inhibition of cardiac pacemaker in: stage II-IV w/ systolic dysfunction, SR >75 bpm + LVEF <35%

Question 20

Which medications affect HF?

Answer 20

• NSAIDs (fluid retention + renal toxicity)
• CCB (fluid retention)
• Pioglitazone
• Antiarrhythmics

Question 21

Which co-morbidities need managing in HF?

Answer 21

• Angina
• Asthma/COPD
• AF
• Diabetes
• Gout
• Renal impairment