✦ Heart failure in practice

✦ How is heart failure classed by ejection fraction?

✦ HFrEF is 40% or less

✦ HFmEF is 41% to 49%

✦ HFpEF is 50% or more

✦ Normal level is 50%

✦ Under then heart not pumping effectively

✦ What are three causes of heart failure?

✦ What are other conditions HF can cause?

✦ Conditions that damage the heart: OH, CCBs, NSAIDs

✦ Conditions that reduce CO: arrhythmias

✦ High cardiac output: anaemia, sepsis, septicaemia

✦ Arrhythmias, depression, cachexia, CKD, cardiac death

✦ Symptoms of heart failure

✦ Breathlessness due to fluid in lungs

✦ Fluid retention results in oedema and ankle swelling

✦ Fatigue and exercise intolerance

✦ Elevated JVP - vein looks full or bulging

✦ Basal crepitations - cracking sounds at base of lungs

✦ Oedema swelling in lower back or legs and ankles

✦ Differences between left and right HF

✦ How to diagnose heart failure

✦ Clinical history and examination

✦ Natriuretic peptides - released when heart is stressed

✦ 2,000 ng/L refer within 2 weeks, 400 - 2000 in 6 weeks

✦ 12 lead ECG - electrodes on chest - detects rhythm issue

✦ Chest X ray, blood tests renal, thyroid, liver, lipids, HbA1c

✦ Transthoracic echocardiography - ultrasound of the heart

✦ Classification of heart failure

✦ Class I - physical activity unaffected

✦ Class II - slight limit of physical activity

✦ Class III - not ordinary limit of activity

✦ Class IV - unable to carry out activity

✦ Management of heart failure

✦ Increase survival

✦ Reduce hospitalisation

✦ Improve quality of life

✦ Reduce symptoms

✦ Review medication patient is taking

✦ Discontinue CCBs, antiarrhythmics, nsaids

✦ Management of HFrEF

✦ Diuretic for congestive symptoms only

✦ Offer ACEI or ARNI if intolerant to ACEI

✦ Offer BB and MRA

✦ SGLT2 inhibitor - quadruple therapy

✦ Hydralazine and nitrate if intolerant to ACEI and ARNI

✦ ACEI/ARB replaced with sacubitril/valsartan EF < 35%

✦ Ivabradine if EF < 35% and HR > 75

✦ Management of HFmEF

✦ Diuretics for congestion only

✦ SGLT2I for all patients

✦ Consider ACEI, ARB, ARNI - only one

✦ BB and MRA

✦ Management of HFpEF

✦ diuretics for congestion only

✦ SGLT2 inhibitor for all patients

✦ Explain diuretics?

✦ Consider only if congestive symptoms

✦ Furosemide, bumetanide, torsemide

✦ Postural hypotension and dehydration

✦ Acute kidney injury and electrolyte imbalance

✦ Excessive diuresis

✦ Explain ACE inhibitors?

✦ Lisinopril, ramipril, perindopril, enalapril

✦ Dry cough, hypotension, dizziness

✦ Angioedema, hyperkalemia, GI disturbances

✦ Examples of ARB?

✦ Losartan and caldesartan

✦ Dizziness, hyperkalemia, GI disturbances

✦ Renal function and BP

✦ Example BB?

✦ Bisoprolol, carvedilol, nebivolol

✦ Not indicated for asthma or bronchospasm

✦ Don’t stop abruptly

✦ Rate limiting CCBs

✦ Example MRA

✦ Mineralocorticoid receptor antagonist

✦ In addition with ACEI and BB

✦ Hyperkalemia, renal function, gynaecomastia

✦ K levels, BP

✦ Worsening heart failure during initiation

✦ Cold extremities

✦ Examples of SGLTI?

✦ Empagliflozin, dapagliflozin

✦ Add to ACEI or ARNI plus BB plus MRA

✦ For HFrEF regardless of diabetes

✦ Avoid in type 1 diabetes

✦ Genital infections

✦ Explain ARNI - sacubitril/valsartan

✦ Replaces ACEI or ARB

✦ Use if EF ≤ 35% and symptomatic

✦ Start only if tolerating ACEI or ARB

✦ Wait 36 hours after stopping ACEI

✦ Do not combine with ACEI or ARB

✦ Hypotension, hyperkalaemia, angioedema

✦ Examples of Ivabradine

✦ Use only if symptoms persist despite standard therapy

✦ HFrEF with LVEF 35% or less

✦ Resting heart rate 75 bpm or higher

✦ On top of ACEI or ARNI, beta blocker, and MRA

✦ Or beta blocker contraindicated or not tolerated

✦ Adverse effects - visual disturbance, dizziness

✦ Examples of hydralazine and long acting nitrate

✦ If symptoms persist despite first line therapy

✦ Or if intolerant to both ACEI and ARB

✦ Consider especially in African or Caribbean patients

✦ NYHA class III to IV with reduced ejection fraction

✦ Adverse effects: headache, dizziness, flushing

✦ Explain digoxin

✦ Worsening HFrEF despite first line therapy

✦ Any degree of heart failure

✦ Narrow therapeutic window - toxicity stop medicaiton

✦ Monitor drug levels, electrolytes, renal function

✦ Interactions: amiodarone, dronedarone, quinine

✦ Non pharmacological management

✦ Annual influenza and pneumococcal vaccination

✦ Smoking cessation and reduce alcohol intake

✦ Salt restriction, avoid potassium-rich salt substitutes

✦ Manage comorbidities

✦ Screen for depression and anxiety

✦ Cardiac rehabilitation, exercise, weight reduction