✦ 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, CKD, cardiac death

✦ Symptoms of heart failure

✦ Breathlessness - fluid present in the lungs

✦ Oedema and ankle swelling - fluid retention

✦ Sacral oedema - lower back swelling

✦ Basal crepitations - cracking at base of lungs

✦ Fatigue, exercise intolerance, elevated JVP

✦ 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 and Chest X ray

✦ Blood tests: renal, thyroid, liver, lipids, HbA1c

✦ Transthoracic echocardiography - ultrasound of the heart

✦ Why do we manage 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

✦ Consider ACEI, ARB, ARNI - only one

✦ BB and MRA

✦ Diuretics for congestion only

✦ SGLT2I for all patients

✦ Management of HFpEF

✦ diuretics for congestion only

✦ SGLT2 inhibitor for all patients

✦ Explain diuretics?

✦ Consider only if congestive symptoms

✦ Does not help with mortality

✦ Furosemide, bumetanide, torsemide

✦ Hypotension, dehydration or excessive diuresis

✦ Explain ACEI?

✦ Lisinopril, ramipril, perindopril, enalapril

✦ Dry cough, dizziness, angioedema

✦ Hyperkalemia, renal impairment

✦ Examples of ARB?

✦ Losartan and caldesartan

✦ Dizziness, angioedema

✦ Renal impairment and hyperkalemia

✦ Example BB?

✦ Bisoprolol, carvedilol, nebivolol

✦ Do not take it with asthma or bronchospasm

✦ Do not stop abruptly

✦ Do not use with rate limiting CCBs

✦ Example MRA

✦ Mineralocorticoid receptor antagonist

✦ In addition with ACEI and BB

✦ Hyperkalemia, renal impairment

✦ Non pharmacological management of HF

✦ Annual influenza and pneumococcal vaccination

✦ Smoking cessation and reduce alcohol intake

✦ Salt restriction and manage diet

✦ Exercise and weight reduction

✦ Manage comorbidities

✦ Screen for depression and anxiety