Heart Failure

2 causes of heart failure

pump failure

overloading

PUMP FAILURE

Damage to the heart muscle so there is a reduction in myocardial contractility.

OVERLOADING

Decreased force, Decreased velocity of contraction and Delayed relaxation of Cardiac muscle

2 types of overloading

Afterload (pressure)

Preload (volume)

causes of pressure afterload

Hypertension

Pulmonary hypertension (lung disease - left ventricle fail)

Valve dysfunction (right ventricular fail)

Is overloading reversible?

no

causes of preload

Renal failure, excessive intravenous infusions or medications.

Hypervolaemia - too much fluid in the body

Uncommon cause of failure

causes of pump failure

1. _{^{Ischaemic heart disease (e.g. angina),}}

2. _{^{Myocardial infarction}}

3. _^Arrhythmias

4. _{^{Viruses & infection, Inflammation, Excessive alcohol}}

Heat failure can be ..

Acute or Chronic

Acute Heart Failure after a myocardial infarction (MI) can be either…

Compensated or Decompensated Heart Failure

signs of Compensated heart failure

1. Cardiac Enlargement,

2. Arterial Constriction

3. Increased Sympathetic Drive

4. salt and Water Retention

Cardiac Enlargement

Left Ventricular Hypertrophy - impairment of heart as a pump

Arterial Constriction

As cardiac output reduced - blood is diverted to organs by arterial constriction causing hypertension - Afterload

Increased Sympathetic Drive

fight or flight triggered by heart under stress - vasoconstriction, increased contractility.

Salt and Water Retention is..

Renal failure, expands blood volume and increases preload (too much fluid)

What are the 3 classic symptoms of heart failure?

Exercise limitation(fatigue), SOB, Oedema

Exercise limitation is because of

decreased blood flow to exercising muscles

SOB is because of ..

fluid accumulates in lungs ( exercising or lying down) ,Can be accompanied by a cough

Oedema causes …

Swelling of ankles & feet from retention of salt & water and lack of clearance of fluid from kidney

These 2 conditions usually co-exist - clinical features are from different aspects of heart failure

hypoperfusion (forward) and congestion/oedema (backward)

Hypoperfusion (forward component) is ..

reduced blood flow to tissues,

Congestion/Oedema (Backward component) is…

increase in pressure in veins draining into the heart

How dose Hypoperfusion (Forward component) present?

Fatigue & exercise intolerance

Cold & pale extremities

Fluid & electrolyte retention

Fast heart rate & Rapid breathing

How does Congestion/Oedema Symptoms (Backward Component) present in LEFT side heart failure?

more common & serious - Oxygenated bld from lungs - Congestion - fluid in the lungs > SOB specifically while lying down, can wake pt at night, Cough/wheeze ,Bluish mucous membranes (lips), Tiredness

How does Congestion/Oedema Symptoms (Backward Component) present in RIGHT side heart failure?

Deoxygenated blood - Oedema > swollen ankles, Enlarged liver, Raised jugular venous pressure, Bluish fingers & toes.

what is the New York Heart Association Classification of Heart Failure Symptoms ?

The cause of heart failure should be established in ALL patients.  This is because ..

it may be reversible or correctable!

3/7 Tests that may be performed

Natriuretic Peptides>heart stress hormones

Echocardiography>pump performance- ejection fraction

Chest x-ray >size of heart and review lungs

4/7 Tests that may be performed

heart rate, rhythm & sounds

ECG >heart's rhythm & electrical activity

Blood tests>renal, thyroid, liver, lipids

spirometry & peak flow

NICE guidance on heart failure recommends ….

initial diagnosis> a loop diuretic

first line treatment> ACE inhibitor & beta blocker combination

how do Angiotensin-converting enzyme (ACE) inhibitors work?

by relaxing and opening up your blood vessels, easier for your heart to pump blood around the body.

Examples of ACE inhibitors ?

ramipril, captopril, enalapril, lisinopril and perindopril.

The most common side effect of ACE inhibitors is

a dry, irritating cough.

ACE Inhibitors are the first line therapy in heart failure. They reduce both…

pre-load and afterload.

How do diuretics work?

reduce the preload, reduce fluid on the lungs (shortness of breath) and swollen ankles.

examples of Loop diuretics: Mainstay of acute treatment ?

furosemide, bumetanide

examples of Thiazides diuretics: Less potent – used for mild heart failure ?

bendroflumethiazide

An atypical thiazide diuretic. Unlicensed and not made in UK now due to cost but is imported. for reduced renal function. used in combination with loop diuretics in resistant heart failure.

Metolazone

Pharmaceutical care problems of diuretics >

hypotension, dehydration, renal impairment and electrolyte disturbances (low potassium and sodium).

What Beta blockers are licensed for heart failure?

bisoprolol, carvedilol, nebivolol (for over 70yrs)

What do Beta Blockers do?

reduce preload and afterload by blocking sympathetic activity

As Beta blockers can cause worsening of symptoms what’s best administration ?

start low go slow.

First line treatment with ACE inhibitors and Beta blockers IF symptoms of heart failure persist

Aldosterone antagonists (or mineralocorticoid receptor antagonist- MRA)

Name the two MRAs used in persistant Heart Failure?

spironolactone, eplerenone

How do MRA’s work?

diuretic effect - they block the action of aldosterone in development of left ventricular hypertrophy.

Which combination is useful for pts who can’t take ACE inhibitors or ARBs.  They can also be used as add on therapy (especially if African or Caribbean origin).  

Hydralazine (Vasodilator antihypertensives) and Nitrates (Isosorbide mononitrate)

what drug is an alternative to beta-blockers and lowers the heart rate and can be used as add on therapy in pts with worsening heart failure?

Ivabradine

what does Ivabradine do?

It slows heart down

can also be used alongside beta blockers

what are side effects of ivabradine?

headaches, dizziness and blurred vision.

which combination drug (nepilysin inhibitor + ARB) is suitable for pts with severe heart failure, whose heart is only able to pump a reduced amount of oxygenated blood around the body

Sacubitril-Valsartan (Entresto®)

What are the side effects of sacubitril-valsartan ?

low blood pressure, high potassium levels and kidney problems.

Which drug improves symptoms, exercise tolerance and hospital admissions but not mortality. It is used as an add on therapy for patients who remain symptomatic despite optimal treatment with other drugs.

Digoxin

How does Digoxin improve your symptoms ?

by strengthening your heart muscle contractions and slowing down your heart rate.

SGLT2 inhibitors for diabetes, that are of benefit in heart failure to pts with or without diabetes?

Dapagliflozin and Empagliflozin

The MRA - Spironolactone may cause ? in men and ? and increased ? in women.

breast enlargement men & breast tenderness, hair growth in women

The MRA - Eplerenone can cause what?

sleeping difficulties, dizziness and headaches.

The most serious side effect of Spironolactone & Eplerenone medicines for which you need regular blood tests is….

dangerously high levels of potassium in your blood.

What are the Side effects of ARBs ?

low blood pressure and high levels of potassium in your blood.

(regular blood tests will monitor potassium level)

Angiotensin-2 receptor blockers (ARBs) work in a similar way to ACE inhibitors by …

relaxing blood vessels and reducing blood pressure.

ARBs are used as an alternative to ACE inhibitors because they don't usually cause a cough, but they are not as what?

effective as ACE inhibitors.

Examples of ARBs ?

candesartan, losartan, telmisartan and valsartan.

Side effects of Hydralazine with nitrate are?

headaches, a fast heartbeat and a pounding, fluttering or irregular heartbeat (palpitations).

What are the Possible side effects of Empagliflozin and dapagliflozin (SGLT2 inhibitors that lower bld sugar)?

thrush, peeing more than usual, a mild skin rash and back pain.

What is a common symptom of heart failure?

swollen ankles

Which conditions are a known cause of pump failure in the heart?

Ischaemic heart disease, Myocardial infarction, Excessive alcohol consumption, Arrhythmia

decompensated heart failure

symptoms worsen and require immediate medical attention

compensated heart failure

heart able to pump enough blood to meet the body's needs, despite underlying condition. symptoms are either stable or absent

Is preload reversible

yes

NT-proBNP

Released into blood when heart stressed > vasodilation, kidneys rid water & salt (more urine) lowers BP and reduces amount blood heart has to pump.

side effect of digoxin

loss of appetite

Viagra (sildenafil) interaction with which drug most likely cause you to refer the patient onwards?

Glyceryl trinitrate (nitrates)

main side effects of tamsulosin

feeling dizzy and problems when ejaculating (such as little or no semen)

Symptoms of tamsulosin interaction with Alcohol

ncrease the blood pressure-lowering effect of tamsulosin, which can make you feel dizzy or light-headed