Heart Failure

What is heart failure?

• clinical syndrome characterised by typical symptoms:

  • SOB, ankle/body oedema and fatigue

What are typical symptoms of heart failure?

• SOB, oedema and fatigue, poor exercise tolerance

What are signs of heart failure?

Why do these signs occur?

• elevated jugular venous pressure, pulmonary crackles (fluid in the lungs), peripheral oedema

• structural/functional cardiac abnormalities that result in a reduced CO

What does LVSD stand for?

What does this mean?

• left ventricular systolic disease

• left ventricle is damaged

What is the symptomatic heart failure ejection fraction?

• EF <40% = symptoms e.g. SOB, oedema etc

What are causes of HF?

• MI

• hypertension

• atrial fibrillation

• alcohol induced cardiomyopathy

• valve disease (HF due to valve stiffening)

• viral infections

• hyperthyroidism (heart beats fast, load too much = HF)

What recreational drug can induce HF?

• cocaine

What are the aims in management of HF?

• improve quality of life

• reduce hospitilisation

• prolong patient survival

Can you improve HF?

• no but you can slow down the decline of patient’s health

When are patients with HF most often breathless?

• at night - due to accumulation of fluid in the lungs (gravity change, when lying down)

What is the difference between stable oedema and decompensated odema?

• stable = has fluid in ankle but is stable

• decompensated = fluid building up in the lungs

What are examinations done to diagnose HF?

• auscultation - sound

• 3rd heart sound (gallop rhythm) - can indicate HF

• jugular venous pressure

What are investigations done to diagnose HF?

• chest xray - fluid in lungs

• echo - for EF value

• ECG - not directly to diagnose, but check for hypertension

What blood tests are done to diagnose HF?

• FBC

• U&Es

• TFTs

• BNP - b-type naturetic peptide

What do iron infusions aid with in patients with HF?

• improves patients’ exercise tolerance regardless of whether they’re anaemic

What are the NYHA classifications of HF?

• I - asymptomatic, even on exercise

• II - HF symptoms but only on exercise

• III - HF symptoms on very mild exercise

• IV - HF symptoms at rest

What does an increase of weight >2kg in 2-3 days indicate for HF patients?

What is a self-monitoring measure patients should take?

• indicates fluid build up

• weighing themself and recording it to check for any sudden weight gain

What are dietary measures that should be recommended for patients with HF?

• reduced sodium intake/salt substitutes (most important as Na causes fluid retention)

• fluid restriction (1.5-2L per day - include soups, water, all fluids)

• moderate alcohol intake

  • alcohol is a cardiotoxin

• weight reduction if patient is obese

What are lifestyle changes that should be implemented in patients with HF?

• smoking cessation

• exercise

What is 1st line for treatment of HF?

Why is it given?

• ACE-I, e.g. enalapril

• slows down the worsening of HF

What are pharmacological management options for HF?

• ACE-I (1st line)

  • enalapril, perindopril, ramipril, lisinopril, captopril, quinapril, fosinopril (all licenced for HF)

• beta-blocker

  • only be started when patient is stable

• aldosterone antagonist

  • where NYHA class is 3 or 4

• sacubitril/valsartan

  • neprilysin inhibitor

  • can cause increase in bradykinin

  • must stop ACE-I for minimum 36hrs before starting

• diuretics

  • relieves symptoms

  • non-compliance issue (increase urination)

• digoxin

  • only if patient is v symptomatic and tried other options

  • or if patient is a fib and fluid in the lungs

• hydralazine/isosorbide

  • not used unless renal impairment and other meds tried

• ivabradine

What is entresto?

What can it cause a build up of that can result in S/E?

What must be stopped and for how long before taking entresto?

• sacubitril and valsartan - neprilysin inhibitor and ARB

• bradykinin

• ACE-I must be stopped for a minimum of 36 hours before starting entresto

Why are diuretics used in HF patients?

What sort of diuretic is predominantly used?

• symptom control

• loop diuretic e.g. furosemide

What is an issue patients on furosemide have?

• pee a lot so there is low compliance with the drug

What is an S/E of furosemide?

• gout and increased urination

What should be monitored when patient is on a loop diuretic?

What dose should be given?

• renal function and electrolytes

• lowest effective dose

Are any patients w/ LVSD not to be on ACE-I?

What dose?

• no unless there is a contraindication

• so, regardless of age, hypotensive, patient with HF/LVSD gets put on ACE-I

• the max dose the patient is able to tolerate

When on diuretics what needs to be monitored?

• monitor renal function and electrolytes

What beta-blocker is cardio selective?

• bisoprolol

What beta blockers are licensed for HF?

• bisoprolol (cardioselective)

• Carvedilol (non cardioselective)

• Nebivolol (only if old, or can’t tolerate other 2)

When are aldosterone antagonists used in HF treatment?

What are examples of aldosterone antagonists?

• in advanced HF patients (class 3-4)

• Spironolactone and epleronone

When is eplerenone better to use than spironolactone?

• if patient has S/E like gynocomastia

• (Epleronone doesn’t cause gynocomastia while spironolactone does)

What are considerations when starting aldosterone antagonists in patients?

• check serum creatinine and potassium (potassium sparing effect)

• Careful in patient on ACE-I/ARB and a high dose diuretic (risk of hyperkalaemia)

What is in entresto?

• sacubitril (neprilysin inhibitor) and valsartan (ARB)

What are the conditions that patients need to meet, to be considered for entresto?

• min 1 hospitalisation in the past year

• EF <35% (echo)

Who starts a patient on entresto?

• primary care (not pharmacists)

When starting entresto what must be stopped and for how long?

Why does it need to be stopped?

• stop ACE-I for minimum 36 hours

• Need to ensure ACE-I is washed out of system, otherwise risk of angioedema developing

Are SGLT-2 inhibitors used in HF patients?

• yes, even if they aren’t diabetic

• Used as a diuretic

What are counselling points for SGLT-2 inhibitors?

• increased urination, risk of UTI, bp drop

When is ivabradine used for HF patients?

• if patient intolerant to beta-blocker or in addition to beta-blockers if HR >75bpm

What does the dose of digoxin depend on?

• depends on renal function

What is the relationship between potassium levels and digoxin?

• hypokalaemia can increase risk of digoxin toxicity

What drugs exacerbate HF?

• NSAIDs and COX-2 inhibitors

• Rate limiting CCB (slows HR down too much)

• Chemotherapy drugs

• Cough/cold medicines e.g. oxymetazoline

• Anti-psychotics e.g. clozapine

• Glitazones

• Corticosteroids and other fluid-retaining drugs

• Meds with high sodium content

• Macro lines e.g. clarithromycin (risk of arrhythmia)