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241

What impact does CHF have on pregnancy?

CHF greatly increases the risk of maternal and neonatal morbidity and mortality

pregnancy and delivery may cause deterioration in women with moderate to severe CHF—pregnancy in mild CHF may be considered for a fully informed patient and her partner

242

Can people with CHF travel?

Increased risk of DVT (need prophylaxis of single injection of LMWH on long-haul flights plus stockings, plus calf stretches.  Anticoagulate if higher risk)
Avoid high altitude destinations (relative hypoxia)
Hot climates = dehydration

243

How do youprevent clinical deterioration post-discharge in a CHF visit?

Patient support by a doctor and pre-discharge review and/or home visit by a nurse is recommended to prevent clinical deterioration.

244

Why shouldn't you initiate beta-blockers in acute decompensated heart failure?

Beta-blockers should not be initiated during a phase of acute decompensation, but only after the patient’s condition has stabilised. Adverse effects of beta-blockade in this setting include symptomatic hypotension, worsening of symptoms due to withdrawal of sympathetic drive and bradycardia. 

245

What is the role of nebivolol in heart failure?

More recently, nebivolol (a selective beta-1 receptor
antagonist) has been approved for use in Australia for the treatment of stable CHF. It has been found to be safe and effective in elderly patients with both relatively preserved and impaired ejection fraction.

246

In someone with stable heart failure, which should you start first, a beta-blocker or an ACEI?

A randomised study has suggested that major clinical
outcomes are similar whether a beta-blocker is started first followed by ACEI, or the opposite (conventional) order is followed.

Therefore, the order of commencing these life-saving heart failure drugs may be left to the individual prescribing physician, dependent on clinical circumstances.

247

Why do beta-blockers work in heart failure?

As with ACEIs, beta-blockers inhibit the adverse effects of chronic activation of a key neurohormonal system (the sympathetic nervous system) acting on the myocardium. 

248

Which three beta blockers have the best evidence fo CHF and why?

Three beta-blockers—carvedilol (beta-1, beta-2 and alpha-1 antagonist), bisoprolol (beta-1 selective antagonist) and metoprolol extended release (beta-1 selective antagonist) prolong survival in patients with mild to moderate CHF already receiving an ACEI. This survival benefit includes both reductions in sudden death, as well as death due to progressive pump failure.

249

Carvedilol or metoprolol in CHF?

A study demonstrated that carvedilol (25 mg bd) was superior to immediate-release metoprolol (50 mg bd) in prolonging survival in patients with mild to moderate symptoms. It is not clear whether these differences relate to the doses used, or the pharmacological effects of carvedilol beyond blockade of the beta-1 adrenoceptor. This study highlights the importance of aiming to achieve the target doses of beta-blockers as used in the major successful trials.

Carvedilol has also been shown to prolong survival in patients with severe symptoms who did not have overt volume overload or recent acute decompensation

250

What effect does aldosterone have on the heart?

Aldosterone receptors within the heart can mediate fibrosis, hypertrophy and arrhythmogenesis. 

251

What is eplenerone indicated for?

A ‘selective’ aldosterone antagonist without antiandrogenic effects, eplerenone, has been found to reduce mortality (and hospitalisation) in the immediate (3–14 days) post-MI period in patients with LV systolic dysfunction and symptoms of heart failure.

This benefit appeared to be additive to those of ACEIs and beta-blockers. Eplerenone is now registered in Australia for this indication; a study of the selective aldosterone antagonist, eplerenone, in patients with systolic heart failure and mild (NYHA Class II) symptoms was recently halted due to overwhelming benefit with regard to the study’s primary composite endpoint of cardiovascular mortality and hospitalisation for heart failure.

252

What is the role of Digoxin in CHF?

Valuable for therapy of AF in CHF patients

Increased mortality of women even in therapeutic range, survival advantage for men.

253

What is the role of ARBs in CHF?

In patients who are ACEI intolerant, angiotensin II receptor antagonists provide morbidity and mortality benefits in comparison to placebo. Therefore, angiotensin II receptor antagonists are recommended as an alternative for patients who experience ACEI mediated adverse effects, such as a cough

254

What is the role of direct sinus node inhibitors in CHF?

Ivrabadine reudces CV mortality and HF hospitalisation in patients who were in sinus rhythm with a rate over 70

Benefit LARGELY contributed to by a reduction in hospitalisation and in addition to patients being on highest tolerated dose of background b-blockade (although they never got past 25% of the target dose).

HR needs to be above 70 for Ivrabadine to have an effect

255

What is the role of CCBs in heart failure?

Non-dihydropyridine calcium-channel blockers that are direct negative inotropes, such as verapamil and diltiazem, are contraindicated in patients with systolic heart failure. 

The dihydropyridine calcium-channel blockers, amlodipine and felodipine, have not shown survival benefits in patients with systolic CHF but, as outcomes were not adverse, may be used to treat comorbidities (such as hypertension and CHD) in these patients.

256

Anti-arrhythmics in heart failure?

Avoid unless beta-blockers or amiodarone

257

Psych drugs in heart failure?

Avoid TCAs and Clozapine

258

Diabetic drugs in heart failure?

Avoid thiazolidendiones

Metformin is safe unless concomitant renal impairment

259

TNF-abs and steroids in heart failure?

Avoid

260

Trastuzumab and heart failure?

Trastuzumab has been associated with the development of reduced LVEF and heart failure.

It is contraindicated in patients with symptomatic heart
failure or reduced LVEF (< 45%). Baseline and periodic evaluation of cardiac status including assessment of LVEF should occur

261

Moxonidine in heart failure?

Avoid

Moxonidine has been associated with increased
mortality in patients with heart failure and is
contraindicated in such patients.

262

When are aldosterone receptor antagonists (spironolactone and eplenerone) indicated in heart failure?

Severely symptomatic despite appropraite doses of ACEI's and diuretics

263

Indication for Ivrabidine in heart failure?

Direct sinus node inhibition with ivabradine should be considered for CHF patients with impaired systolic function and a recent heart failure hospitalisation who are in sinus rhythm where their heart rate remains > 70 bpm despite efforts to maximise dosage of background beta- blockade.

264

First line heart failure drugs in order of prescription are...

ACEIs
Diuretics
Beta-blockers (when still symptomatic)
Aldosterone blockade (spironolactone) (when still symptomatic)
Aldosterone blockade (epleronone)
ARBs (alternative to ACE, can consider dual therapy)
Ivrabadine (if on max b-blockade)

265

What are the second line agents in CHF?

Digoxin - symptom relief and reduction of hospitalisation, AF

Hydralazine + isosorbide dinitrate --> intolerant of ACE/ARBs and no other tx option

Fish oil - symptomatic despite standard therapy

266

What is the general mx of asymptomatic LV dysfunction (NYHA class I)?

- Exercise and RF modification
- ACEI
- B-Blocker
- Disease specific rx (i.e. CHD - aspirin, statin etc)

267

Which class of NYHA heart failure should you give b-blockers

These should be given irrespective of class, just need to not be fluid overloaded.

268

When would you consider cardiac transplant in heart failure?

<65
Class IV heart failure and no major comorbidities, refractory or intolerant to beta-blocker therapy

269

How do you decide between spironolactone and eplerenone?

Symptomatic on therapy and LVEF >40 = spironolactone

Symptomatic on therapy and LVEF <40 = eplerenone

270

What are the contraindications to eplerenone?

Eplerenone is contraindicated in patients with hyperkalaemia, severe renal impairment (creatinine Cl less than 30 ml/min), or severe hepatic impairment (Child-Pugh score C). The manufacturer of eplerenone also contraindicates ( relative C.I. ) concomitant treatment with ketoconazole, itraconazole or other potassium-sparing diuretics (though the manufacturer still considers taking these drugs to be absolute C.I.) Potential benefits should be weighted against possible risks.