Clinical Management of Heart Failure

Question 1

What is heart failure

Answer 1

• Heart cannot function resulting in raised BP inadequate cardiac output
• Usually caused by left ventricular MI
• survival after 5 yrs progressive

Question 2

Acute heart failure

Answer 2

Sudden deterioration in HF which can lead to hospitalization

Question 3

Chronic heart failure

Answer 3

• Established diagnosis of HF or gradual onset of symptoms
• HF with preserved EF
• HF with reduced EF

Question 4

Ejection Fraction

Answer 4

• Blood pumped out of a filled ventricle when it contracts
• Normal EF aprox 50%

Question 5

Three main features of Heart failure

Answer 5

• Fatigue
• Breathlessness
• Oedema

Question 6

Fatigue when having heart failure

Answer 6

Decrease cardiac output causing impaired oxygen levels causing less oxygen reach muscle

Question 7

Oedema

Answer 7

• Pulmonary or peripheral
• Mix of fluid retention increases pressure in heart and pulmonary muscles

Question 8

Breathlessness

Answer 8

• Can occur on exertion
• Lying down causing abnormal pressure on diaphragm redistribute oedema on lungs
• Sleep with multiple pillows

Question 9

Diagnosis of Heart failure

Answer 9

• Signs and symptoms
• Patient history
• Blood levels of NT-proBNP
• ECG check HF
• Exercise tolerance test
• Transthoracic echocardiography assess VF function

Question 10

Role of NT-proBNP

Answer 10

• N-terminal pro-B-type natriuretic peptide is released in response to pressure changes
• <400ng/L less likely to be HF
• > 2,000ng/L very high levels

Question 11

NT-proBNP levels exception

Answer 11

• Reduced by obesity and African background
• Levels high over 70

Question 12

Grading severity

Answer 12

• New York Heart Association
• Based on symptoms dependent on quality of life

Question 13

Treatment aims of heart failure

Answer 13

• Improve symptoms, functional capacity and quality of life
• Slow condition progression
• Prevent hospitalisation
• Reduce mortality

Question 14

Managing Heart Failure with Preserved EF

Answer 14

• Preserved EF = EF over 40%

Question 15

Loop diuretic

Answer 15

• Furosemide
• Titrated dose needed
• Relieve congestive symptoms and fluid retention
• To keep EF high and slow deterioration

Question 16

Managing heart failure with reduced ejection fraction

Answer 16

• First line ACE inhibitor & Beta blocker

Question 17

ACE inhibitor for ejection fraction

Answer 17

• ramipril
• decrease morbidity and mortality to improve symptoms
• Start with low dose and gradually increase to max tolerated dose

Question 18

Beta blocker

Answer 18

• Bisoprolol
• Decrease morbidity and mortality improve symptoms
• Start with low dose and gradually

Question 19

Mineralocorticoid Receptor Antagonists

Answer 19

• Spironolactone or eplerenone
• Decrease mortality and hospitalisation; improve symptoms
• Add in if still having symptoms despite ACEi and BB

Question 20

ACE inhibitors side effects

Answer 20

• Dry persistent cough
• Dizzy and light headed
• Headache and diarrhea
• Increase sodium and potassium

Question 21

Monitoring for ACE inhibitor

Answer 21

• Sodium, potassium and renal function
  before starting
• Blood pressure before and after each dose

Question 22

Loop diuretics side effects

Answer 22

• Electrolyte imbalance
• Acute kidney injury
• Fatigue

Question 23

Loop diuretics red flags

Answer 23

• Stop if causing low potassium levels

Question 24

Mechanism of action for loop diuretics

Answer 24

• Blocks re-absorption of sodium, chloride and water from renal tubules
• Excretion of urine

Question 25

Loop diuretics monitoring

Answer 25

- Monitor electrolytes -Monitor renal function

Question 26

Specialist Treatment Options

Answer 26

- Add to first line treatment - Entresto, Digoxin, Ivabradine

Question 27

SGLT2 Inhibitors

Answer 27

- Added if all Do not work - Use dapagliflozin or empagliflozin to treat symptomatic HF with reduced EF - Decrease risk of dying

Question 28

SGLT-2 Inhibitors side effects

Answer 28

- Constipation -Hypoglycemia when used with insulin -Hypovolemia & high BP

Question 29

Red flags

Answer 29

STOP if develop diabetic ketoacidosis and do not re-start

Question 30

Mechanism of SGLT2 inhibitor

Answer 30

- Reversibly inhibit sodium glucose co-transporter - lower BP less strain on heart

Question 31

Monitor for SGLT2 inhibitor

Answer 31

- Renal function and ketones

Question 32

HF in reducing ejection fraction CKD

Answer 32

- Chronic kidney disease impair reserve available for kidney in response to congestion

Question 33

HF secondary care

Answer 33

- IV diuretics by furosemide diuretic - Monitor renal function

Question 34

Lifestyle advice

Answer 34

- Regular exercise can be physically active - Sleep time diuretic as urination symptoms - Balance diet and alcohol reduction

Question 35

Cardiac rehab program

Answer 35

- For stable HF exercise based training program

Question 36

Co-morbidities with HF

Answer 36

- Diabetes mellitus * Renal failure * Hypertension * Myocardial infarction

Question 37

Optimal drug management doesn’t work

Answer 37

- Possible heart transplant - Long waiting list risk of rejection - Life long immunosuppressed

Question 38

Palliative care

Answer 38

- HF continue to worsen aimed to optimise quality of life for life threatening condition

Question 39

Symptom control

Answer 39

- Breathlessness - repeat dose opioid (Oromorph) - Morphine - Midazolam help anxiety and agitation - Nausea and vomiting cyclizine