Heart Failure

Question 1

Pharmacological Management of HFrEF

Answer 1

1. ACEI or ARB
2. Add Mineraocorticoid receptor agonist.
   
   • Eplerenone 25mg PO OD -> 50mg PO OD
   • Spironolactone 25mg PO OD -> 50mg PO OD
3. Add heart-failure beta-blocker
   - Uptitrate above medications to maximum tolerated doses. Initially favour uptitrating beta-blocker first unless congested or heart rate < 50bpm.

Repeat echo in 3-6 months

4. If persistent HFrEF with LVEF < 40%, change ACEi/ARB to ARNI
   
   • Entresto: Sacubitril (Neprilysin-i)/ Valsartan (ARB)
     
     • Blood vessels relax and less water is retained by the body.

4 Ivabradine 5mg PO OD (inhibits sino-atrial pacemaker current). Consider if 3 ineffective and HR >=77bpm + LVEF < 35% + NYHA Class II-III

Medication monitoring
- Review at initiation of treatment and each dose escalation and should include Clinical review, BP, Renal function, Potassium and HR.

Question 2

General Management of HFrEF

Answer 2

• Daily weight charts as indicator of fluid retention
• Limit fluid intake to 1.5L per day if congested
• Restrict salt intake to <6g per day
• Reduce bodyweight to BMI 18-25
• Referral to cardiac rehabilitation program
• Screen regularly for mood disorder such as depression.

Question 3

NYHA Grading for severity of CHF disease

Answer 3

Class 1 - No limitations.
Class II - Slight limitation in physical activity causing fatigue, palpitation, dyspnoea, angina
Class III - Marked limitation in physical activity. Less than ordinary activity leads to symptoms.
Class IV - Unable to carry on any physical activity without discomfort.

Question 4

Heart Failure Specific Beta Blockers

Answer 4

• Carvedilol 3.125mg PO BD -> 50mg PO BD
• Bisoprolol 1.25mg PO OD -> 10mg PO OD
• Nebivolol 1.25mg PO OD -> 10mg PO OD
• Metoprolol Succinate 23.75mg PO OD -> 190mg PO OD

Start at lower dose and increase to maximum tolerable dose every 3 weeks.

beta blocker should be considered as first medication to titrate up unless congested or HR < 50bpm.

Question 5

CXR findings of APO

Answer 5

• Kerley lines on lateral inferior area of lung fields bilat
• Increased heart size
• Pleural fluid
• Pulmonary oedema (widespread haziness of parenchyma)
• Widened vascular pedicle

Question 6

Treatment for APO

Answer 6

Pharmacological
- Frusemide IV/IM/PO 20-80mg Q20minutely
- O2 if sats < 94%
- Inadequate response? Add GTN if SBP > 100mmHg
- GTN Spray 400microg subling Q5min Max 1200microg
- GTN tablet 300-600mcrog subling Q5min Max 1800microg

In hospital?
- Consider CPAP
- GTN infusion titrate to SBP
- Morphine 1-2,5mg IV - Help with anxiety and distress.