heart failure

Question 1

HF symptoms

Answer 1

SOB, persistent cough/wheeze, fatigue, reduced exercise tolerance, ankle swelling

Question 2

management of chronic HF

Answer 2

annual influenza vaccine and a once-only pneumococcal vaccination

ACEi and BB - 1st line
- start at low dose and titrate up to max tolerated dose
- Bisoprolol, carvedilol and nebivolol (>70) licensed for HF
- ARBs - candersartan, losartan and valsartan

add aldosterone antagonist - if symptoms persist - spironolactone or eplerenone

loop diuretics - to relieve breathlessness and oedema in fluid retention

symptoms persist:
- replace ACE with Sac/Val if EF <35%
- SGLT2 inhibitor
- Ivabradine in sinus rhythm if HR >75 bpm and EF <35%
- hydralazine + nitrate (esp in afro-carribean)
- digoxin in sinus rhythm to improve symptoms (62.5-125mcg OD)

preserved ejection fraction - specialised care:
- low to medium dose loop diuretic

Question 3

monitoring requirements

Answer 3

K, Na, renal function and BP monitored before starting, 1-2 weeks after starting and at dose changes

once stabilised - monthly for 3 months then 6 monthly