Heart Failure and Treatment

Question 1

What are the DEFINING FEATURES of HEART FAILURE (HF)?

Answer 1

1) Dyspnoea, Fatigue or Oedema due to Cardiac Dysfunction
2) At Rest or On Exertion
3) Accompanying Neurohormonal Activation

Question 2

What are the SALIENT EPIDEMIOLOGICAL FEATURES of HF?

Answer 2

1) Approx. 40-60,000 Patients with HF/Left Ventricular Systolic Dysfunction (LVSD) in Scotland
2) > Prevalence and Incidence With Age (>74 years)
3) Financial Burden on NHS
4) > Inpatient Stay and > Re-Admissions

Question 3

What are the SYMPTOMS of HF?

Answer 3

1) Dyspnoea
2) Fatigue
3) Oedema
4) < Exercise Tolerance

Question 4

What are some of the SIGNS of HF?

Answer 4

1) Tachycardia
2) Distended JVP
3) Chest Crepitations
4) Displaced Apex Beat
5) 3rd Heart Sound
6) Oedema

Question 5

Why is it DIFFICULT to DIAGNOSE HF based on clinical SIGNS ALONE?

Answer 5

Non-Specific Signs

*Objective Evidence of Cardiac Dysfunction Necessary

Question 6

What is the DIAGNOSTIC CRITERIA for a HF diagnosis?

Answer 6

1) Symptoms or Signs of HF
AND
2) Objective Evidence of Cardiac Dysfunction
AND (in some cases)
3) Response to Therapy

Question 7

What are the MAIN INVESTIGATIONS for CARDIAC DYSFUNCTION in HF?

Answer 7

1) Echocardiography
2) ECG
3) FBC - Mainly U and Es and Brain Natriuretic Peptide (BNP)

Question 8

Why is a TEST of BNP levels in the blood SIGNIFICANT in HF?

Answer 8

• > BNP in HF
  1) Highly Sensitive Test
  2) < BNP Excludes HF

Question 9

What are some of the CARDIAC PRECIPITANTS of HF?

Answer 9

1) LVSD
2) Valvular Disease
3) Pericardial Constriction or Effusion
4) Myocardial Ischaemia or MI
5) Arrhythmias
6) Restrictive Cardiomyopathy
7) RVF

Question 10

Why should LV EJECTION FRACTION (LVEF) NOT be CALCULATED via ECHO?

Answer 10

• Very Difficult to Accurately Quantify

i. e. Due to Quality of Images; Experience of Operator, etc

Question 11

What is considered a NORMAL LVEF?

Answer 11

50-80%

Question 12

What is considered a MILD LVEF?

Answer 12

40-50%

Question 13

What is considered a MODERATE LVEF?

Answer 13

30-40%

Question 14

What is considered a SEVERE LVEF?

Answer 14

< 30%

Question 15

What are some of the OTHER INVESTIGATIONS of CARDIAC DYSFUNCTION in HF?

Answer 15

1) Radionuclide Ventriculography (RNVG/MUGA)
2) Left Ventriculography
3) Cardiac MRI

Question 16

What are the TYPES of HF?

Answer 16

1) Systolic HF/HFrEF (< EF and Fluid Back Up in Lungs)

2) Diastolic HF/HFpEF (LVH and < Compliance; < EDV)

Question 17

What is the PROGNOSIS for patients with HF?

Answer 17

Poor Prognosis

1 Year Survival Rate for HF Worse than Several Cancers

Question 18

What are the some of the RISK FACTORS for HF?

Answer 18

1) Hypertension
2) Coronary Artery Disease
3) Alcoholism
4) Previous MI
5) Valvular Disease
6) Diabetes
7) Congenital Heart Defects
8) OSAD
9) Obesity
10) Smoking
11) > Age

Question 19

What are the MAIN GOALS of HF MANAGEMENT?

Answer 19

Improve Symptoms

Improve Survival

Question 20

What are the MAINSTAY TREATMENTS for alleviating SYMPTOMS in HF?

Answer 20

Loop Diuretics, i.e. Furosemide

Question 21

What are some of the SIDE EFFECTS of DIURETICS?

Answer 21

1) Dehydration
2) Hypotension
3) Hypokalaemia
4) Hyponatraemia (< Na+)
5) Gout

Question 22

What FACTORS must be CONTROLLED to < MORTALITY in HF?

Answer 22

1) Sympathetic Activation
- Beta Receptor Blockade
2) RAAS Activation
- Angiotensin Blockade
- Aldosterone Blockade
3) Neurohormonal Activation
- > Levels of ANP/BNP

Question 23

What CLASSES of DRUGS are IMPORTANT in < ACTIVATION of RAAS during HF and attenuating symptoms and mortality?

Answer 23

1) ACEIs, i.e. Ramipril or Enalapril

2) ARBs, i.e. Losartan or Valsartan

Question 24

What are some of the SIDE EFFECTS of ACEIs?

Answer 24

1) Initial Hypotension
2) Cough
3) Angioedema
4) Renal Impairment/Failure
5) Hyperkalemia

Question 25

ARBs are considered not as effective as ACEIs in treating HF; when is it BENEFICIAL to use ARBs instead of ACEIs?

Answer 25

If the Patient is Intolerant of ACEIs

Question 26

What is an ALTERNATIVE to ACEIs/ARBs which both < RAAS activation and enhances neurohormonal activation?

Answer 26

Angiotensin Receptor Neprilysin Inhibitor (ARNI), i.e. Valsartan-Sacubitril

Question 27

What are the ADVANTAGES and DISADVANTAGES of ARNIs?

Answer 27

Advantage: > Effectiveness in < Morbidity and Mortality from HF, in Comparison to ACEI/ARBs Disadvantages: > Cost

Question 28

What OTHER DRUGS can be used in COMBINATION with ACEIs to < mortality and improve symptoms in HF?

Answer 28

1) K+ Sparing Diuretic - Spironolactone | 2) Beta-Blockers, i.e. Carvedilol or Bisoprolol

Question 29

What are the STRENGTHS and WEAKNESSES of BETA-BLOCKER use in patients with HF ( < LVEF)?

Answer 29

Strength < Morbidity and Mortality by 30% in Mild/Moderate and Severe HF Weakness Potentially Hazardous * Start Low Dose * Use in Combination with Diuretics and ACEI * Only Use if Patient is Stable

Question 30

What TWO DRUGS can be used in the treatment of HF, but have a NARROW THERAPEUTIC INDEX and must be MONITORED closely?

Answer 30

1) Digoxin | 2) Warfarin

Question 31

Other than symptomatic and clinical relief, what else MUST BE MONITORED in patients being treated for HF?

Answer 31

Weight (due to Diuretic use and subsequent fluid loss) | *Daily Weight Assessment