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How to treat HF with ejection fraction <45%/impaired systolic function?

- Diuretics
- ACEi
- Beta-blockers
- Aldosterone receptor antagonists
- Devices: CRT/ICD


How to treat HF with ejection fraction >45%/preserved LV function?

- Diuretics
- Treatment of co-morbidities (HTN, DM)


What is the function of ACEi and what are some examples?

Block the conversion of angiotensin I to II. They are 1st line treatment along with beta blockers. Action:
- Inhibit LV hypertrophy and remodelling
- Inhibit vasoconstriction and therefore lower arterial constriction and increase venous capacity
- Decrease salt and water retention
- Lisinopril, ramipril, captopril, enalapril


What is the function of beta blockers?

- First line treatment along with with ACEi
- Bisoprolol, carvedilol, nebivolol
- ATENOLOL NOT licensed for HF


What is the function of aldosterone receptor antagonists?

- Also called mineralocorticoid receptor antagonist
- Used in treatment of severe LV dysfunction (EF<35%, NYHA II)
- Eplerenone, spironolactone
- Anti-fibrotic effects


What is the treatment flow of heart failure?

1. ACEi and titrate upwards (or ARB if ACEi not tolerated e.g. cough) - diuretic might need to be added to control congestive symptoms and fluid retention
2. Beta blocker and titrate upwards - add digoxin if sinus rhythm remains symptomatic (unless in AF - 1st line)
3. Add a mineralocorticoid receptor antagonist e.g. spironolactone if still symptomatic


What needs to be monitored whilst on diuretics, ACEi or ARB?

- Renal function
- BP


What is a CRT device?

- Atrial, RV and LV lead
- Improves synchronicity between LV and RV and within LV
- Shown to improve mortality in HF patients with EF <35% and QRS duration >120ms.


What is an implantable cardiac defibrillator (ICD)?

- Sudden cardiac death accounts for approx 50% of HF mortality
- ICDs can detect and treat ventricular arrhythmias - can attempt to overdrive pace VT or deliver electrical shock to cardiovert VT/VF


What is the management for AF?

- Beta blocker or rate-limiting calcium-channel blocker as initial monotherapy
-Base drug on symptoms, HR, comorbidities and preferences
- Consider digoxin monotherapy for people with non-paroxysmal AF only if sedentery


When should cardioversion not be used as a treatment for AF?

Clots can form from AF with an increased risk after being in AF for longer than 48 hours. If cardioverted clots would be dislodged and cause an embolic stroke. So if the onset of AF is unknown or the patient has been in AF for longer than 48 hours cardioversion is not recommended.


What is the treatment of AF if cardioversion is not recommended?

Control the rate with appropriate medication and anti-coagulate the patient.


What is the management of HF?

- Stop smoking/alcohol. Eat less salt. Optimise weight and nutrition.
- Treat the cause
- Treat exacerbating factors e.g. anaemia, thyroid disease, infection, increased BP
- Avoid exacerbating factors e.g. NSAIDs (fluid retention) and verapamil (-ve inotrope)
- Annual flu vaccine, one-off pneumococcal vaccine
- Drugs


What are the side effects of diuretics?

e.g. furosemide, bumetanide
- Hypokalaemia
- Renal impairment
- If refractory oedema, consider adding a thiazide


What is the main side effect of ACEi?



How does cardioversion work?

- Electrically or with anti-arrhythmic drugs
- Echo performed before to check thromboembolic risk


What is CHADS-2

A scoring system for predicting the long-term risk of stroke in valvular AF:
C - congestive HF
H - hypertension
A - age > 75 yrs
D - diabetes mellitus
S2 - prior stroke or TIA


Describe anticoagulation based on CHADS2 score

0 - Low: aspirin or no treatment (no anti-thrombotic therapy)
1 - moderate: aspirin or warfarin (aspirin daily or raise INR to 2.0-3.0, depending on factors)
>/= 2 - moderate/high: warfarin (raise INR to 2.0-3.0 unless contraindicated e.g. GI bleeding, inability to obtain regular INR screening


What is the management of acute heart failure?

- Loop diuretic (furosemide) - improves dyspnoea by increased LV filling pressures
- Other options (not routinely offered) - opiates, GTN infusion, inotropes/vasopressors