heart_failure
Heart Failure
Definition
A complex clinical syndrome with symptoms and signs that result from any structural or functional impairment of ventricular filling or ejection of bloodCauses
- IHD, MI, valvular heart disease (VHD)
- hypertension
- Others
- familial,genetic, RV pacing, peripartum or stress-induced cardiomyopathies
- amyloidosis
- cardiotoxicity with cancer or other treatments
- substance abuse - alcohol, cocaine, or methamphetamine
- tachycardia, myocarditis, autoimmune causes, sarcoidosis,
- iron overload, including haemochromatosis
- thyroid disease and other endocrine metabolic and nutritional causes
Symptoms
- breathlessness - many other causes of SOB though
- leg swelling
- orthopnoea
- bendopnoea
New York Heart Failure Classification
I - cardiac disease but no symptoms or limitation of daily activitiesII - mild symptoms and slight limitation to ordinary activity
III - significant limitation due to symptoms. Comfortable only at rest
IV - severe limitation and symptoms at rest
Signs
- raised JVP
- a square-wave response to the Valsalva manoeuvre
- pitting oedema of legs
- fine crep's on chest auscultation - beware other causes
Investigations
- FBC, U&E's (Ca++, Mg++), LFTs, Glu, TSH
- fasting lipid profile
- Fe studies (serum iron, ferritin, transferrin saturation)
- urinalysis
- ECG and ECHO
Management
Treatment of HF is dependent on classification:HFrEF
Goal of Heart Failure Mx. The 4 pillar approach:
- ACEi or ARB or ARNi
- a β-blocker
- an MRA
- SLGT2i
To prescribe a combination of all at low initial doses and titrate to target/max tolerated doses (with doubling of doses), one at a time.
Hypervolaemic
diuretics should be commenced to achieve euvolaemia where possible- ACEi or, if not tolerated, ARB and
- MRA then when euvolaemic, add
- heart failure β blocker
STRATEGY
- double the dose of each, one at a time, every 2–4/52(except MRAs; up-titrated in 4–8/52), or as tolerated.
- add the next drug before reaching target or maximum tolerated dose, eg, if the patient is euvolaemic, a heart failure beta blocker may be started before achieving target or maximum tolerated dose of an ACE inhibitor.
- clinical and lab review every 1–2/52 after each medicine initiation and dose increase.
Medications
ACE inhibitors (ACEi)
Medications
ACEi | initial | target |
---|---|---|
enalapril | 2.5mg OD | 20mg OD |
lisinopril | 2.5mg OD | 50mg OD |
perindopril | 2.5mg OD | 10mg OD |
ramipril | 2.5mg bd | 5mg bd |
Angiotensin Receptor Blockers (ARB)
ARB | initial | target |
---|---|---|
candesartan | 4mg OD | 32mg OD |
irbesartan | 75mg OD | 300mg OD |
losartan | 25mg OD | 100mg OD |
valsartan | 40mg bd | 160mg bd |
olmesartan | 10mg OD | 40mg OD |
Heart β-blockers
β blockers | initial | target |
---|---|---|
bisoprolol | 1.25mg OD | 10mg OD |
carvedilol | 3.125mg bd | 50mg bd |
nebivolol | 1.25mg OD | 10mg OD |
Aldosterone Receptor Antagonists (MRA)
MRA | initial | target |
---|---|---|
spironolactone | 25mg OD | 50mg OD |
eplerenone | 25mg OD | 50mg OD |
Angiotensin Receptor/Neprilysin Inhibitors (ARNi)
ARNI | initial | target |
---|---|---|
sacubitril/valsartan | 49/51mg bd | 97/103mg bd |
SGLT-2 inhibitors
Dapagliflozin | 10mg OD |
---|---|
Canagliflozin | 100-300mg OD |
Empagliflozin | 10mg OD |
Ertuglifozin | 5-15mg OD |
Other
other | initial | target |
---|---|---|
ivabradine | 5mg bd | 7.5mg bd |
If symptoms persist, consider:
- add hydralazine and nitrate (esp if Afro-Caribbean)
- digoxin for those in sinus
- for LVEF ≤ 35%, change ACE inhibitor (or ARB) to an angiotensin receptor-neprilysin inhibitor (ARNI).
- for LVEF ≤ 35%, add ivabradine(hyperpolarization-activated cyclic nucleotide-gated (HCN) channel blocker) for sinus HR>75
Author: Dr Dylan Jenkins, Oct 2023
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