Heart Failure

Information

• HF is lethal - annual mortality is 20%

• Severe HF - annual mortality up to 50%

Types

• HFrEF = Reduced EF < 50%

• HFpEF - Preserved > 50%

Symptoms

• Dyspnoea (90%)

• Orthopnea

• PND

• Peripheral oedema

• Cough

• Unexplained confusion or fatigue

• Decreased eercise tolerance

• Nausea or abdominal pain

• Chest pain

Classification (NYHA)

• Class I - No limitations. Ordinary activity unaffected.

• Class II - Slight limitation. Ordinary activity causes fatigue, palpitations, dyspnoea, angina

• Class III - Marked limitation of physical activity. Less than ordinary activity leads to symptoms.

• Class IV - Unable to carry on any physical activity without discomfort.

Risk factors and causes

• Coronary artery disease

• Pressure overload (HTN, AS)

• Volume overload (MVR)

• Uncontrolled arrhythmias e.g. AF

• Valvular disease

• Viral myocarditis

• Thyroid dysfunction

• Postpartum

• Frequent VEB

• Inherited cardiomyopathy

• Diabetes

• CKD

• COPD

• OSA

• Systemic illness e.g. amyloid, sarcoid

• COVID-19 drug use

• Malnutrition

• Aclohocol

• Smoking

• Family history

Exam

• Pulse rate and rhythm

• Blood pressure

• Tachypnoea

• Weight

• Cardiac ausculatation (murmurs, S3)

• Signs fluid retention

• Exam often normal

Investigations

• FBC, UEC, LFT, TFT, Lipids, Glucose

• NT-proBP = $70

• ECG looking for

  • Ischaemic

  • Previous MI

  • Arrhythmias

  • LVH

  • Low voltage

  • Conduction defect

• CXR

  • Normal does not exclude

  • May see pulmonary congestion (cardiomegaly, pulmonary venous changes)

  • Main reason is to identify non-cardiac causes

• Echo to distinguish HFrEF and HFpEF

  • Detect valvular disease

  • Detected pulmonary hypertension

• Consider urinalysis, Holter, CT chest, CTPA, V/Q etc

Management

• Cardiology referral for all patients with heart failure

• Treat

  • Atrial fibrilation

  • Diabetes

  • Lipids

  • Smoking

  • Alcohol

  • Hypertension

  • Obesity

• Provide information

  • Heart failure action plan

• Diet

  • Advise 1.5 to 2.0 litres daily.

  • Limit caffeine to 1 to 2 drinks per day.

  • Limit salt to 2g daily

  • Limit alcohol to one drink per day

• Exercise

  • Encouraged exercise to avoid wasting

• Palliative care and advanced care planning

• Cardiac rehab

• Regular review for symptoms control

• Vaccinations including pneumococcal

• Monitor for depression and anxiety

Exacerbation

• Assess fluid and cardiovascular status

• Determine cause of exacerbation

  • Ischaemic

  • Poor adherence to medication

  • Infection

  • Uncontrolled hypretension

  • Arrhythmia

  • Poor adherence to salt and fluid restrcitions

  • Valvular dysfunction

  • Anaemia

  • Renal failure

  • PE

  • Thyroid

• Increase diuretics to get back to target weight

• If not responding seek cardiology advice

HF reduced EF

• If congested start

  • Loop diuretic

    • Furosemide 20 to 40mg intially once or twice daily

  • ARNI or ACEI

    • Entresto 49/51mg orally twice daily

    • Perindopril 2.5mg orally OD

  • SGLT-2

    • Empagliflozin 10mg once daily

  • Add Mineralocorticoid receptor antagoniist MRA once symptoms improved

    • Spironolactone 25mg orally daily

  • Add B-Blocker once euvolaemic (before or after MRA)

    • Metoprolol 25mg orally OD

• If euvolemic start

  • ARNI or ACEI

  • B-blocker

  • Add MRA

  • Add SGLT-2

• Uptitrate to maximally tolerated

  • B-blocker first unless congested or HR < 50

  • Double doses of medication, one at a time, every 2 weeks or as tolerated

  • Monitor with clinical review, blood pressure, renal function, potassium heart rate

• Treat Ferritin < 100

HF preserved EF

• Focus on treating

  • Causes e.g. if HTN then ACEI

  • Precipitating factors e.g. B-Blocker if AF

  • Symptoms e.g. Loop diuretic if congestion

  • Co-morbidities e.g. Diabetes, obesity, IHD, OSA

  • Exercise training

• Start SGLT-2 - to decrease cardiovascular mortality and hospitalisation

• Review medications that can cause harm

  • Diuretics

  • Venodilators e.g. Isosorbide dinitrate

  • Artierla vasodilators e.g. Hydrazlazine

  • NSAIDs

  • Gliazones

  • Digoxin

• Monitor

  • UEC

  • Weight daily

• Consider low-dose spironolactone to reduce hospital admissions

Reference

• HNEPathways on HF