Malady Wise

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Heart Failure

Maladywise

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

  • 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