Clinical Management of Heart Failure

• What is heart failure (NICE)?

  A complex syndrome in which the ability of the heart to maintain the circulation of blood is impaired as a result of a functional or structural impairment of ventricular filling or ejection
• Heart failure can be classified into two types based on whether it affects the left side of the heart (left-sided HF) or both sides of the heart (biventricular HF).
• What is the average age of HF diagnosis?

  78
• What are the causes of HF?

  Ischaemic heart disease

  Lung disease

  Congenital heart disease

  Genetic cardiomyopathies

  Hypertensive heart disease

  Infection

  Pregnancy

  Valvular heart disease

  Arrhythmias

  Cardiotoxins

  Thyroid disease/anaemia
• What is the main cause of HF?

  Ischaemic heart disease

  60% of HF cases
• How can ischaemic heart disease lead to HF?

  Ischaemic heart disease -> damage/deatg of cardiac tissue -> regional movement abnormalities of cardiac myocytes & reduced contractility
• What are the different types of HF?

  Reduced ejection fraction

  Preserved ejection fraction

  Midly preserved ejection fraction

  Left

  Right

  Cor pulmonale
• What are the typical symptoms of HF?

  Breathlessness

  Orthopnoea

  Paroxysmal noctural dyspnoea

  Reduced exercise tolerance

  Fatigue

  Oedema
• What are the signs of HF?

  Elevated JVP

  Third heart sound (gallop rhythm)

  Laterally displaced apical impulse
• What are the investigations of HF?

  CXR

  ECG

  FBC

  U&Es

  LFTs

  Thyroid

  BNP
• What is the first line treatment for HF (in ED)?

  O2

  Duiretics
• What are the 4 pillars of HF?

  ARNI (sacubitril/valsartan)

  Beta blocker

  MRA (spironolactone)

  SGLT2 inhibitor

  Aim is maximum tolerate therapy
• How is BNP used in heart failure?

  BNP is a hormone secreted by cardiomyocytes in the ventricles in response to stretching

  NT-proBNP (biologically inactive) is measured in blood

  NT-proBNP > 400 mg/l -> refer to be seen by cardio

  Not diagnostic, used to rule out HF
• Other than HF, what are other causes of raised BNP?

  Acute & chronic renal failure

  HTN

  Pulmonary HTN

  COPD

  Pneumonia

  PE

  Adult respiratory distress syndrome (ARDS)
• What is ejection fraction?

  The percentage of blood pumped out of the heart with each contraction.

  Calculation = (amount of blood pumped out)/(amount of blood in the chamber)
• What are the different types of ejection fraction in HF?

  Preserved EF = 55 - 70%

  Mid-range EF = 41 - 49%

  Reduced EF = > 40%
• What are the non-pharmacological treatment options for HF?

  Devices

  • cardiac resynchronisation therapy (CRT pacing)
  • implantable cardioverter defibrillator (ICD)

  Advanced therapies

  • left ventricular assist device (LVAD)
  • heart transplant
• What are the lifestyle changes advised for non-pharmacological management of HF?

  Abstinence

  Salt restrictions

  Fluid restrictions

  Weight loss/healthy diet

  Heart failure rehab
• Heart failure has a difficult disease trajectory, makes end of life care very difficult to predict.