Heart failure - medical management

What outcome benefits doe aldosterone antagonists have in heart failure?

Improved survival, reduced hospitalisation.

Studies have not shown benefit of beta-blocker therapy over placebo in patients with

HFPEF

Optimisation of CCF therapy may take [how long]?

several months

What are two indications for the use of digoxin in patients with heart failure?

1) AF, 2) patients with sinus rhythm when heart failure is not adequately controlled by optimal doses of ACEI, beta blocker, loop diuretic and aldosterone antagonist.

How long does it take to reach steady-state after starting a digoxin dose?

5 days (and longer with renal impairment). Digoxin levels should be monitored.

A patient experiences a mild rise in creatinine when put on an ACE-I and frusemide. What should you do?

A mild increase in serum creatinine (fall in estimated glomerular filtration rate [eGFR]) is commonly observed in patients with heart failure when they are started on combined ACEI and diuretic therapy. This is not usually an indication to stop the ACEI therapy, but requires monitoring (with weight, kidney function and electrolytes) and may require (diuretic) dose titration.

If a patient has symptomatic hypotension on combination therapy, it is advised to reduce the dose of...(2)

ACEI and frusemide before reducing the dose of beta blocker

Which CCF patients should be put on an ACE-I or an ARB?

ACEI improve prognosis in all grades of heart failure. ARB offer a potential alternative therapy in patients who are intolerant of an ACEI, except where there are contraindications to either class of drug, such as in situations where ACEI therapy results in the development of angioedema or worsening kidney failure due to bilateral renal artery stenosis.

Which drug combinations with and ACE-I or ARB can cause life-threatening hyperkalaemia in renal patients?

Aldosterone antagonist or potassium-sparing diuretic (i.e. amiloride)

What should be considered in any diuretic regimen?

An aldosterone antagonist should be considered in any diuretic regimen, as this has been shown to improve survival and reduce complications.

How should an ace-inhibitor be introduced in patients on high doses of frusemide?

In patients already taking high doses of potent diuretics, or combinations of diuretics (eg loop diuretic plus thiazide diuretic), the dose(s) of diuretic(s) should be reduced 24 to 48 hours before commencing ACEI therapy.

In which patients should you use an aldosterone antagonist?

In patients with HF-LVSD whose symptoms are not controlled on a combination of optimal doses of an ACEI, a beta blocker and a loop diuretic, consider adding an aldosterone antagonist.

What is HF-PEF? What is HF-LVSD?

heart failure with preserved left ventricular ejection fraction (HFPEF) and with left ventricular systolic dysfunction (HFLVSD)

ARB therapy requires frequent monitoring for

hypotension, renal impairment and/or hyperkalaemia.

Major complications of beta-blocker therapy in patients with heart failure include

initial worsening of the failure, severe hypotension and bradyarrhythmias

Conditions which should not stop you from prescribing and ACE-I and beta-blocker

peripheral arterial disease (without critical limb ischaemia), erectile dysfunction, interstitial lung disease or chronic obstructive pulmonary disease without reversibility.

When might you use a GTN patch for CCF patients (2)? What is the mechanism of action?

For the relief of symptoms of left ventricular failure, particularly nocturnal dyspnoea. Nitrates cause prompt but temporary lowering of pulmonary venous pressure. Patients with heart failure in association with elevated blood pressure or ischaemia are particularly likely to benefit.

What is an alternative for patients who are intolerant of ACE-I and ARBs?

Hydralazine AND isosorbide dinitrate (can be used with beta-blocker also)

What drug can be used to control the heart rate of patients with HF-LVSD who are in sinus rhythm but who are intolerant of beta blockers or have poor rate control (heart rate more than 70 beats per minute) despite maximum dose of a beta blocker?

Ivabradine (adjusted to heart rate)

In addition to patients with AF, which other CCF patients benefit from warfarin?

Oral anticoagulation with warfarin is beneficial to prevent stroke and systemic embolism in patients with heart failure, particularly in those with severe left ventricular systolic dysfunction or previous systemic embolism. Oral anticoagulant therapy should be strongly considered in these patients.

Which type of heart failure patient might not benefit from ACE-I?

Patients with HFPEF may benefit from ACEI and this is often indicated for a comorbidity (eg hypertension, diabetes, ischaemic heart disease) but there is insufficient evidence of effectiveness to recommend general use in this condition.

Who should be put on a beta-blocker and when should it be started?

Some beta blockers improve symptoms and prognosis in patients with HF-LVSD and should be started when the patient is stable and euvolaemic. Beta blockers may also be indicated in patients with heart failure with preserved left ventricular ejection fraction (HFPEF), particularly in the setting of atrial fibrillation, where there is a fast resting heart rate, or with coexisting ischaemic heart disease.

Side-effects of beta-blockers can be minimised by...

Start low and go slow. Monitor symptoms and daily weight. Adjust concominant drugs. Don't start during acute decompensation. Do not add a vasodilator at the same time. Don't use with dilitiazem or verapamil.

Almost all patients with clinical heart failure require combination therapy with (3)

an angiotensin converting enzyme inhibitor (ACEI), a beta blocker and a diuretic

In the drug management of CCR, it is important to start with low doses and to titrate slowly while not being afraid of the side-effects of...(3)

an asymptomatic fall in blood pressure (eg systolic blood pressure of 90 versus 110 mm Hg), a slight rise in serum creatinine (with the combination of ACEI or angiotensin II receptor blocker [ARB] and diuretic) or a slight rise in serum potassium (with an aldosterone antagonist)

Which beta blockers are recommended for heart failure?

bisoprolol, carvedilol, metoprolol succinate or nebivolol.

Clinical trials have demonstrated the unequivocally beneficial effects of some beta blockers (in combination with ACEI) in patients with HF-LVSD, with improved

control of heart failure, improved left ventricular ejection fraction, reduced hospitalisations and reduced mortality, including reduction in sudden deaths.

In patients without significant pulmonary oedema, therapy can begin with... (2)

either an ACEI or a beta blocker