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Heart Failure
Failure of the heart to perform its function Results from deficiency in the heart's function as a pump, where the delivery of blood, and therefore oxygen and nutrients, becomes inadequate for the needs of the tissues.
Causes
The common underlying aetiologies in patients with heart failure are coronary artery disease and hypertension. Identifiable causes of heart failure include aortic stenosis, cardiomyopathy, mechanical defects such as cardiac valvular dysfunction, hyperthyroidism and severe anaemia.
Classification
S/Sx:
Clinical Manifestations
reduced cardiac output, impaired oxygenation fatigue Shortness of breath occurs on exertion (dyspnoea) Orthopnoea Paroxysmal nocturnal dyspnoea Patients with heart failure may appear pale and their hands cold and sweaty. Reduced blood supply to the brain and kidney can cause confusion and contribute to renal failure, respectively. Oedema affects the lungs, ankles and abdomen. The sputum may be frothy and tinged red from the leakage of fluid and blood from the capillaries.
Primary Signs and Symptoms Associated with all types of CHF (uncompensated): severity depends on the degree of CHF
Clinical Manifestations
Laboratory Tests
Atrial natriuretic hormone
Reference Value: 20-77ng/L ANH is secreted from the atria and acts as an antagonist to renin and aldosterone It is released during expansion of the atrium, produces vasodilation and increases GFR.
Clinical Manifestations
Laboratory Tests
Brain natriuretic peptide
Reference values: Desire value: <100pg/mL : Positive value: .100pg/mL BNP test aids in the diagnosis of heart failure Considered to be more sensitive test than ANP for diagnosing HF.
Blood test
Diagnosis
Diagnosis
12-lead electrocardiogram
A normal ECG usually excludes the presence of left ventricular systolic dysfunction. An abnormal ECG will require further investigation
Chest radiograph
A chest radiograph (X-ray) is performed to look for an enlarged cardiac shadow and consolidation in the lungs
Echocardiography
An echocardiogram is used to confirm the diagnosis of heart failure and any underlying causes, for example, valvularheart disease
Desired Outcome
The aims of drug treatment are to control symptoms and to improve survival. By slowing disease progression the aim is to maintain quality of life.
Pharmacologic Treatment
Pharmacologic Treatment
DRUG COMMENT
Thiazide
Bendroflumethiazide
Metolazone
effective in the treatment of sodium and water retention, although there is generally a loss of action in renal failure (GFR <25 mL/min). Metolazonehas an intense action when added to a loop diuretic and is effective at low GFR Loop diuretics are preferred in the treatment of sodium and water retention where renal dysfunction is evident or more severe grades of heart failure present. Agents can be given orally or by infusion, and all are effective at low GFR
Loop
Furosemide Bumetanide Torasemide
DRUG
COMMENT
Aldosterone antagonist
Spironolactone
Can enhance diuretic effect of loop and/or thiazide. Due to slow onset of action needs 23 days before maximum diuretic effect reached. Spironolactone can improve survival when given as an adjunct to ACE inhibitor and diuretic therapy at a recommended dose of 25 mg daily (initial dose of 25 mg daily or on alternate days) In early post-MI patients with symptomatic heart failure (or asymptomatic patients with diabetes mellitus), eplerenone 50 mg daily improved survival when added to optimal therapy (initial dose of 25 mg daily)
Aldosterone antagonist
Eplerenone
DRUG
COMMENT First-dose hypotension may occur. May worsen renal failure. Adjust dose in renal failure. Hyperkalaemia, cough, taste disturbance and hypersensitivity may occur particularly with captopriL.
ACE inhibitor
Captopril Enalapril Lisinopril Ramipril Trandolapril Cilazapril Fosinopril Perindopril Quinapril
B-Blocker
Carvedilol Bisoprolol
May initially exacerbate symptoms but if initiated at low dose and slowly titrated can improve long-term survival, even in elderly patients with heart failure . Half-life of nebivolol can be 35 times longer in slow metabolisers
DRUG
COMMENT
Nitrates
Glyceryl trinitrate Isosorbide dinitrate Isosorbide mononitrate
Isosorbide dinitrate metabolised to isosorbide mononitrate. High doses needed. Tolerance can be prevented by nitrate-free period of >8 h. Protective effect against cardiac ischaemia. GTN given intravenously for sustained effect in acute/severe heart failure but limited by tolerance. Light sensitive. Acts on veins and arteries. Cyanide accumulation and acidosis limit treatment duration
Nitroprusside
DRUG
COMMENT
Comparable effectiveness to ACE inhibitor in patients with ACE inhibitor intolerance, although similar effect on renal function and blood pressure. Recent evidence suggests improved survival when ARB used as adjunctive therapy. However, increased potential for deterioration in renal function and/or hyperkalaemia Hydralazine has a direct action on arteries. Tolerance occurs. May cause drug-induced lupus and sodium retention
Hydralazine
DRUG
COMMENT In renal failure, half-life of digoxin is prolonged. Dosage individualisation required. Serum drug concentration monitoring used to confirm or exclude toxicity or effectiveness. CNS,visual and GI symptoms linked to digoxin toxicity. No benefit in terms of mortality, but use associated with improved symptoms and reduced hospitalisation for heart failure. Beneficial in AF, although risk of arrhythmias with high doses. Used only in severe heart failure as adjunctive therapy. Associated with arrhythmias and increased mortality with chronic use
Cardiac glycosides
Digoxin Digitoxin
Phosphodiesterase inhibitors
Enoximone Milrinone
SOAPPP
Plan
Pharmacologic
Non-pharmacologic
Limit salt intake to 2g (approx. 1 tsp) Excessive alcohol use can lead to cardiomegaly, therefore alcohol should be avoided. Avoid smoking for it deprives the heart of oxygen. Obesity increases CV problems, Pt should be in low fat and low calorie diet.