Heart Failure – notes on Alan Wong’s talk 6/9/17

Mortality from heart failure is 45% at five years – that’s worse than a lot of cancers.

1 in 10 patients over 70yrs have heart failure.

1-2% of the population have heart failure.

1 – 3% of hospital admissions are due to heart failure.

 

Pulmonary oedema isn’t fluid overload, it’s fluid in the wrong space.

 

Bloods to do for ?Heart failure are U&Es, FBC, BNP.

 

Heart failure diagnosis requires specific set of parameters to be met:

Signs / Symptoms / Biochemical

Heart Failure with Reduced Ejection Fraction (HF-REF)

  • Orthopnoea + Short of Breath
  • Bibasal Creps
  • Raised JVP
  • Reduced Left Ventricular Ejection Fraction

{What is ejection fraction? it’s quite a basic measure of the size of the LV in diastole compared to the size of the LV in systole – so at 50% the volume is 50% smaller in systole than diastole. Normal ejection fraction is: 55% or higher}

Note: Congestion drives worsening renal function in heart failure – so you often need more diuretics not less!

Heart Failure with preserved Ejection Fraction (HF-PEF)

  • Signs and symptosm
  • Ejection fraction normal or low (not high and not lower than 40%)
  • Left ventricular hypertrophy
  • Left Atrial Enlargement – structural heart disease

 

If you want to diagnose Heart Failure, look at the size of the left atrium.

  • The left atrial pressure is what increases in heart failure of any cause – so the left atrium becomes dilated
  • If the left atrium is normal then it’s not heart failure (don’t look at the left ventricle – HF-PEF will be missed!!)

BNP

  • Brain Natriuretic Peptide is secreted from the brain and the heart – the heart when it’s under higher pressure
  • ANP (Atrial Natriuretic Peptide)  is secreted from the atria of the heart

Pro Tip: If a patient has had a palpitation if it’s SVT then the ANP will be released and if so they will need to urinate after BNP/ANP has been release (natriuretic means getting rid of salt – obviously gets rid of water as well – this is the heart trying to offload the pressure by getting rid of water).

Ectopics and AF (as causes for palpitations) won’t cause a release of ANP and therefore won’t cause the same need to pee.

 

BNP is influenced by other factors:

  • age – if theyre more than 80 you’d need the BNP to be over 1000 to diagnose HF
  • Kidney disease
  • caucasian
  • Being obese
  • Diabetes
  • Gender

HFrEF = LVEF < 40%

HFmEF = LVEF 40 – 49%

HF pEF = LVEF >/=50%

Drugs for Heart failure:

ACE-i (angiotensin-converting-enzyme inhibitor) – such as Ramipril / Captopril / Enalapril / Perindopril / Lisinopril)

ARB (angiotensin II receptor blockers) – such as Losartan / Candasartan / Valsartan

BB (beta blockers) – such as Propranolol, bisoprolol, Atenolol, Carvedilol, Labetalol

MRA (Minerocorticoid receptor antagonist) such as Spironolactone, eplerenone

ARNI (angiotensin-receptor-neprilysin inhibitor)Entresto is the first this new class of drugs, valsartan combined with sacubitril 

 

Tips:

Don’t stop the ACE-i if the Creatinine goes up slightly (eg 90 to 130)

Withould ACE / ARB and the MRA on sick days – eg vomiting or diarrhoea days

Stop Sprionolactone if the K goes over 5.5

Ivabradine / digoxin is useful if the heart rate is up dispite maximum betablocker

Bisoprolol has a more potent effect on heart rate compared to bisoprolol.