Looking at heart failure, most common causes are HTN and IHD, most patients eventually have heart

failure, doesnt function as a pump and reduced cardiac output. Average age is 75, important thing is poor prognosis, heart failure has a worse one than most cancers, 50% dead in 10 years. Average length of stay is 8 days, accounts for a lot of healthcare expenditure. Heart failure, patient presents with breathlessness, initially on exertion but then at rest, orthopnoea, paroxysmal nocturnal dyspnoea. Signs, tachycardia, limbs are swollen, peripheral oedema, raised JVP, third heart sound, pleural effusion, dull percussion note on right lung base. To prove it definitely, perform an echo, reduction in LVEJ, should be 70%, can be 20-40%. In practice, make the diagnosis clinically, another test for diagnosis is blood test, BNP >1,000, indicative of heart failure, real value is in the negative predictive value, >99%. If you do have heart failure, radiological appearance bats wing, pulmonary oedema white-out, predominantly in mid and lower zones, purely gravitational. What do you do? Make sure patient is oxygenated. May be distressed, they might be having an MI! Appropriate to give morphine in this situation, 2.5-5mg IV, give cyclimorph due to anti-emetic effect. Patient starts to feel better after opiate, also have vasodilatory properties, reduce pressure on the heart, mainstay of treatment is giving IV diuretics, dont give oral diuretics or thiazides, GIVE IV FUROSEMIDE 20-40mg, need to get rid of fluid. Some patients may already have low BP, danger of kidney under perfusion. No role for digoxin in acute heart failure, unless atrial fibrillation. Important distinction between acute and chronic failure, chronic is separate and approached differently. Be careful of balance between fluid overload and hypovolemia. In some patients with huge resistance to loop diuretics, then combine with thiazide. Vasodilators excellent in heart failure, isosorbide mononitrate, reduces pressure on the heart, use it in CHF as well. What if pressure goes too low? Dobutamine would be the drug of choice, b1 agonist, increase cardiac output, then give other medications as well, can use dopamine as well but not as good. Write a brief note on the management of acute heart failure, know t he treatments and the issues around the treatment.

Chronic heart failure. This is when patient is stabilised. Now the issue is different, make sure they dont get it again, survival is increased and the symptoms resolve, huge change in this treatment in recent decades. Used to give digoxin and loop diuretic, used to call it dropsy. The slide with treatment algorithm will answer any question on CHF. ACE inhibitor is absolutely vital!!!!!! Should be on a beta blocker and a diuretic. Overactivation of RAAS and autonomic nervous system, principal goal in treatment, antagonising these two systems. Mouse and cheese model of activating RAAS using diuretic, heart failure is condition where you gradually get worse. Can go down one of two pathways, add an ARB in addition to vasodilator and digoxin, or aldosterone antagonist, vasodilator and glycoside. NEVER add ARB, ACEI and aldosterone antagonist (favourite MCQ question on this triad). Diuretics, over activate RAAS, angiotensin II is main culprit, give a loop diuretic (thiazides for HTN), combine with ACEI or ARB. No real role for thiazide diuretics in heart failure. ACEI are cornerstone of treatment, drugs of first choice. Consensus trial, 1987, used to be diuretics and digoxin. Pay attention to atrial fibrillation, no P waves, 1/3 of patients with HF will have AF, most will also have HTN or CHD. When you add in enalapril after 6 months, halved the mortality rate, in placebo group, 44% were dead in 6 months. First study to show conclusively that ACEI were game changers. ACEI as initial therapy, stabilise the patient then introduce the ACEI. Dont give immediately, way too much going on, wait for 2-3 days before introduction. Key point about treatment of HF, take it up to the highest dose you can possibly tolerate, may as well be taking two glasses of water if on lower dose, ramipril 10mg, even if symptoms are controlled on 5mg, probably the biggest error in therapeutics of HF. What are the things which cause poor toleration? Poor renal function, watch out creatinine levels. Timeframe for upping the dose, 1.25mg for 3 days, move on to 2.5mg, probably on 5mg after discharge (average 11 days), push the BNP down below 1,000, will be standard of care soon. REMEMBER RAMIPRIL, peanuts, 4 for 5mg per day.

Beta blockers

Give them in heart failure, antagonising sympathetic nervous system, sodium and water retention, RAAS stimulation. Number of pivotal trials in mid 90s. Carvedilol is drug of choice, also bisoprolol. Average age of people in trials was 66, decade below patients we see, thats why we cant get to top doses of beta blockers, elderly patients cant tolerate well, still try and get as high as possible. On top of ACEI (Reduce mortality by 30%), reduces mortality by an EXTRA 34%. Contraindications, heart block, diabetes, Raynauds, asthma, COPD. Try to introduce beta blocker while patient is in hospital, start low and go slow. Watch the pulse rate. 3.125mg twice daily carvedilol, increase as much as you can, target is 25mg bd but we never reach that because patients are usually elderly. Tell patients to check their weight! Weight gain may be first sign of changes. Potassium-sparing diuretic is spironolactone, adding on spironolactone to BB, ACEI and diuretic is very good as shown by RAIL study, further 35% increase in survival. Other route is to add in ARB, will get a reduction in mortality, 25% reduction in mortality, remember candesartan, ARB of choice, losartan is crap, valsartan is BD, candesartan is cheapest, OD and has good outcome data. Principle, start with 4mg and work up to 32mg. Vasodilator therapy, if you have to add in spironolactone or ARB, immediately add in a nitrate, cant stress the importance of this enough. Allows you to unload so much better but no pressure on the kidneys. Isosorbide mononitrate, if ACEI and ARB intolerant, add in hydralazine with nitrate, only other combination that will reduce mortality in HF, 5-10 patients per year. Digoxin, product of the foxglove. Particularly used due to positive inotropic effect for atrial fibrillation, or in CHF, wont help survival or mortality, very good improvement in symptoms and hospitalisation. Add in digoxin even if no AF, to help patients symptoms.