Heart Failure

Heart failure can be defined as either having a reduced or preserved ejection fraction:

  • Heart failure with reduced ejection fraction= Left ventricle loses its ability to contract normally and therefore presents with an ejection fraction of less than 40%.
  • Heart failure with preserved ejection fraction= Left ventricle loses its ability to relax normally therefore the ejection fraction is normal or only mildly reduced.

                   Symtoms include: 

  • Dyspnoea – during rest or an activity
  • Exercise intolerance / fatigue
  • Odema- Pulmonary odema =breathlessness
    peripheral odema = swollen ankles or legs

Non Pharmacological Advice

Smoking cessation

Reducing alcohol consumption

Increasing physical exercise if appropriate

Weight control

Dietary changes such as increasing fruit and vegetable consumption and reducing saturated fat intake.

Patients should be encouraged to weigh themselves daily at a set time of day and to report any weight gain of more than 1.5–2.0 kg in 2 days

.

Salt and fluid intake should only be restricted if these are high, and a salt intake of less than 6 g per day is advised

Contraception and pregnancy should be discussed with women of childbearing potential and heart failure.

Pharmacological Treatment

FIRST LINE


An angiotensin-converting enzyme (ACE) inhibitor + beta-blocker licensed for heart failure (e.g. bisoprolol fumarate, carvedilol, or nebivolol) – if already on beta blocker for other reasons it should be switched to beta blocker licensed for HF

An angiotensin II receptor blocker (ARB) licensed for heart failure (e.g. candesartan cilexetil, losartan potassium, or valsartan) can be considered if ACE inhibitors are not tolerated.

Hydralazine hydrochloride combined with a nitrate can be considered under the advice of a heart failure specialist in patients who are intolerant of both ACE inhibitors and ARBs.

ADD ON THERAPY


Spironolactone or eplerenone can be used if heart failure symptoms persist unless it is contraindicated (e.g. due to hyperkalaemia or renal impairment).

PERSISTENT SYMPTOMS 

Advice from a heart failure specialist should be sought on the use of amiodarone hydrochloride, sacubitril with valsartan, ivabradine, empagliflozin, or dapagliflozin.

For patients in sinus rhythm, digoxin is recommended as add-on therapy in worsening or severe heart failure despite optimal treatment

DIURETICS


Diuretic for fluid overload: Loop diuretics such as furosemide, bumetanide, are usually the diuretics of choice. Thiazide diuretics are only beneficial in patients with mild fluid retention and an eGFR greater than 30 mL/minute/1.73 m

CAUTION

AVOID
  • Verapamil hydrochloride and diltiazem hydrochloride) (rate limiting CCB’s)
  • Nifedipine, or nicardipine hydrochloride) (non-rate liminting CCBs)

Should be avoided in patients who have heart failure with reduced ejection fraction as these drugs reduce cardiac contractility. 

SAFE to use 

Patients with heart failure and angina may safely be treated with amlodipine.