Transcript Heart Failure

Heart Failure
Hazel Phillips
Cardiac Support Nurse
Bedford Hospital NHS Trust
Heart Failure
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“Complex clinical syndrome that impairs
the ability of the heart to respond to
physiological demands for an increased
output” ( Sign 2007)
“ It is recognised to be a chronic
disease with poor outcomes worse than
many cancers” ( Cowie & Zaphirious,
2004)
Causes of Heart Failure
Coronary Heart
Disease (MI )
 Hypertension
 Valvular heart
disease (Aortic and
Mitral valve)
 Cardiac arrhythmias
(heart block atrial
fibrillation
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Cardiomyopathy
(dilated,
hypertrophic
alcoholic,&
idiophatic
Symptoms of Heart Failure
Shortness of breath
Fatigue
Proximal Nocturnal
Dyspnoea
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Orthopnoea
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Nocturnal cough
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Increase in weight
Peripheral oedema
Anorexia
Diagnosis
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Full medical history and examination
ECG
Blood screen & BNP(Brain natriuretic
peptide ) best taken off diuretic therapy
If BNP positive request referral to H F
clinic
Heart Failure Clinic
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Bloods for U&E, TFT, LFT, Glucose, Lipid
profile, Full blood count
Chest X-ray
ECG
Echo (Gold standard)
Full examination
Diagnosis and Medical plan given
Echocardiogram
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Developed 50 yrs ago Elder & Herz
Ultrasonic waves are used to investigate
and display the action of the heart as it
beats.
Non invasive test,painless, safe
Examines size, function, and blood flow
through the heart
LV Ejection Fraction
LV ejection fraction
>75%
55-75%
40-54%
30-39%
<30%
Qualitative assessment
Hyper-dynamic
Normal
Mildly
Moderate
Severe
NYHA Classification
Class I
No Limitation on activity
Annual Mortality
No fatigue, breathlessness, palpitations
3%-5%
on ordinary physical activity
Class II Pt are comfortable at rest but physical
activity such as climbing stairs results in
10%
symptoms
Class III Pt have marked limitations on physical
activity, but comfortable at rest
12%-15%
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Class IV Pt have symptoms at rest and any activity
results in discomfort
15% - 20%
worse prognosis than
some cancers
Medication
Loop Diuretic
 Furosemide, Bumetanide
Use lowest dose to reduce fluid
overload
, Side effects hypotension (causing
dizziness, light-headedness, or
confusion) and hypokalemia.
Regular checks of U&E
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Diuretics
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Metolazone
Used for intractable oedema
Use with close monitoring of renal
function
Can cause hyponatraemia
Profound diuresis when used with loop
diuretics
Beta-blockers
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Increase life expectancy
Contra indicated in Asthma and COPD
Pt should be stable not fluid overloaded
Start low and increase slowly
Licensed for HF Carvedilol 3.12mg25mg BD, Bisoprolol 1.25mg-10mg OD,
or Nebivolol 1.25mg-10mg OD
Beta-Blockers
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May worsen HF symptoms
Monitor BP & pulse rate
Side effects hypotension, bradycardia,
cold extremities (causing paraesthesia),
sleep disturbances (including
nightmares), and sexual dysfunction
Angiotensin-Converting Enzyme
(ACE) inhibitor
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Improves symptoms and life expectancy
Base line U&E’s
Start low and increase slowly
Lisinopril 2.5mg –30mg OD
Ramipril 2.5mg – 10mg OD
Enalapril 5mg –10mg OD
Warn pt of first dose hypotension
ACE Inhibitors
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Monitor Creatinne & Potassium levels
Side effects Hypotension, Cough, rash,
tiredness etc
If cough troublesome can swap to a
angiotensin II receptor antagonists
(ARB) ie. Losartan, candesartan
Aldosterone Antagonist
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Moderate to severe HF NYHA Class III –
IV symptomatic on usual therapy
Reduces mortality
Spironolactone 25mg only drug licensed
Eplerenone only licensed for LVF post
MI
Monitor U&E Potassium sparing
diuretics
Aldosterone Antagonist
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Side effect: gastro-intestinal
disturbances impotence,
gynaecomastia, lethargy, headache etc
Digoxin
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Used if pt has an arrhythmia ie AF
Can be used as last “resort” if all other
medication have not improved
symptoms
Monitor for side effect and toxicity.
Contraindicated Medication
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NSAID
Calcium Channel Blocker(except
amlodipine & diltiazem)
Metformin
Glitazones
Corticosteriods
Tricylic antidepressants
Non-Pharmacological Advice
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Self management of condition
Monitor weight daily
Avoid salty food & “lo salt”replacement
products
Influenza & Pneumococcoal vaccinations
Lifestyle advice
Exercise advice/ Cardiac rehabilitation
Six monthly review
Cardiac Cachexia
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Complication of end stage HF
Loss of muscle mass & adipose tissue
Resulting in reduced exercise
tolerance,fatigue and dyspnoea
Ensure adequate nutrition supplements
Advice from dieticians
Other treatment options
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Dual chamber pacemakers + ICD
Revascularisation (CABG PCI)
Transplantation
Left ventricular assist devices (LVAD)
Palliative care
Further Information
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National Service Frame work (2000)
Chapter six Heart failure
NICE Clinical Guideline 5 (2003)
Management of chronic heart failure in
adults in primary and secondary care
Modernisation Agency (2004)
Supportive and palliative care for
advanced heart failure
Further information
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Scottish Intercollegiate Guidelines
Network (Sign) 2007
Management of Chronic Heart Failure
Any Questions