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Microsoft word - hf fact sheet - final

Symptoms and signs of heart failure
Other investigations:
Signs: tachycardia, displaced apex, gallop rhythm, elevated JVP, leg and sacral oedema, hepatomegaly. ascites. Serum natriuretic peptides:
Expensive test, please do not use as breathlessness screen !

NTPro-BNP
High > 2000 pg/ml (236pmol/l) > 400 pg/ml (>116 pmol/l)
Raised 400-2000 pg/ml (47-236pmol/l) 100-400pg/ml (29-116 pmol/l)
Normal < 400pg/ml (47pmol/l)
Other causes of elevated BNP/NT-BNP include ischaemia, tachycardia, LVH and chronic renal failure. BNP may be normal in very well controlled heart failure. Differential diagnoses to consider:
Aetiology
Drug induced ankle swelling esp calcium ch blockers NYHA Classification
I no limitations, no symptoms with ordinary physical activity
II slight limitation, symptoms with ordinary activity
III marked limitation, symptoms with less than ordinary activity
IV breathless at rest, any physical activity increases symptoms
Symptoms: dyspnoea, fatigue, palpitations
Diastolic HF (Heart Failure with Preserved Ejection Fraction - HFPEF)
Just because LV function is normal, doesn’t mean it isn’t heart failure but only
consider if HF-PEF if BNP elevated. Due to reduced ventricular filling in diastole eg
References: NICE Chronic Heart Failure August 2010, NICE Cardiac Resynchronisation Therapy 2007; Map of Medicine. stiff ventricle or loss of atrial kick in AF. Typical picture is elderly hypertensive with Timing recommendations may vary according to local circumstances but should be an aspiration. fluid retention. Difficult to diagnose, echocardiogram may show ‘diastolic markers’ Further references available on request. This isn’t perfect, there are bits missing; there is only so much you can fit on or left ventricular hypertrophy but absence of these doesn’t necessarily rule it out. one sheet of A4. Comments please andrew.gallagher@gp-P81056.nhs.uk ; Dr.Seed@bfwhospitals.nhs. uk Oct 2010 Drug Treatment for Heart Failure Due to LVSD
ACE inhibitors

Start low and titrate upwards at intervals of every 2 weeks Measure urea, creatinine and electrolytes with each dosage increment Up-titration to be limited by symptomatic low blood pressure and renal function only if creatinine increases by > 50% or to > 200mmol/l. Beta-blockers

‘Start low and go slow’, dosage increments every 2-4 weeks Monitor P, BP and clinical status after each titration Warn patients that they may experience transient mild symptomatic deterioration but should improve with continued treatment Switch stable patients on βB for co-morbidty to a βB licensed for heart failure, 50mg of atenolol is approx equivalent to 10mg bisoprolol Up-titration to be limited by symptomatic low blood pressure or by bradycardia (if symptomatic or heart rate < 50) Most patients with COPD without reversibility will tolerate Effective and safe in elderly, PVD, DM, ED. Aldosterone antagonists

Option if symptomatic in spite of optimised treatment esp in NYHA III-IV Monitor renal profile at 1w, 1m and every 6m if on ACEI/ARB Consider as alternative to ACEI if intolerant Consider addition to ACEI if unable to take βB, care with renal function! On specialist advice in addition to ACEI and βB if persistent symptoms ACEI+βB+ either ARB or aldosterone antagonist, NOT both Digoxin

Usual dosage 125mcg; no need to monitor levels Aspirin

Target doses Ramipril
Candesartan 32 mg daily Nebivolol 10mg daily Monitoring
Monitor all patients. Include:

Clinical assessment of functional capacity, fluid status, cardiac rhythm (min at least pulse), cognitive status and nutritional status Re-iterate lifestyle advice especially diet, exercise, smoking Lifestyle advice
Drugs to avoid
CRT (resynchronisation pacing +/- ICD)
Review of drug treatment include need to change and monitoring for * Broad QRS and low EF = HIGH risk*
Exercise: encourage regular exercise within
Minimum of urea, electrolytes, creatinine, eGFR Monitor at short intervals (days to 2 weeks) if clinical condition or drug Diet: encourage salt free diet
treatment has changed, otherwise monitor at least 6 monthly. Smoking: strongly advise patients not to smoke
Alcohol: advise patients with alcohol related
Diastolic heart failure/HF-PEF
Palliative Care phase if….
are referred to a HF specialist for treatment optimisation and consideration of device Sexual activity: be prepared to discuss
Currently no trial evidence for ACEIs or Vaccination: offer annual vaccination against
beta blockers but look for an excuse to use NB. CRT without ICD is relatively cheap and has significant short term symptom benefit as well as mortality benefit , often appropriate Driving: consult DVLA guideline re HGV/PSV
in the elderly. …….please check QRS duration.

Source: http://clahrc-gm.nihr.ac.uk/cms/wp-content/uploads/HF-fact-sheet-FINAL.pdf

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