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Heart Failure

Heart Failure. Hazel Phillips Cardiac Support Nurse Bedford Hospital NHS Trust. Heart Failure. “ Complex clinical syndrome that impairs the ability of the heart to respond to physiological demands for an increased output” ( Sign 2007)

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Heart Failure

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  1. Heart Failure Hazel Phillips Cardiac Support Nurse Bedford Hospital NHS Trust

  2. Heart Failure • “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)

  3. Coronary Heart Disease (MI ) Hypertension Valvular heart disease (Aortic and Mitral valve) Cardiac arrhythmias (heart block atrial fibrillation Cardiomyopathy (dilated, hypertrophic alcoholic,& idiophatic Causes of Heart Failure

  4. Shortness of breath Fatigue Proximal Nocturnal Dyspnoea Increase in weight Peripheral oedema Anorexia Symptoms of Heart Failure • Orthopnoea • Nocturnal cough

  5. Diagnosis • 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

  6. Heart Failure Clinic • 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

  7. Echocardiogram • 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

  8. LV Ejection Fraction LV ejection fraction Qualitative assessment >75% Hyper-dynamic 55-75% Normal 40-54% Mildly 30-39% Moderate <30% Severe

  9. 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% . Class IV Pt have symptoms at rest and any activity results in discomfort 15% - 20% worse prognosis than some cancers

  10. 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

  11. Diuretics • Metolazone • Used for intractable oedema • Use with close monitoring of renal function • Can cause hyponatraemia • Profound diuresis when used with loop diuretics

  12. Beta-blockers • 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 3.12mg-25mg BD, Bisoprolol 1.25mg-10mg OD, or Nebivolol 1.25mg-10mg OD

  13. Beta-Blockers • May worsen HF symptoms • Monitor BP & pulse rate • Side effects hypotension, bradycardia, cold extremities (causing paraesthesia), sleep disturbances (including nightmares), and sexual dysfunction

  14. Angiotensin-Converting Enzyme (ACE)inhibitor • 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

  15. ACE Inhibitors • 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

  16. Aldosterone Antagonist • 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

  17. Aldosterone Antagonist • Side effect: gastro-intestinal disturbances impotence, gynaecomastia, lethargy, headache etc

  18. Digoxin • 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.

  19. Contraindicated Medication • NSAID • Calcium Channel Blocker(except amlodipine & diltiazem) • Metformin • Glitazones • Corticosteriods • Tricylic antidepressants

  20. Non-Pharmacological Advice • 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

  21. Cardiac Cachexia • 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

  22. Other treatment options • Dual chamber pacemakers + ICD • Revascularisation (CABG PCI) • Transplantation • Left ventricular assist devices (LVAD) • Palliative care

  23. Further Information • 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

  24. Further information • Scottish Intercollegiate Guidelines Network (Sign) 2007 Management of Chronic Heart Failure

  25. Any Questions

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