Heart Failure

Hazel PhillipsCardiac 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)

“ 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

Cardiomyopathy (dilated, hypertrophic alcoholic,& idiophatic

Symptoms of Heart Failure Shortness of

breath Fatigue Proximal

Nocturnal Dyspnoea

Increase in weight Peripheral

oedema Anorexia

Orthopnoea

Nocturnal cough

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

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

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

LV Ejection Fraction

LV ejection fraction Qualitative assessment>75% Hyper-dynamic55-75% Normal40-54% Mildly 30-39% Moderate<30% 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%. 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

Diuretics Metolazone Used for intractable oedema Use with close monitoring of renal

function Can cause hyponatraemia Profound diuresis when used with

loop diuretics

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

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

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

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

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

Aldosterone Antagonist Side effect: gastro-intestinal

disturbances impotence, gynaecomastia, lethargy, headache etc

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.

Contraindicated Medication NSAID Calcium Channel Blocker(except

amlodipine & diltiazem) Metformin Glitazones Corticosteriods Tricylic antidepressants

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

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

Other treatment options Dual chamber pacemakers + ICD Revascularisation (CABG PCI) Transplantation Left ventricular assist devices

(LVAD) Palliative care

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

Further information Scottish Intercollegiate Guidelines

Network (Sign) 2007Management of Chronic Heart Failure

Any Questions