Heart failure management

1st line: sit patient up, high flow O2, IV furosemide (40-120mg, lower dose in diuretic-naive patients), do not offer morphine, IV nitrates increasingly used (not NICE recommended)

2nd line (special circumstances): NIV, mechanical ventilation (tired patient unable to maintain oxygenation), inotropes/vasopressors (cardiogenic shock), ultrafiltration, mechanical assist devices, surgery for valvular disease

After stabilisation: beta blockers, ACEis

Resistant to treatment: salt and fluid restriction, bed rest, DVT prophylaxis, increase diuretic dose or use IV route, combine loop + thiazide diuretic (watch U+Es), consider dobutamine infusion if very resistant (also for cardiogenic shock), high dose bendroflumethiazide/metolazone may be needed

Symptom relief (decrease SOB and fluid retention):

• diuretics
• ACEi
• digoxin if still symptomatic on optimal dose ACEi/diuretics

Survival benefits:

• ACEi
• beta blockers
• spironolactone (post-MI)

Example: furosemide

Used to control oedema and SOB

Effect on survival untested

Monitor U+Es and weight

Common adverse effects: urinary frequency, hypokalaemia, volume depletion, renal impairment, gout, urinary retention

ACEis:

• Titrate to effective dose
• Improves survival
• Common adverse effects: cough, renal impairment, hypotension, hyperkalaemia, angioedema
• Monitor U+Es and BP
• Consider switching to ARB if ACEi-specific adverse effects.

ARBs:

• Common adverse effects: renal impairment, hypotension, hyperkalaemia

Start with low dose and increase cautiously

Intensify ACEis and diuretics if symptoms develop

Improves survival

Common adverse effects: bradyarrhythmias, cold extremities, bronchospasm, fatigue, worsening HF, intermittent claudication

Improves survival

Common adverse effects: hyperkalaemia, gynaecomastia

Monitor U+Es (especially potassium levels)

Only in patients with persistent symptoms or AF

Improves symptoms but not survival

Definite role if still symptomatic despite optimal ACEi dosing

Common adverse effects: digoxin toxicity (N+V, abdo pain, confusion, bradyarrhythmias, tachyarrhythmias)

• hydralazine + nitrates
• cardiac rehabilitation
• cardiac resynchronisation
• correction of valvular disease
• dysrhythmia management
• transplantation