How to Prolong

Life in Heart
Failure
Katherine Chappelle

SUNDERLAND HBP MEDICINE

Plan
Aetiology
Diagnosis
Classification
Treatments

Improving symptoms

Improving mortality

Aetiology of heart failure

Cardiac disease

1.

2.

Myocardial disease
Valvular disease
Arrhythmias

Systemic disease

Diagnosis of heart failure

Detailed

clinical history and exam, plus:

Serum
natriuretic
peptides

and/or

Transthoracic
doppler
echocardiograph
y

Classification of heart failure

1.

Systolic (heart failure

due to left ventricular
systolic dysfunction)

2.

Diastolic (heart failure

with preserved ejection
fraction)

Treatments in heart failure

Improving

symptoms

Improving

mortality

Managing

comorbidities

Treatments in heart failure

Improving symptoms

Loop diuretics

Morphine

Digoxin
Nitrates
Oxygen
Inotropes

Improving mortality

ACE inhibitors

Beta-blockers

Aldosterone antagonists

Angiotensin receptor blocker

Hydralazine + nitrates

Treatments which improve

symptoms
Loop

diuretics

Morphine
Digoxin
Nitrates
Oxygen
Inotropes

Treatments which improve

mortality
ACE

inhibitors

Beta-blockers
Aldosterone

antagonists (K+ sparing diuretics)

Angiotensin

receptor blocker

Hydralazine

+ nitrates

Treatments which improve mortality

NICE Guidelines
ACE

inhibitors

Beta-blockers

1st line

Aldosterone

antagonists

Angiotensin

receptor blockers 2nd line

Hydralazine

+ nitrates

Treatments which improve mortality

ACE inhibitors (1)

ACE

inhibitors affect left ventricular

remodeling

Not

only improvement in mortality

Treatments which improve mortality

ACE inhibitors (2)

Situations

where ACEI cannot be used

CONSENSUS,

SOLVD

Treatments which improve mortality

Beta-blockers (1)
Anti-ischaemic

events, improve ejection

fraction

Hospital

Only

admissions

specific beta blockers

Treatments which improve mortality

Beta-blockers (2)
Cautions

CIBIS,

with beta-blockers

COPERNICUS, MERIT-HF

Treatments which improve mortality

Aldosterone antagonists (1)

Eplerenone,

Reduced

spironolactone

mortality, hospital admissions

Treatments which improve mortality

Aldosterone antagonists (2)

Side

effects

RALES,

EMPHASIS-HF, EPHESUS

Treatments which improve mortality

Angiotensin receptor blockers

No

clear reduction in mortality

Useful

alternative to ACE inhibitors

CHARM,

Val-HeFT

Treatments which improve mortality

Hydralazine + nitrates
Hydralazine

combined with isosorbide

dinitrate

Ethnicity

dependent response

V-HeFT-I,

A-HeFT

Summary (1)
Treatments

that improve mortality

apply to systolic heart failure only

1st

line treatments are ACE inhibitors +

beta-blockers

2nd

line treatments are aldosterone

antagonists, ARBs + hydralazine with
nitrates

Summary (2)
Strongest

evidence for ACE inhibitors,

beta-blockers and aldosterone
antagonists

Not

only improvement in mortality,

significant improvement in hospital
admissions, symptoms and exercise
capacity