Lesson topic №27 ХСН (Сhronic heart failure )
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Digoxin
In patients with symptomatic HF and AF, digoxin may be useful for the treatment of patients with HFrEF and AF with rapid ventricular rate, when other therapeutic options cannot be pursued.
Digoxin may be considered in patients with HFrEF in SR to reduce the risk of hospitalization.
Management of heart failure with reduced ejection fraction
Management of heart failure with reduced ejection fraction
Implantable cardioverterdefibrillator
An ICD is recommended to reduce the risk of sudden death and all-cause mortality in patients who have recovered from ventricular arrhythmia causing haemodynamic instability, and who are expected to survive for > 1 year with good functional status, in the absence of reversible cause or unless the ventricular arrhythmia has occurred < 48 h after MI.
An ICD is recommended to reduce the risk of sudden death and all-cause mortality in patients with symptomatic HF (NYHA class II-III) of an ischaemic aetiology (unless they had a MI in the prior 40 days – see below), and an LVEF 35% despite 3 months of optimal medical therapy, provided they are expected to survive substantially longer than 1 year with good functional status.
An ICD should be considered to reduce the risk of sudden death and allcause mortality in patients with symptomatic HF (NYHA class II-III) of nonischaemic aetiology, and an LVEF 35% despite 3 months of optimal medical therapy, provided they are expected to survive substantially longer than 1 year with good functional status.
Cardiac resynchronization therapy
CRT is recommended for symptomatic patients with HF in SR with a QRS duration ≥ 150 ms and left bundle branch block QRS morphology and with LVEF.
CRT rather than right ventricular pacing is recommended for patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high degree AV block in order to reduce morbidity. This includes patients with AF.
CRT should be considered for symptomatic patients with HF in SR with a QRS duration ≥ 150 ms and non-LBBB QRS morphology and with LVEF ≤ 35% despite OMT in order to improve symptoms and reduce morbidity and mortality.
CRT should be considered for symptomatic patients with HF in SR with a QRS duration of 130-149 ms and LBBB QRS morphology and with LVEF ≤ 35% despite OMT in order to improve symptoms and reduce morbidity and mortality.
Patient education
Topic |
Goal for the patient |
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Activity and exercise |
To undertake regular exercise and be |
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physically active. |
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The choice of exercise that recognizes |
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physical and functional limitations, |
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such as frailty, comorbidities. |
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Fluids |
To avoid large volumes of fluid intake. |
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A fluid restriction of 1.5–2 L/day may |
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be considered in patients with severe |
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HF/hyponatraemia to relieve symptoms |
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and congestion. |
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Healthy diet |
To be able to prevent malnutrition and |
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know how to eat healthily, avoiding |
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excessive salt intake (>5 g/day) and |
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maintaining a healthy body weight. |
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Patient education
Topic |
Goal for the patient |
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Alcohol |
To be able to abstain from or avoid |
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excessive alcohol intake (2 units per |
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day in men or 1 unit per day in |
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women), especially for alcohol-induced |
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cardiomyopathy. |
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Immunization |
To be aware of the need for |
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immunization for influenza and |
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pneumococcal disease. |
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Smoking |
Stop smoking (including e-cigarettes). |
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Symptom monitoring and symptom |
In the case of increasing dyspnoea or |
self-management |
oedema or a sudden unexpected weight |
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gain of >2 kg in 3 days, patients may |
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increase their diuretic dose and/or |
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alert their healthcare team. |
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Follow-up of chronic heart failure
Patients with HF, even if symptoms are well controlled and stable, require follow-up to ensure continued optimization of therapy, to detect asymptomatic progression of HF or its comorbidities and to discuss any new advances in care.
The follow-up at intervals no longer than 6 months to check symptoms, heart rate and rhythm, BP, full blood count, electrolytes, and renal function.
For patients recently discharged from hospital, or in those undergoing uptitration of medication, follow-up intervals should be more frequent.
Telemonitoring may be considered for patients with HF in order to reduce the risk of recurrent CV and HF hospitalizations and CV death.
Thank you for your attention.