Diagnosis

There are a number of factors which can lower NT-proBNP in a patient with possible heart failure. These include: 

• obesity

• African or African-Caribbean descent

• treatment with diuretics, ACE inhibitors, angiotensin II receptor blockers, beta-blockers or mineralocorticoid antagonists such as spironolactone.

All patients presenting with symptoms and signs suggestive of heart failure, should have serum natriuretic peptides measured and proceed to echocardiography depending on the result. Those with very high levels of serum natriuretic peptides should be referred for specialist assessment and echocardiography within two weeks as very high levels carry a poor prognosis.

Resource:

NICE. Chronic Heart Failure in Adults: diagnosis and management. NG106. 2018.

Management

Patients with a clinical diagnosis of heart failure should ideally have echocardiographic examination carried out to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle and detect intracardiac shunts.

All patients with heart failure due to left ventricular systolic dysfunction should be considered for treatment with an ACE inhibitor, which effectively treats symptoms and improves mortality.

If the patient cannot tolerate an ACE, then an angiotensin 2 receptor antagonist can be substituted - with a relatively high dose possibly required.

The beta-blockers bisoprolol and carvedilol are of value in any grade of stable heart failure and left ventricular systolic dysfunction. They would not be advised in this man with asthma.  Particular care is required in prescribing beta-blockers as they should be started in low dose as symptoms can initially deteriorate.

The aldosterone antagonist spironolactone can be added to an ACE and a beta-blocker, with a reduction in symptoms and mortality.

Digoxin improves the symptoms of heart failure and exercise tolerance but does not reduce mortality.

A 74-year-old man has heart failure with a preserved ejection fraction. He is breathless on exertion.

According to current guidance, which is the SINGLE MOST appropriate medication for symptomatic relief?

Drugs have not been shown to be effective for heart failure with preserved ejection fraction, although the NICE guidelines states that a low to medium dose of furosemide (<80 mg) can be used to help symptoms.

A 72-year-old has heart failure due to systolic dysfunction. He takes furosemide 40 mg daily and ramipril 5 mg daily. When considering the next step in treatment which of the five options below represents the SINGLE MOST appropriate addition to his treatment?

1. Spironolactone

2. Nitrate

3. Beta blocker

4. Thiazide diuretic

5. Digoxin

Many large clinical trials have shown both increase in life expectancy and reduction in hospitalisation in patients with heart failure due to systolic dysfunction. Beta blockers (usually bisoprolol or carvedilol) should be initiated after angiotensin-converting enzyme (ACE) inhibitors. Whilst digoxin probably has a place in heart failure (especially if there is associated atrial fibrillation) it should not be used in place of a beta blocker unless there is a contraindication to the latter. The evidence for spironolactone is in severe heart failure (after beta blockers) whilst thiazides (usually as metolazone) are used for symptomatic treatment in severe heart failure since they act synergistically with loop diuretics. Nitrates should be given under specialist supervision in this context.

Amlodipine should be considered for the treatment of co-morbid hypertension and/or angina in patients with heart failure, but verapamil, diltiazem or short-acting dihydropyridine agents should be avoided.

HOCM

Cardiomyopathy is the most common inherited cardiovascular disease, affecting one in 500 of the general population. The vast majority of those affected are asymptomatic and unaware of their condition. It is a common cause of sudden cardiac death. The investigation of families of those diagnosed with cardiomyopathy is complex and requires a number of investigations, as well as genetic counselling and testing. Referral to specialist services is essential. Antidysrhythmics can be used to prevent complications, but they should be initiated by a specialist.

Clinicians should be careful when prescribing new medication for people with left ventricular outflow tract obstruction. Nitrites act as a peripheral vasodilator decreasing afterload which can cause significant hypotension and should be avoided in these circumstances.

Resource

Moncrieff G, Williams H, Bond R. Cardiomyopathy. InnovAiT 2020; 13(5): 297–305.

References

• Acute heart failure: diagnosis and management: Acute heart failure: diagnosis and management (NICE, 2014)

• Chronic heart failure: Heart failure - chronic (CKS)​​, Heart failure (NHS Choices)

• NICE. Chronic Heart Failure in Adults: diagnosis and management. NG106. 2018.

• SIGN. Management of chronic heart failure.

• Cardiomyopathy: Cardiomyopathy (NHS Choices), Dilated cardiomyopathy (NHS Choices), Hypertrophic cardiomyopathy (NHS Choices), Restrictive cardiomyopathy (NHS Choices)

• Echocardiogram: Echocardiogram (NHS Choices)