Makindo Medical Notes.com

Related Subjects: |Managing Chronic Heart Failure |Heart Failure and Pulmonary Oedema |Loop Diuretics |Entresto Sacubitril with Valsartan |Ivabradine |Furosemide |Angiotensin Converting Enzyme Inhibitors |Cardiac Resynchronisation Therapy (CRT) Pacemaker

Interpreting BNP and NT-proBNP Levels

• BNP:
  • BNP levels below 100 pg/mL are considered normal.
  • Levels between 100-300 pg/mL suggest possible heart failure.
  • Levels above 300 pg/mL strongly suggest heart failure, with higher values indicating more severe dysfunction.
• NT-proBNP:
  • Under 50 years old: NT-proBNP < 300 pg/mL is normal.
  • 50-75 years old: NT-proBNP < 900 pg/mL is typically normal.
  • Over 75 years old: NT-proBNP < 1800 pg/mL is considered normal.

Interpreting Elevated Levels

• Mildly Elevated BNP/NT-proBNP: May suggest early or less severe heart failure or other causes include ACS, pulmonary hypertension, CKD, COPD, and advanced age.
• Moderately to Severely Elevated BNP/NT-proBNP: Usually indicates heart failure, with higher levels correlating with worse prognosis and greater severity.
• NYHA Classification:
  • Class I: BNP < 300 pg/mL (NT-proBNP < 300 pg/mL)
  • Class II: BNP 300-600 pg/mL (NT-proBNP 300-1000 pg/mL)
  • Class III: BNP 600-900 pg/mL (NT-proBNP 1000-1800 pg/mL)
  • Class IV: BNP > 900 pg/mL (NT-proBNP > 1800 pg/mL)

Clinical Considerations

• Heart Failure Diagnosis: Elevated BNP/NT-proBNP in a patient with symptoms like shortness of breath, fatigue, and fluid retention strongly supports heart failure diagnosis. However, consider other causes of elevation.
• Monitoring Heart Failure: Serial measurements can monitor the effectiveness of treatment; decreasing levels often indicate clinical improvement.
• Prognostic Value: Higher levels are associated with a worse prognosis in heart failure, predicting outcomes like hospitalization and mortality.

Factors Affecting BNP/NT-proBNP Levels

• Increased Levels: Can occur due to renal impairment, acute coronary syndrome, advanced age, or pulmonary hypertension.
• Decreased Levels: Obesity can lead to lower levels, potentially masking the severity of heart failure.

Right And Left Heart Failure

Initial Assessment

• Clinical: Assess dyspnoea, fatigue, and fluid retention.
• Identify risk factors: hypertension, coronary artery disease, diabetes, prior MI.
• Echocardiography: to determine ejection fraction (EF) and differentiate between
  • HFpEF (EF ≥50%)
  • HFrEF (EF <40%)
  • HFmrEF (EF 41-49%) mid-range.
• Bloods: BNP or NT-proBNP levels, U&E, TFTs to guide diagnosis and management.
• Assess for Comorbidities: Manage comorbidities such as AF, CKD, frailty, obesity.

Management of HFrEF (EF <40%)

• First-Line Pharmacotherapy:
  • ACE Inhibitors/ARBs: both reduce morbidity and mortality. Titrate to target dose.
  • Beta-Blockers: Choice of bisoprolol, carvedilol, metoprolol succinate after stabilizing with ACE inhibitors/ARBs. Titrate to target dose.
  • Mineralocorticoid Receptor Antagonists (MRAs): Add spironolactone or eplerenone in symptomatic patients with NYHA class II-IV.
• Additional Therapies:
  • ARNI (Sacubitril/Valsartan): replace ACEi/ARB with an ARNI for further mortality reduction.
  • SGLT2 Inhibitors: Add Dapagliflozin/Empagliflozin. Improves outcomes in HFrEF patients, regardless of diabetes status.
  • Ivabradine: symptomatic HF despite optimal beta-blocker therapy and a heart rate ≥70 bpm.
• Device Therapy:
  • Implantable Cardioverter-Defibrillator (ICD): EF ≤35% after optimal medical therapy for primary prevention of sudden cardiac death.
  • Cardiac Resynchronization Therapy (CRT): Consider in patients with symptomatic heart failure, EF ≤35%, and LBBB with QRS duration ≥150 ms.
• Monitoring and Follow-Up: Regularly monitor symptoms, renal function, electrolytes, and adjust medications accordingly. Schedule follow-up echocardiography to reassess EF and heart function.

Management of HFpEF (EF ≥50%)

• Control Hypertension: Lower blood pressure with ACEi, ARBs, or beta-blockers.
• Diuretics: loop diuretics e.g. furosemide to manage fluid retention symptoms.
• Manage Comorbidities:
  • Atrial Fibrillation: Rate control and rhythm management are critical.
  • Coronary Artery Disease: antiplatelet therapy and revascularization as indicated.
  • Obesity: weight loss and exercise to improve symptoms and overall prognosis.
• Exercise Training: cardiac rehabilitation program to improve exercise capacity and quality of life.
• Emerging Therapies: Consider SGLT2 inhibitors (e.g. Empagliflozin) for reducing hospitalization in HFpEF patients.
• Regular Monitoring: worsening symptoms, manage exacerbations promptly, and reassess comorbidities periodically.

Lifestyle and Supportive Measures

• Dietary Recommendations: Low-sodium diet to reduce fluid retention.
• Fluid Management: monitor weight and fluid restriction if severe fluid retention.
• Smoking Cessation: Key for long term survival.
• Patient Education: Educate patients and caregivers. Compliance with medication adherence.
• Psychosocial Support: Manage depression and anxiety related to chronic heart failure.