IM1.{21-24,27} | Heart Failure Management and Procedures — Summary & Reflection

KEY TAKEAWAYS

Heart failure management is stratified by EF category and clinical state:

Non-pharmacological (all HF): Sodium <2 g/day, daily weight monitoring, moderate aerobic exercise (stable patients), smoking cessation, alcohol restriction, vaccinations.

HFrEF pharmacological GDMT (four pillars — all unless contraindicated):
1. ACEi (ramipril/enalapril) or ARNI (sacubitril/valsartan, preferred if tolerated)
2. Beta-blocker: carvedilol, bisoprolol, or metoprolol succinate only
3. MRA: spironolactone 25–50 mg (monitor K⁺ and creatinine; contraindicated eGFR <30 or K⁺ >5.0)
4. SGLT2 inhibitor: empagliflozin or dapagliflozin 10 mg
5. Diuretic (furosemide) for symptom relief — no mortality benefit
6. Digoxin: adjunctive; reduces hospitalisation not mortality; narrow therapeutic window (0.5–0.9 ng/mL)

Device therapy (HFrEF LVEF ≤35% after ≥3 months GDMT):
- LBBB + QRS ≥150 ms → CRT (or CRT-D)
- NYHA II–III → ICD (primary prevention SCD)

Surgical/interventional:
- Ischaemic CM + hibernating myocardium → coronary revascularisation (CABG/PCI)
- Valvular disease → PMBV (MS, Wilkins ≤8), repair/replacement (AS, MR, AR) — correct before irreversible LV dysfunction
- End-stage refractory → LVAD → cardiac transplantation

Acute decompensated HF: Wet-Warm → IV furosemide + vasodilators (GTN); Wet-Cold → low-dose inotrope + diuretics; always treat precipitant.

IM injection: Ventrogluteal site preferred; 90-degree needle insertion; aspirate before injecting; do not massage site; dispose sharps immediately.

INR targets: Mechanical aortic valve INR 2–3; mechanical mitral valve INR 2.5–3.5.

REFLECT

Heart failure management is a paradigmatic example of how understanding the pathophysiology transforms prescribing from a memorised list into a logical, personalised therapeutic strategy. Each of the four GDMT pillars blocks a distinct maladaptive neurohormonal pathway — and the clinical trials that established their benefit were designed precisely because the investigators understood those pathways. Reflect on Rajan from the opening hook: his LVEF improved from 34% to 42% over three months on GDMT. This phenomenon — reverse cardiac remodelling — is now an established expectation with early initiation of all four pillars. As a future physician, how will you communicate the importance of medication adherence to a patient who feels well and questions the need for 'so many tablets'? How will you remember to uptitrate to target doses at each clinic visit rather than leaving patients on the starting dose indefinitely? The management framework you have learned in this module is not just examination knowledge — it is the roadmap for preventing thousands of preventable hospitalisations and deaths.