Live Discussion with Dr. Rajpal Singh
Questions doctors asked during the Jivo Masterclass on Detection and Management of Heart Failure: What's to be Done and When to Refer, taught by Dr. Rajpal Singh, MRCPI, CCST (UK), Director and Senior Interventional Cardiologist, Lead for TAVI and Advanced Device Therapy, Fortis Hospitals, Bannerghatta Road, Bangalore, India, on . Written by Jivo Healthcare from the transcript of the session, drafted with AI assistance and edited by the Jivo team.
Why can beta blockers initially worsen symptoms before improving survival in heart failure?
Asked by Dr. Ivan Ipavu, Uganda
A failing heart compensates by increasing its heart rate. A beta blocker slows the heart rate, and the heart takes time to adjust; it is also an antihypertensive drug, so it lowers blood pressure. With both heart rate and blood pressure reduced, cardiac output falls and the patient feels rough at first. Within a couple of weeks this settles and patients tolerate the drug better. In quality-of-life assessments in the trials, many patients reported that the first few weeks were very bad, and some stopped the drug. So always counsel patients about this initial dip when you start a beta blocker: they may feel rough for the first two weeks, but they should persevere because it will get better. A heart failure clinic or heart failure nurse provides very good liaison for this.
Answered by Dr. Rajpal Singh
Can BNP be normal in acute heart failure, and how does BNP help distinguish cardiac from respiratory dyspnoea?
Asked by Dr. Ivan Ipavu, Uganda
BNP is released in response to stretch or stress on the myocardium. A normal BNP means there is no significant myocardial stress, which tells you the cause of the patient's symptoms is very likely non-cardiac, although BNP can be lower than expected in obese patients and very early in flash pulmonary oedema. It is a very good tool, whether you use NT-proBNP or BNP, each with its own reference values. If a patient has a normal BNP and a normal ECG, heart failure is very unlikely to be the cause of the acute deterioration. The cause may be respiratory, and that is worth looking at.
Answered by Dr. Rajpal Singh
How would you manage severe ascites and oedema with normal blood pressure in a patient with heart failure and liver cirrhosis?
Asked by Dr. Waiswa Kaziba, Uganda
This is the picture of congestive cardiac failure, a combination of right and left heart failure, and the patient should usually be hospitalised. If that is not possible, make sure the patient is on appropriate diuretic therapy and is decongested, monitoring creatinine and liver function tests regularly. Symptomatically, treat them like anyone else: if renal function is good and there is no hepatorenal syndrome, the conventional drugs can be used, perhaps with a higher dose of spironolactone in this case. There is growing evidence for acetazolamide (Diamox) in NYHA class 3 and 4 patients who need hospitalisation: given orally or intravenously in addition to loop diuretics, it improves diuresis and resolves heart failure much more quickly. We now add it to conventional drugs in many patients presenting in congestive cardiac failure or acute LVF, and it is of benefit as long as renal function is not too poor. If blood pressure is low, I add low-dose (renal-dose) dopamine to diuretics, particularly in right heart failure with valve dysfunction; in my experience it makes a real difference, although no large randomised trial supports it, and in hospital inotropic or vasopressor support may be needed.
Answered by Dr. Rajpal Singh
What is the risk of recurrent UTI with SGLT2 inhibitors?
Asked by Dr. William Gadaga, Zimbabwe
SGLT2 inhibitors work by producing glycosuria, which is a nidus mainly for genital fungal infections, balanitis in men and vulvovaginal thrush in women; the increase in urinary tract infection is small. Genital infections occur in around 5 to 6%. When we start these drugs we counsel patients on two things: personal hygiene is paramount, and if they develop symptoms (balanitis in men, burning micturition in women) they should be seen, with a urine culture and sensitivity if a urinary infection is suspected. If infection is confirmed, we take the SGLT2 inhibitor off and treat the infection.
Answered by Dr. Rajpal Singh
What is the role of dobutamine in acute heart failure?
Asked by Dr. William Gadaga, Zimbabwe
There is no beneficial role as such. In a patient with low cardiac output and poor perfusion you can start it to improve output and tide over the acute stage, but in a profoundly hypotensive patient noradrenaline is preferred, because dobutamine can lower blood pressure further. Giving dobutamine in the long run is like flogging a dead horse: you increase output transiently, but without benefit. We no longer use it routinely.
Answered by Dr. Rajpal Singh
When should the Sgarbossa criteria not be used?
Asked by Moderator
The Sgarbossa criteria are not related to heart failure. They apply to a patient with chest pain and a left bundle branch block, where it is difficult to tell whether the ECG changes are old or new: ST elevation of 1 mm or more in the same direction as the QRS, ST depression of 1 mm or more in V1 to V3, or ST elevation disproportionately large in the opposite direction to the QRS indicates an acute myocardial infarction despite the left bundle branch block. They do not apply to heart failure.
Answered by Dr. Rajpal Singh