46. Heart failure

Question 1

Chez les patients qui reçoivent un nouveau diagnostic d’insuffisance cardiaque, déterminez les___ puisque le traitement ne sera pas le même.

Answer 1

les causes sous-jacentes

Question 2

Chez un patient qui manifeste des symptômes compatibles avec l’insuffisance cardiaque avec fraction d’éjection normale, n’excluez pas ce diagnostic.

Question 3

Chez un patient atteint d’insuffisance cardiaque, évaluez périodiquement la perte fonctionnelle à l’aide d’outils validés. Nommez des examples d’outils.

Answer 3

classe de la NYHA, activités de la vie quotidienne

Question 4

Describe : NYHA classification for severity of symptoms

Answer 4

• I = No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
• II = Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
• III = Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
• IV = Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

Question 5

Dans le but d’orienter le traitement d’un patient qui présente une exacerbation de l’insuffisance cardiaque,
* a) Identifiez les déclencheurs possibles (p. ex. infection, arythmie, non-respect du traitement, alimentation, ischémie)
* b) Envisagez les comorbidités (p. ex. insuffisance rénale)

Question 6

Nommez les médicaments qui réduisent la mortalité et traitent les symptômes d’insuffisance cardiaque congestive

Answer 6

• diurétiques
• bêtabloquants
• iECA
• digoxine

Question 7

Chez les patients atteints d’insuffisance cardiaque, assurez l’éducation du patient et l’autosurveillance, telle que quoi ?

Answer 7

• surveiller systématiquement son poids
• bien s’alimenter
• observer le tx médicamenteux
• arrêter de fumer
• et faire de l’exercice
  afin de réduire les exacerbations au minimum

Question 8

Chez un patient atteint d’insuffisance cardiaque, reconnaissez la non-réponse au traitement comme un indicateur de quoi ?

Answer 8

d’un pronostic qui s’assombrit

Question 9

Chez un patient atteint d’insuffisance cardiaque, dont l’évolution clinique se détériore progressivement, quoi faire ?

Answer 9

• Donnez au patient et à sa famille un pronostic réaliste.
• Introduisez les principes de soins palliatifs lorsque cela est pertinent pour le patient

Question 10

Describe diagnosis : Heart failure

Answer 10

B-type Natiuretic Peptide (BNP)
* LOW : Rule out, look for other cuases
* HIGH : Confirms dx
* Not for monitoring / trending

If unclear, obtein echocardiogram (most useful test, but not initial investigation, no longuer just CHF have to determine the TYPE)

Question 11

Name phenotypes of heart failure

Answer 11

• Wet
• de Novo
• Worsening
• Cardiorenal
• Frail

Question 12

Name TYPES of heart failure

Answer 12

• Preserved EF >= 50% (HFPEF, formerly diastolic)
• Mid-rang HFmEF
• Reduced <= 40% HFrEF (formerly systolic)

Question 13

Describe sx : Heart failure (7)

Answer 13

• Breathlessness
• Fatigue
• Weight gain
• Peripheral edema
• Orthopnea
• Paroxysmal nocturnal dyspnea (LR
• Confusion in elderly

Question 14

Name risks : Heart failure (9)

Answer 14

• Hypertension
• Ischemic heart disease (LR 3.1)
• Valvular heart disease
• Diabetes mellitus
• Alcohol, substance use
• Chemotherapy/radiation therapy
• Family history cardiomyopathy
• Smoking
• Hyperlipidemia

Question 15

Describe physical exam : Heart failure (8)

Answer 15

• Bilateral lung crackles
• Elevated JVP
• Positive abdominal jugular reflex
• Peripheral edema
• Laterally isplaced apex
• S3 , S4 or any heart murmur
• Low BP or HR>100
• Note: In heart failure with narrow pulse pressure, think high output heart failure (eg. anemia, thyrotoxicosis)

Question 16

Describe : HFmrEF (mid-range) (3)

Answer 16

• LVEF 40-49%
• Elevated natriuretic peptide
• Relevant structural heart disease (LVH +/- LAE) or diastolic dysfunction

Question 17

Describe : HFpEF (preserved) (4)

Answer 17

• 💡 A preserved ejection fraction on a routine echocardiogram does not rule out the clinical syndrome of heart failure
• LVEF >50%
• Elevated natriuretic peptide
• Relevant structural heart disease (LVH +/- LAE) or diastolic dysfunction

Question 18

Name labs : Heart failure

Answer 18

• CBC
• Ferritin
• Glucose
• Electrolytes
• Creat/eGFR
• TSH
• UA
• LFTs
• Lipids & A1c (risk factor management)

Consider if diagnosis uncertain or if high suspicion
* Troponin → r/o ACS and prognosis
* NT-proBNP >125pg/mL → consider echocardiography. HF unlikely if < 300; highly likely if > 900 (1800 if age >75)
* BNP>50 pg/mL → consider echocardiography. HF unlikely if < 100; highly likely if >400

Question 19

Name investigations heart failure (besides labs) (4)

Answer 19

• ECG
• Lung ultrasound
• CXR
• Echocardiography

Question 20

What to look for in ECG for heart failure (5)

Answer 20

• Afib
• new T-wave change Q waves
• LVH
• LBBB
• HR>100

Question 21

What to look for in lung ultrasound for heart failure (2)

Answer 21

• B-profile bilaterally
• pleural effusion

Question 22

What to look for in CXR for heart failure (5)

Answer 22

• Cardiomegaly
• pulmonary venous redistribution
• pulmonary edema
• pleural effusion
• Kerley B lines

Question 23

What to look for in echocardiography for heart failure (6)

Answer 23

• Decreased LVEF
• Increased LV diameter/LVH
• Wall motion abnormalities, diastolic dysfunction
• Increased RV size, RV dysfunction
• Valve dysfunction
• Elevated pulmonary arterial pressures (PAP)

Question 24

Describe ACUTE management heart failure

Answer 24

💡 LMNOP (Lasix, Modify medications, Nitroglycerine, Oxygen, Position (upright) +/- Positive Pressure (BiPAP)

• Oxygen ≥ 90-92%
• NIPPV (BiPAP > CPAP) if SpO2 < 90% despite supportive O2
• Position upright
• Hypotension (cardiogenic shock)→ Pressor (eg. Norepinephrine) to maintain ** MAP 65-80**
• Hypertension (SCAPE)→ High-dose nitroglycerin IV
• If suspect total body hypovolemia vs hyperovlemia
• Consider consultations (e.g., cardiology, ICU) for advanced measures (e.g., intra-aortic balloon pumps, LVAD, ECMO, etc.)

Question 25

Describe ACUTE management of heart failure if HYPERTENSION

Answer 25

**High-dose nitroglycerin IV** * Nitroglycerine (NTG) SL 0.4mg x 3 q5 mins until IV nitroglycerine started (note SL nitro only 40% bioavailable) * Nitroglycerine 100mcg/min IV infusion, increase by 20mcg/min every 10 mins until sBP decreases * Then maintain until improvement in symptoms, then gradually reduce IV infusion until stop * Alternatively may give intermittent nitroglycerin bolus 1-2mg IV q3-5 minutes * Avoid in PDE5 inhibitors (e.g., sildenafil) or concomitant inferior STEMI (preload dependent)

Question 26

In heart failure, names signs that susject total body hypovolemia (2)

Answer 26

* no B-lines on lung ultrasound * hypoperfusion

Question 27

If suspect total body hypovolemia in heart failure, what to do ?

Answer 27

Consider careful fluid bolus challenge (250mL isotonic crystalloid)

Question 28

In heart failure, names signs that susject total body HYPERvolemia (4)

Answer 28

* B-lines on lung ultrasound * pedal edema * jugular vein distension * history of nonadherence to diuretics or missed hemodialysis

Question 29

True or False Many patients may be euvolemic and have a maldistribution of fluids into the lungs

Answer 29

True

Question 30

If suspect total body hypervolemia in heart failure, what to do ? (2)

Answer 30

* Furosemide (Lasix) 20-80mg IV bolus (once stable) * Monitor diuretic effect ~q6h while stabilizing

Question 31

How to give furosemide in heart failure (if hypervolemia) ? (3)

Answer 31

* Furosemide (Lasix) 20-80mg IV bolus (once stable) * If taking regular furosemide at home, can give home PO dose as IV * Consider the addition of acetazolamide 500mg IV daily to improve loop diuretic efficiency

Question 32

How to monitor diuretic effect in heart failure (if hypervolemia) ? (4)

Answer 32

* Monitor diuretic effect ~q6h while stabilizing * Monitor daily weights and urine output, goals: urine output 3-5 L; 0.5-1.5 kg weight loss * Increase/decrease diuretic by ~25-50% to meet above criteria * If not responsive, consider adding metolazone 1.25-5mg one to seven times per week

Question 33

Name Discharge Goals of heart failure (3)

Answer 33

* Improvement in clinical status (i.e., presenting symptoms & vital signs resolved and stable, return to “dry” weight, comorbidities under control) * Supportive investigations : Imaging evidence of resolution of congestion (CXR, ultrasound) * BNP or NT-proBNP : Consider discharge home if **> 30% ↓ from admission value** (along with clinical improvement)

Question 34

For ambulatory patients (i.e., outpatients), an increase in BNP/NT-proBNP of > ____ from baseline warrants more frequent follow-up +/- intensification of HF therapy

Answer 34

30%

Question 35

Describe Lifestyle Management in CHRONIC management

Answer 35

1.Treat risk factors - HTN, DM, smoking, obesity - Annual influenza vaccine - Periodic pneumococcal pneumonia vaccine 2.Sodium restriction between 2-3g/day 3.Weight daily if fluid retention

Question 36

Describe pharmacologic management of HFrEF (LVEF < 40% and symptoms)

Answer 36

Quadruple Therapy * IECA (or ARA if not tolerated) * BB (Careful initiating in NYHA III-IV) * Antagonistes de l’aldostérone (Monitor potassium, creatinine) : Target Spironolactone 50mg * SGLT2 Inhibitor

Question 37

In quadruple therapy, name IECA and ARA used

Answer 37

* IECA: Ramipril 10mg, Perindopril 8mg, or Lisinopril 20-35mg * ARA: Candesartan 32mg

Question 38

In quadruple therapy, name BB used (2)

Answer 38

* Bisoprolol 10mg * Metoprolol CR/XL 200mg

Question 39

In quadruple therapy, name Antagonistes de l’aldostérone used (1)

Answer 39

Monitor potassium, creatinine **Spironolactone** 50mg

Question 40

In quadruple therapy, name SGLT2 Inhibitor used (2)

Answer 40

Target * Jardiance 10-25mg * or Dapagliflozin 10mg

Question 41

What to do if persistent/worsening symptoms despite adequate quadruple therapy ?

Answer 41

* Convert from IECA/ARA to un inhibiteur du récepteur de l'angiotensine-néprilysine (**ARNi**) * **Entresto** 200mg BID (97mg:103mg)

Question 42

Describe management : HFpEF (2)

Answer 42

💡 There is less evidence supporting the benefit of pharmacotherapy for patients with preserved EF (HFpEF). For patients with HFpEF consider **SGLT2 and Antagonistes de l’aldostérone** as first-line therapies.

Question 43

Additional therapies should be considered for patients with HFrEF and persistent NYHA II-IV symptoms, despite optimization of quadruple therapy. Name them.

Answer 43

Diuretic at lowest effective dose to maintain euvolemia Consider (with specialist involvement) * **Ivabradine** if sinus rhythm and HR ≥ 70 bpm despite BB * **Vasodilators** (e.g., hydralazine/Isosorbide dinitrate) if renal intolerance to ACEi/ARB/ARNI * **Digoxin** (e.g., if poorly controlled AF despite BB) * **Device therapy** (implantable cardioverter-defibrillator, Cardiac Resynchronization Therapy) if LVEF ≤ 35% and NYHA I-IV (ambulatory)