Congestive Heart Failure

Question 1

Definition Congestive Heart Failure

Answer 1

Is defined as a clinical syndrome that results in cardiac dysfunction from myocardial loss or dysfunction and is characterized by left ventricular hypertrophy, dysfunction, or both.

HF stimulates a cascade of neurohormonal and circulatory responses that are reflected in the signs and symptoms commonly associated with HF: shortness of breath, fatigue, reduced exercise tolerance, and fluid retention

Question 2

The mortality rate for Medicare

Answer 2

The mortality rate for Medicare patients with HF remains at 50% after an HF hospitalization The cost burden associated with this prevalence is estimated to increase from $21 billion to $53 billion in direct costs during this period

Question 3

Key of reducing hospitalization and improving QOL

Answer 3

Managing HF symptom exacerbation in the primary care setting is paramount to improving quality of life and reducing hospitalizations for this population.

Question 4

2. List the signs and symptoms commonly associated with CHF. (Article)

Answer 4

• shortness of breath. • Fatigue. • Reduced exercise tolerance. • Fluid retention.

Question 5

3. What are the two elements that lead to HF

Answer 5

Disminución en el cardiac output o fallo de bomba

Question 6

4. In CHF Describe the pathophysiology of HF

Answer 6

a. Primary factors in pump dysfunction leading to ventricular dilation cause by endothelial dysfunction in the cardiac, coronary vascular, and peripheral vascular systems,

Question 7

b. In CHF What is the consequence of pump dysfunction

Answer 7

•leading to ventricular dilation.

Question 8

c. In CHF What happens after ventricular dilation?

Answer 8

The remodeling (which occurs as a consequence of neurohormonal stress, cytokine activation, and hemodynamic compromise) may be halted or reversed through medications and therapeutic interventions such as cardiac resynchronization therapy and left ventricular assist devices.

Question 9

d. In CHF What can stop remodeling?

Answer 9

El remodeling puede interrumpirse (halted) o revertirse mediante medicamentos e intervenciones terapéuticas, como: • Terapia de resincronización cardíaca. • Dispositivos de asistencia ventricular izquierda. (Left ventricular assist devises.)

Question 10

5. What are the comorbid conditions that affect how a patient responds to treatment for CHF?

Answer 10

a. Hypertension (HTN) b. Diabetes. c. Sleep apnea: El pte de fallo no responde bien al to casi siempre porque no corrige, sino que usa el C-pap. d. Atrial fibrillation. e. Coronary heart disease (CHD). f. Gout. g. Dyslipidemia. h. Reactive airway disease.

Question 11

6. List the common triggers of HF

Answer 11

Common triggers include: • Consumption of foods with high sodium content. • Excessive fluid intake. • Non-adherence to medical therapy. • Recurrent ischemia. • worsening valvular heart disease.

Question 12

7. Classification of HF according to 2013 ACCF/AHA guidelines

Answer 12

HF and EF Reducido el EF <40 % HF pEF >50% p=preservada Borderline 41-49% Improved> 40%

Question 13

Classification of HF: HF and EF Reducido

Answer 13

el EF <40 % También se conoce como HF sistólica. Los ensayos clínicos aleatorios han incluido principalmente pacientes con HFrEF y sólo en estos pacientes se han demostrado terapias eficaces hasta la fecha.

Question 14

Classification of HF Heart Failure with Preserved Ejection Fraction (HFpEF)

Answer 14

EF ≥50% También se conoce como HF diastólica. Se han utilizado varios criterios diferentes para definir mejor el HFpEF. El diagnóstico de HFpEF es un reto porque es en gran medida una de excluir otras posibles causas no cardiacas de síntomas sugestivos de IC. Hasta la fecha, no se han identificado terapias eficaces.

Question 15

Classification of HF . HFpEF, Borderline

Answer 15

EF : 41% to 49% Estos pacientes caen en un grupo límite o intermedio. Sus características, patrones de tratamiento y resultados parecen similares a los del paciente con HFpEF.

Question 16

Classification of HF : HFpEF, Improved

Answer 16

EF: >40% Se ha reconocido que un subconjunto de pacientes con HFpEF previamente había HFrEF. Estos pacientes con mejoría o recuperación en EF pueden ser clínicamente distintos de aquellos con EF persistentemente conservado o EF reducido. Se necesitan más investigaciones para caracterizar mejor a estos pacientes.

Question 17

ACCF/AHA stages of HF vs NYHA funcional cathegory A vs None

Answer 17

ACCF /AHA: A- At High risk for HF but without structural heart disease or symtoms of HR NYHA : None

Question 18

ACCF/AHA stages of HF vs NYHA funcional cathegory B vs I

Answer 18

ACCF /AHA: B = Structural heart disease but without sign s or symtoms of HF NYHA : I = no limitation of physical activity. ordinary physical activity does not cause symptoms of HF

Question 19

ACCF/AHA stages of HF vs NYHA funcional cathegory C vs 1-IV

Answer 19

ACCF/AHA C= Structural heart disease with prior or current symptoms of HF NYHA : I= no limitation of physical activity. ordinary physical activity does not cause symptoms of HF II= Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity result in symptoms of HF III= Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. IV= Unable to carry on any physical act. without symptoms of HF, or symptoms of HR at rest.

Question 20

ACCF/AHA stages of HF vs NYHA funcional cathegory D vs IV

Answer 20

ACCF /AHA D= refractory HF requiring specialized interventions NYHA IV= Unable to carry on any physical act. without symptoms of HF, or symptoms of HR at rest.

Question 21

9. What should be included in the H&P of a patient with HF?

Recomendation level B

Answer 21

1. A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF (Identificar trastornos o comportamientos de condiciones cardiacas y no cardiacas que pueden causar o acelerar el desarrollo de la HF. )
2. In patient with idopatic DCM a 3-generational family history should be obtained to aid in establishing the diagnosis of familial DCM. Hx familiar de condiciones cardiacas. En paciente con DCM (disease congestion miocardic). Se debe obtener el family history de hasta 3 generaciones para ayudar en el establecimiento del diagnostico de DCM.
3. Volume status and vital signs should be assessed at
   each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venouspressure and the presence of peripheral edema or orthopnea.
   
   1. (En cada encuentro con el paciente se tiene que medir el estatus de volumen y los vital sings: • Se pesa en cada visita • Se mide presión venosa yugular • Se evalúa por ortopnea • Edema periferal • Signos vitales.)

Question 22

What is the initial lab evaluation of patients with HF? (Slide presentation)

Answer 22

1. CBC, U/A.
2. Serum electrolito: Magnesio y calcio.
3. Urea Nitrógeno
4. Creatinina serum
5. Glucosa.
6. Fasting lipid profile (FLP)
7. Pruebas de función hepática
8. TSH.

Question 23

List the other diagnostic tests for HF and the areas that are evaluated with each

Answer 23

De acuerdo con la guía de 2013, la ecocardiografía bidimensional con doppler sigue siendo el método preferido para la evaluación diagnóstica de la fracción de eyección del ventrículo izquierdo (FEVI), el tamaño del VI, el espesor de la pared y la función de la válvula.

Como alternativa, la ventriculografía con radionucleidos es también un instrumento diagnóstico Es útil para medir volúmenes de LVEF y LV.

Question 24

Efectos 2rios de de medicamentos

Answer 24

Los ARB te ocasionan hypercalemia , no tanta tos

Los antagonistas de aldosterana hypercalemia

Beta blocker –enmascara los signos de hypoglisemia, vigilar los ptees diabético

Los diuréticos de tipo Loop son tóxicos en oído.

Los thiazidas se administran 30 minutos antes de los loop y se potencia el efecto diurético de la droga. (en pacientes con overload)

Los nitratos no los puedo usar junto con los resucitadores del miembro (cialis, levita)

Question 25

CHF Tx : Angiotensin converting enzyme inhibitors (ACE-I) Names:

Answer 25

Enalapril (Vasotec) Ramipril (Altace) Captopril (Capoten) Lisinopril (Zestril/Prinivil) Trandolopril (Mavik) Quinapril (Accupril) Benazepril (Lotensin)

Question 26

Mecanismo accion: Angiotensin converting enzyme inhibitors (ACE-I)

Answer 26

Blocks the conversion of angiotensin I to angiotensin II (potent vasoconstrictor) enhancing vasodilation, reducing fluid volume, and reducingperipheral vascular resistance After myocardial infarction,reduces ventricular remodeling

Question 27

ACE - I adverse effects and key points in monitoring

Answer 27

Volume depletion Worsened kidney function Cough Hypotension \*Angioedema (mouth or lip edema) with or without anaphylaxis (a rarebut serious side effect). Blood pressure (BP)— evaluate for orthostasis if patient is symptomatic. Serum electrolytes to evaluate kidney function (potassium, BUN, and creatinine)

Question 28

Angiotensin II Receptor Blockers names

Answer 28

1. Candesartan (Atacand) 2. Irbesartan (Avapro) 3. Losartan (Cozaar) 4. Valsartan (Diovan Similar act

Question 29

ARB Mechanims of action

Answer 29

Similar action to ACE-I, resulting in vasodilation, reduced blood volume, and prevention of ventricular remodeling

Question 30

ARB Adverse effects and key points to monitor

Answer 30

1. Worsened kidney function 2. Hyperkalemia 3. Not likely to cause a cough 4. Less likely to cause angioedema Monitor : Blood pressure (BP)— evaluate for orthostasis if patient is symptomatic Serum electrolytes to evaluate kidney function (potassium, BUN, and creatinine)

Question 31

``` Aldosterone antagonists (also known as potassium sparing diuretic) names ```

Answer 31

Spironolactone (Aldactone) Eplerenone (Inspra)

Question 32

Aldosterone antagonist : mechanims of action , advers effects and key points to monitor

Answer 32

MA : Inhibits aldosterone, resulting in retention of ion potassium and excretion of Naþ/Cl-/water. AE: Hyperkalemia, Gynecomastia, (10% incidence) Monitor : 1. Monitor serum potassium 1 day, 1 2. week, and 1 month after starting 3. Avoid foods or medications high in potassium 4. Avoid salt substitutes containing potassium

Question 33

Beta Blockers\* (only use betablockers that are FDA approved for use in HF)

Answer 33

Bisoprolol (Zebeta) Carvedilol (Coreg) Metoprolol (Lopressor or Toprol) MA: 1. Blocks sympathetic nervous system resulting in decreased BP, heart rate (HR), and myocardial oxygen demand 2. Blocks renin release from nephrons 3. Helps decrease angina in patients with HF from ischemic etiology Adverse effects 1. Bradycardia, 2. Heart block, 3. Hypotension, 4. Severe bronchospasm in patient with reactive airway disease (RAD) 5. Temporary fluid retention in patients with HF 6. Fatigue 7. Depression 8. May mask signs of hypoglycemia

Question 34

BB what to monitor

Answer 34

1. HR, BP, and heart rhythm 2. Orthostasis, if dizzy 3. Wheezing in patients with RAD 4. Peripheral edema and weight gain 5. in patients with HF 6. Educate patients with diabetes to monitor for hypoglycemia

Question 35

Digoxin

Answer 35

names: Digoxin (Lanoxin) Digoxin dosing and therapeutic levels are lower than previously recommended—digoxin level 0.8-2.0 ng/ml Starting dose: 0.125 mg daily if older than 70 and 0.25 mg daily if less than 70 and normal renal function MA: Weak inotrope, slows atrioventricular conduction Adverse Effects: 1. Cardiac dysrhythmias, especially in 2. patients with hypokalemia or hyperkalemia 3. Bradycardia 4. Heart block 5. Digoxin toxicity

Question 36

Digoxin key points to monitor

Answer 36

1. Heart rate and rhythm 2. Adjust dose for age, lean body 3. mass, and renal function 4. Observe for signs of digoxin 5. toxicity: nausea, vomiting, diarrhea, 6. fatigue, yellow or blurred vision, flulike 7. symptoms

Question 37

Diuretic Loop

Answer 37

Names : 1. Furosemide (Lasix) 2. Torsemide (Demadex) 3. Bumetanide (Bumex) MA 1. Blocks reabsorption of Na+/Cl- and water at Loop of Henle Adverse effects: 1. Hypotension 2. Volume depletion 3. Dehydration 4. Electrolyte abnormalities: hypokalemia, hypomagnesemia, hyponatremia, or hyperglycemia 5. May worsen kidney function 6. Hyperuricemia 7. Ototoxicity, more common in high doses or if given with other ototoxic medications

Question 38

Diuretics loop key points to monitor

Answer 38

Monitor : 1. BP for hypotension and orthostasis 2. HR if BP decreases (reflex tachycardia) 3. Overdiuresis: dizziness, oliguria, 4. thirst, excessive weight loss 5. Serum electrolytes 6. Ototoxicity

Question 39

Thiazide

Answer 39

names : 1. Hydrochlorothiazide (HCTZ) 2. Chlorthalidone 3. Metolazone, a thiazide-like diuretic MA 1. Blocks reabsorption of Na+ / Ca- and water 2. Same as above, administered 30 minutes before loop diuretic to enhance effect of loop for patients with HF Adverse effects 1. Same as loop 2. No ototoxicity

Question 40

Thiazide key point to monitor

Answer 40

Point to monitor 1. Same as loop diuretics 2. BP for hypotension and orthostasis 3. HR if BP decreases (reflex 4. tachycardia) 5. Overdiuresis: dizziness, oliguria, thirst, excessive weight loss 6. Serum electrolytes 7. Ototoxicity

Question 41

Nitrates

Answer 41

names: 1. Nitroglycerin various routes: 2. Sublingual—spray or tablet 3. Oral—short and long acting forms 4. Transdermal 5. Intravenous MA 1. Vascular smooth muscle dilation in periphery and 2. coronary arteries AE 1. Headache 2. Dizziness 3. Reflex tachycardia 4. Flushing 5. Syncope

Question 42

1. Nitratos key points to monitor

Answer 42

1. BP 2. Do not administer within 24 hours of sildenafil (viagra) or 48 hours of tadalafil (cialis) 3. Vardenafil is contraindicated with nitrates 4. Ensure a nitrate-free interval of 10-12 hours

Question 43

Hydralazine

Answer 43

Name : 1. Hydralazine (Apresoline) MA 1. Direct vasodilator through 2. arteriolar smooth muscle 3. relaxation AE 1. Reflex tachycardia 2. Fluid retention Points to monitor 1. BP 2. HR, especially if BP drops

Question 44

CHF JPN common medications:

Answer 44

1. Angiotensin converting enzyme inhibitors (ACE-I): Enalapril (Vasotec), Ramipril (Altace), Captopril (Capoten) 2. Angiotensin II receptor blockers: Candesartan (Atacand) 3. Irbesartan (Avapro), Losartan (Cozaar), Valsartan (Diovan) 4. Aldosterone antagonists (also known as potassium sparing diuretic) - Spironolactone (Aldactone) Eplerenone (Inspra) 5. Beta Blockers\* (only use betablockers that are FDA approved for use in HF) : Bisopropolol (zebeta) Carvedilol (coreg), metoprolor (lobresor or toprol) 6. Digoxin- lanoxin 7. Diurtics-loop- Furosemide (Lasix), Torsemide (Demadex) Bumetanide (Bumex 8. Thiazide - Hydrocholrothiazide (HCTZ) , metolazone, thiazised like diruetic, Chlorthalidone 9. Nitrates- nitroglycerin varous routes 10. Hydralazine- Hydralazine - Apresoline

Question 45

Approaches to reduce hospitalization in the management of CHF patient

Answer 45

When integrated into a comprehensive system, this option promotes self-care and provides substantive patient surveillance in an effort to reduce HF hospitalizations. **Son los frecuent fliers** que vuelan mucho y van mucho al hospital 1. include telemonitoring, : Telemonitoring consists of a digital transmission of physiologic data and symptom reporting to remote providers 2. Structured telephone supports through automated phone calls provide a second alternative to providing patient follow-up communication and support for patients with chronic HF support, and 3. disease management -\> engage in self-care, -\> provide focused interventions over a defined period with a multidisciplinary approach.

Question 46

Stages, phenotypes and treatment of HF STAGE A

Answer 46

1. Stage A - At high risk for HF but without structural heart disease or symptoms of HF. 2. patient with * HTN * Arterosclerotid disease * DM * obesity * metabolic sindrome * uso de tabaco y otros agentes cardiotoxicos 3. patient * using cardiotoxins * with family hx of cardiomypathy 4. Therapy goal: heart healthy lifestyle * prevent vacular coronary disease * prevent LV structural abnormalities 5. drugs: * ACEI or ARB in approprieate pts. for Vscular diseas or DM * statins as appropriate * (comienzas controlando HTN, y lipidos para reducir risk de HF. no tx se trata de prevenir fallo de bomba.

Question 47

Stages, phenotypes and treatment Stage B

Answer 47

Stage B - Structural heart disease but without signs or symptoms of HF. 1. patient with: * Previous MI * LV remodeling including LVH and Low EF * Asyntomatic valcular disease 2. Therapy goal: * Prevent HF symtoms * prevent futrher cardiac remodeling 3.drugs: * ACEI or ARB in approprieate pts. for Vscular diseas or DM * Beta blockers as appropriate 4. in selected patients * ICD * revascularization or valvular surgery as appropriate

Question 48

Stages, phenothypes and Treatment of HF Stage C HF pEF

Answer 48

Structural heart disease with prior or current symptoms of HF Patient with known structural Heart diseas and HF symptoms ans signs HF pEF: 1. goals : control symtoms, improved HRQOL, prevent hospitalization, prevent mortality 2. strategies: identification of comorbidities 3. treatment : diuresis to relieve symptoms of congestions, follow guideliesn driven indication for comorbilidities eg. HTN, AF, CAD, DM 4. Revascularizacion or vasvular surgery as appropiate

Question 49

Stages, phenothypes and Treatment of HF Stage C - HF r EF

Answer 49

Structural heart disease with prior or current symptoms of HF Patient with known structural Heart diseas and HF symptoms ans signs HF rEF: 1. goals : control symtoms, pt education, prevent hospitalization, prevent mortality 2. Drug for rutine use : diuretics for fluid retention, ACEI, or ARB, Beta blockers, Aldostreone antagonist 3. Drugs for use in selected patients: 1. hydralazine / isosorbide dinitrate 2. ACEI and ARB 3. Digoxin 4. In selected patient 1. CRT 2. ICD 3. Revascularizacion or vasvular surgery as appropiate

Question 50

Stages, phenothypes and Treatment of HF Stage D -Refractory HF

Answer 50

Structural heart disease with prior or current symptoms of HF Patient with : marked HF symptoms at rest despite GDMT recurrent hospitalizations 1. goals : control symtoms, improved HR QOL, reduce hospital readmisions, establish patients end of life goals 2. options: 1. Advance care measures 2. heart transplant 3. chronic inotrpes 4. temporary or permament MCS 5. experimental surgery or drugs 6. paliative care and hospice 7. ICD deactivation

Question 51

The brain natriuretic peptide (BNP)

Answer 51

1. **El péptido natiuretico tipo B (BNP)** es una hormona producida por el corazón. 2. Se libera en respuesta a cambios en la presión dentro del corazón. Estos cambios pueden estar relacionados con la insuficiencia cardíaca. 3. En general, el nivel de BNP aumenta cuando la insuficiencia cardíaca se desarrolla o empeora, y disminuye cuando la condición es estable. 4. En la mayoría de los casos, los niveles de BNP son más altos en pacientes con insuficiencia cardíaca que las personas que tienen una función cardíaca normal. 5. Es posible que su equipo de atención médica se refiera al BNP como NT-proBNP. Los niveles de BNP y NT-proBNP pueden medirse para ayudar a diagnosticar y monitorear pacientes con insuficiencia cardíaca. Es importante no comparar BNP con NT-proBNP, ya que puede haber una diferencia de 5 a 10 veces entre los resultados de la prueba. 6. **A normal level of NT-proBNP**, based on Cleveland Clinic’s Reference Range is: * Less than 125 pg/mL for patients aged 0-74 years * Less than 450 pg/mL for patients aged 75-99 years 7. **If you have heart failure**, the following NT-proBNP levels could mean your heart function is unstable: * Higher than 450 pg/mL for patients under age 50 * Higher than 900 pg.mL for patients age 50 and older

Question 52

CXR & echocardiogram slide 37

Answer 52

1. Patients with suspected or new-onset HF, or those presenting with acute decompensated HF, should undergo a chest x-ray to assess heart size and pulmonary congestion, and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patients’ symptoms. 2. A 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function. 3. Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy.

Question 53

Recommendations for Noninvasive Imaging: COR Strengh of recommendation and LOE quality of evidence or level.

Answer 53

1. Patients with suspected, acute, or new-onset HF should undergo a chest x-ray : COR I LOE=C 2. A 2-dimensional echocardiogram with Doppler should be performed for initial evaluation of HF ; I vs C 3. Repeat measurement of EF is useful in patients with HF who have had a significant change in clinical status or received treatment that might affect cardiac function, or for consideration of device therapy. I vs C 4. Noninvasive imaging to detect myocardial ischemia and viability is reasonable in HF and CAD IIa vs 5. Viability assessment is reasonable before revascularization in HF patients with CAD IIa vs B 6. Radionuclide ventriculography or MRI can be useful to assess LVEF and volume IIa vs C 7. MRI is reasonable when assessing myocardial infiltration or scars IIa vs B 8. Routine repeat measurement of LV function assessment should not be performed III: No Benefit vs B

Question 54

BNP in ambulatory setting #29 y # 30

Answer 54

1. In ambulatory **_patients with dyspnea_**, measurement of BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP) is useful **_to support clinical decision making_** regarding the diagnosis of HF, especially in the setting of **_clinical uncertainty._** 2. Measurement of BNP or NT-proBNP is useful for ***_establishing prognosis or disease severity in chronic HF_***. 3. \* guided HF therapy can be useful to achieve **_optimal dosing of GDMT_** in select clinically euvolemic patients followed in a well-structured HF disease management program. 4. Usefulness to reduce hospitalization or mortality in HF pts. not well established. 5. Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with chronic HF.

Question 55

Recommendations for Biomarkers in HF slide 34

Answer 55

A. Natriuretic peptides: 1. Diagnosis or exclusion of HF in Ambulatory, Acute (I and A) 2. Prognosis of HF in ambulatory, acute (I and A) 3. Achieve GDMT ambulatory - in acute - IIb and A 4. Guidance of acutely decompensated HF therapy in Acute - IIb and C B. Biomarkers of myocardial injury 1. Additive risk stratification in Acute, Ambulatory, I and A C. Biomarkers of myocardial fibrosis 1. Additive risk stratification 1. in Ambulatory IIb and B 2. in Acute IIb and A

Question 56

CHF Treatment by stages (slide 48, 53) Stage A

Answer 56

1. Hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of HF. 2. Other conditions that may lead to or contribute to HF should be controlled or avoided. * such as obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents,

Question 57

CHF Treatment by stages (slide 48, 53) Stage B

Answer 57

1. In all patients with a recent or **_remote history of MI or ACS and reduced EF_**, * ACE inhibitors should be used to prevent s-HF and reduce mortality. * In patients intolerant of ACE inhibitors, * ARBs are appropriate unless contraindicated. 2. In all patients with a recent or remote **_history of MI_** or ACS and **_reduced EF_**, ​e**_vidence-based beta blockers_** should be used to reduce mortality 3. In all patients with a recent or remote **_history of MI_** or ACS, **_statins_** should be used to prevent symptomatic **_HF and cardiovascular events._** 4. **_BP should be controlled_** to prevent s- HF 5. **_ACE inhibitors_** should be used in all patients with a **_reduced EF t_**o prevent HF 6. **_Beta blockers_** should be used in all patients with a **_reduced EF_** to prevent HF 7. An **_ICD i_**s reasonable in patients with asymptomatic ischemic cardiomyopathy who are at **_least 40 d post-MI, have an LVEF ≤30%, and on GDMT_** 8. **_Nondihydropyridine calcium channel blockers may be harmful in patients with low LVEF_** Guideline Determined Medical Therapy Iimplantable cardioverter-defibrillator

Question 58

**Farmacology Tx of Stage C HFrEF** **= NYHA I-IV**

Answer 58

HFr EF Stage C HFrEF = NYHA I-IV 1. ACE or ARB & Beta blockers * for all volume overload, NYHA class II-IV patients * add lop diuretics * for persitently simptomtic African americans, class III -IV * add Hydral -nitrates * for class II-IV patients provided estimate creatinine \> 30 ml/min and K+\< 5.0 meq/dl * add Aldosterne antagonist : spronolactone=12.5 to 25 mg, eplerenone: 25mg once note: * Diuretics are recommended in patients with HFrEF who have evidence of fluid retention, unless contraindicated, to improve symptoms. * ACE inhibitors are recommended in patients with HFrEF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality. * ARBs are recommended in patients with HFrEF with current or prior symptoms who are ACE inhibitor-intolerant, unless contraindicated, to reduce morbidity and mortality.

Question 59

CHF non pharmacological interventions:

Answer 59

* **Continuous positive airway pressure (CPAP)** can be beneficial to increase LVEF and improve functional status in patients with HF and sleep apnea. * **Cardiac rehabilitation** can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL, and mortality. * Patients with HF should receive specific education to facilitate HF **self-care.** * **Exercise training** (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participa**te to improve functional statu**s. * **Sodium restriction is** reasonable for patients with symptomatic HF to reduce congestive symptoms.

Question 60

CHF med that are potentially harmful in stage C

Answer 60

1. Nutritional supplements as treatment for HF 2. Hormonal therapies other than to correct deficiencies 3. Drugs know to adversely affect clinical status of ptes with HF with HFrEF 1. (e.g., most antiarrhythmic drugs, 2. most calcium channel blocking drugs (except amlodipine) 3. NSAIDs, or TZDs)

Question 61

**Management of stage C HFrEF part 1**

Answer 61

1. **Diuretics** are recommended in patients **with HFrEF with fluid retention** 2. **ACE inhibitors** are recommended for **all patients** **with HFrEF** 3. **ARBs** are recommended in **patients with HFrEF** who **are ACE inhibitor intolerant** 4. **ARB are seasonable** alternatives to ACE inhibitor as first **line therapy in HFrEF** 5. The addition of an **ARB may be considered in persistently symptomatic patients** with HFrEF on **GDMT** 6. Routine combined use of an **ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful**

Question 62

1. Part 2 Management of Stage C CHF HFrEF

Answer 62

1. Beta Blockers: Use of 1 of the 3 beta blockers proven to reduce mortality is recommended for all stable patients 2. Aldosterone Antagonists: Aldosterone receptor antagonists are recommended in patients with NYHA class II-IV HF who have LVEF ≤35% * Aldosterone receptor antagonists are recommended in patients following an acute MI who have LVEF ≤40% with symptoms of HF or DM * Inappropriate use of aldosterone receptor antagonists may be harmful 3. Hydralazine and Isosorbide Dinitrate: * The combination of hydralazine and isosorbide dinitrate is recommended for African-Americans, with NYHA class III–IV HFrEF on GDMT * A combination of hydralazine and isosorbide dinitrate can be useful in patients with HFrEF who cannot be given ACE inhibitors or ARBs 4. Digoxin can be beneficial in patients with HFrEF 5. Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardioembolic stroke should receive chronic anticoagulant therapy 6. Statins are not beneficial as adjunctive therapy when prescribed solely for HF 7.

Question 63

CHF common triggers

Answer 63

* Consumption of foods with high sodium content. * Excessive fluid intake. * Nonadherence to medical therapy. * Recurrent ischemia. * worsening valvular heart disease

Question 64

Preferable method for dx evaluation

Answer 64

1. De acuerdo con la guía de 2013, la ecocardiografía bidimensional con doppler sigue siendo el método preferido para la evaluación diagnóstica de la fracción de eyección del ventrículo izquierdo (FEVI), el tamaño del VI, el espesor de la pared y la función de la válvula. 2. Un diagnóstico de HF. Un CXR (chest x ray) debe ser evaluado para las siguientes anomalías: * Cardiomegalia. * Infiltrados pulmonares, pleurales y derrames pericárdico 1. **Un ECG de 12 derivaciones** en un paciente con HF puede revelar cambios isquémicos: * hipertrofia ventricular izquierda. * Bloqueo de rama izquierda (LBBB). * Bloqueo de rama derecha (RBBB). * Trastorno del ritmo, como: fibrilación auricular o taquicardia. 1. En los pacientes con angina o sospecha de isquemia que son candidatos potenciales para la revascularización, se recomienda la angiografía coronaria

Question 65

Precausiones con medicamentos HF

Answer 65

* Los ARB te ocasionan hypercalemia , no tanta tos * Los antagonistas de aldosterana hypercalemia * Beta blocker –enmascara los signos de hypoglisemia, vigilar los ptees diabético * Los diuréticos de tipo Loop son tóxicos en oído. * Los thiazidas se administran 30 minutos antes de los loop y se potencia el efecto diurético de la droga. (en pacientes con overload) * Los nitratos no los puedo usar junto con los resucitadores del miembro (cialis, levita)