Heart failure

Question 1

Define heart failure and how to diagnose it

Answer 1

Spectrum of disease caused by impaired ventricular filling and contraction
Diagnosis of HF based on presence of structural heart disease with current or previous symptoms

Question 2

Symptoms suggestive of HF are non-specific; list 4

Answer 2

1) JVD
2) Orthopnea
3) SOB
4) Leg edema

Question 3

Increased _______load = increased cardiac workload

Answer 3

afterload

Question 4

List some risk factors for HF

Answer 4

1) Age
2) Hypertension, T2DM, Ischemic heart disease, & Arrhythmia, especially A. Fib
3) Lifestyle factors: Physical inactivity, Obesity, Smoking
4) Other conditions: chronic lung disease, sleep apnea, anemia, cognitive dysfunction, depression, and renal disease

Question 5

What is the MOA in volume overload in HF?

Answer 5

Fall in cardiac output, leading to alterations in renal function, due in part to activation of sodium-retention from the renin-angiotensin-aldosterone and sympathetic nervous systems …. leads to fluid retention

Question 6

Dyspnea is high ______________for HF (89 percent), but ________________ is low (51 percent)

Answer 6

sensitivity; specificity

Question 7

HF may manifest as ______________________: legs, and ascites, scrotal edema, hepatomegaly, and splenomegaly

Answer 7

peripheral edema

Question 8

You may note ___________________ reflux with peripheral edema

Answer 8

hepatojugular

Question 9

_______________________________________ is usually present if peripheral edema is due to HF

Answer 9

Elevated jugular venous pressure (JVD)

Question 10

Primary care patients: There can be a displaced apical impulse; why?

Answer 10

HFpEF typically have a nondilated heart, so displacement of the apical impulse is not a helpful finding for diagnosis of HFpEF

Question 11

List 2 cardiac exam findings you may find in HF

Answer 11

1) Displaced apical impulse
2) Gallop rhythm and elevated jugular venous pressure (JVD, HJR)

Question 12

Describe S3 gallop

Answer 12

“Ventricular” gallop
AV valve opening and blood hitting the (non)compliant ventricular wall (HFpEF)
May be normal in adults, kids, pregnant women and athletes

Question 13

Describe S4 gallop

Answer 13

“Atrial” gallop
Atrial kick and blood hitting a non-compliant ventricular wall
Rarely normal

Question 14

What is HF diagnosis based on; explain

Answer 14

Based on presence of structural heart disease + current or previous symptoms
Signs and symptoms HF are non-specific

Question 15

EKG findings supporting HF include what?

Answer 15

1) Chamber enlargement
-Left atrial enlargement: leads II and V1
-+/- LAD and LVH, +/- repolarization abnormality
2) Ischemia (ST changes)
3) Arrhythmia

Question 15

Describe some S/Sx seen in 3 suspected HF tests

Answer 15

1) CXR – pulmonary edema, cardiomegaly
2) B-type natriuretic peptide (BNP) or N-Terminal prohormone assay (N-PBNP) – strong negative predictive value, change with stages, not precise enough to guide therapy
3) Echocardiogram – guides therapy as can estimate EF, etc.

Question 16

Cxr findings in HF include what? How specific are they?

Answer 16

Peribranchial cuffing, Kerley B lines, bilateral pleural effusions, and alveolar edema have a 95% or greater specificity for HF

Question 17

Is CXR useful to Dx HF? Explain

Answer 17

Moderately helpful in confirming the diagnosis but not for exclusion

Question 18

Natriuretic peptides:
1) When/ where are they released?
2) Which are clinically relevant to HF (best at ruling out HF as a cause)?

Answer 18

1) Released from cardiac muscle because of a variety of triggers, most commonly myocardial stretch
2) Brain-type natriuretic peptide (BNP) and its precursor N-terminal pro–brain natriuretic peptide (NT-proBNP)

Question 19

Describe the cutoff values for BNP & NT pro-BNP

Answer 19

1) In the acute care setting, ACC/AHA recommend use of a BNP level less than 100 pg/mL and an NT pro-BNP level less than 300 pg/mL to r/o acute HF
2) The cutoffs for NT-proBNP vary with age as well as chronicity of HF, whereas those for BNP are not dependent on age

Question 20

What are the go-to markers of myocyte injury?

Answer 20

Troponins I and T

(pretty sensitive)

Question 21

What is the most common arrhythmia in patients with HF, regardless of EF?

Answer 21

AFIB

Question 22

Describe AFIB in HF

Answer 22

1) Most common arrhythmia in patients with HF, regardless of EF; onset of AF may result in acute HF symptoms
2) If hemodynamically unstable: DC cardioversion may be indicated

Question 23

HF grading is characterized by what 3 things?

Answer 23

1) Stage
2) Ejection fraction (EF)
3) Symptom/functional status – New York Heart Associated classification

Question 24

How many stages of HF grading are there? What do they describe?

Answer 24

4 stages: 1&2) First 2 stages describe at risk patients 3&4) 2nd two stages describe patients with HF

Question 25

Define stage A ("at risk") of HF

Answer 25

1) Presence of risk factors with no structural changes or symptoms (HTN, DM, CAD, etc) 2) Controlling these risk factors can prevent progression to HF

Question 26

Describe Stage B: “pre-heart failure” and give an example

Answer 26

1) Patients have structural changes but without S/S now or in the past -Seen on echocardiogram 2) Ex. of structural heart disease: ventricular remodeling, congenital heart disease (CHD), valvular heart disease (VHD)

Question 27

Grading EF is based on what?

Answer 27

EF

Question 28

1) Define HFrEF (heart failure with reduced ejection fraction) 2) Define heart failure with mildly reduced EF HFmrEF

Answer 28

1) LVEF 40% or less 2) LVEF 41-49%

Question 29

1) Define HFpEF (HF with preserved EF) 2) Define HF with improved EF (HFimEF)

Answer 29

1) LVEF 50% and greater = HF with preserved EF (HFpEF) 2) Any movement in EF from reduced to greater than 40%

Question 30

Grading functional status is based on what?

Answer 30

Symptoms & functional capacity (HF stages C/D)

Question 31

How do you Tx stage A of HF?

Answer 31

1) Manage comorbidities/risk factors 2) SGLT-2 inhibitors (“flozin” drugs) should be used in patients with DM or at increased risk of CVD -Reduces hospitalization by reducing risk of symptomatic HF (Stages C/D)

Question 32

Describe the Tx of stage B of HF

Answer 32

1) **Focus** on guideline directed medical therapy for comorbid conditions resulting in structural changes (HTN, dyslipidemia, DM) 2) **Additions to stage A intervention:** -HFrEF despite being asymptomatic -ACEi, ARB as alternative if ACEi not tolerated -h/o ACS with HFrEF = cardioprotective BB (bisoprolol, carvedilol, or metoprolol succinate XL) 3) **Avoid** Thiazolidinediones (TZD) and non-dihydropyridine CCB if EF < 50%

Question 33

How do you Tx stages C/D of HF?

Answer 33

1) Guideline directed medical therapy is key to management of stage C HF 2) Stage D HF, patients require specialized teams to direct management; mgmt focuses on: -Advanced therapies: Transplants; left ventricular assist devices Or -Palliative and hospice

Question 34

Patients with symptoms (Stage C/D) should receive all four components of guideline directed medical therapy. Why?

Answer 34

Reduces all causes of mortality by 73% compared to no Tx

Question 35

List some appropriate Renin-angiotensin system inhibitors for HF

Answer 35

ACEi or ARB or ARB/neprilysin inhibitor (ARNI) (Entresto)

Question 36

List some appropriate B blockers for HF

Answer 36

Cardioprotective – bisoprolol, carvodilol, metoprolol succinate XL

Question 37

List some appropriate Mineralocorticoid receptor antagonists for HF

Answer 37

Spironolactone, eplerenone

Question 38

What group of drugs is called “flozin drugs"?

Answer 38

SGLT-2 inhibitors

Question 39

What are some other Rxs for HF?

Answer 39

Isosorbide dinitrate and hydralazine

Question 40

**HFrEF:** Describe how to use Renin-angiotensin system inhibitors

Answer 40

ARNi recommended in patients with HFrEF and NYHA class II or III: 1) Symptomatic hypotension is more common on ARNi than ACEi 2) 2nd line: ACEi are preferred over ARB if ARNi not tolerated 3) 3rd line: ARB -ARNi may cause angioedema – 36-hour “washout” from last ACEi dose suggested before 1st dose of ARNi Initiate in hospital or at d/c

Question 41

True or false: ACEi or ARB or ARB/neprilysin inhibitor (ARNi) (Entresto) are all effective in reducing mortality in HF

Answer 41

True

Question 42

**HFrEF:** Describe when to use beta blockers (Cardioprotective: bisoprolol, carvedilol, metoprolol succinate XL)

Answer 42

Initiate during initial hospitalization

Question 43

**HFrEF:** Describe how to use Mineralocorticoid receptor antagonists

Answer 43

1) Spironolactone or eplerenone; benefits consistent across all EF 2) Avoid in CKD with eGFR 30 mL/min or less (CKD-4) 3) D/c Tx if K+ level cannot be maintained at < 5.5 mEq/L

Question 44

**HFrEF:** Describe the use of SGLT-2 inhibitors

Answer 44

1) Recommended in HF regardless of DM status 2) Increase risk of UTI, euglycemia ketoacidosis, and need for diuretic adjustment to avoid fluid depletion 3) $$$$, but long-term cost effective

Question 45

**HFrEF:** Describe the use of other Rxs

Answer 45

1) Isosorbide dinitrate and hydralazine to black patients with NYHA class III or IV, or in patient who can not tolerate first line treatments above 2) Omega-3 polyunsaturated fatty acids

Question 46

All components of guideline directed medical therapy benefit patients with HFmrEF. This includes what?

Answer 46

1) SGLT-2i 2) Cardioprotective BB 3&4) ARNi or ACEi or ARBs and mineralocorticoid antagonist

Question 47

HFmrEF: When should you use diuretic therapy?

Answer 47

If evidence of fluid overload (scheduled and PRN)

Question 48

HFpEF: How common is it? Do all components of therapy benefit these pts?

Answer 48

~ 50% of clinically diagnosed HF Some components of GDMT do not improve outcomes

Question 49

What do HFpEF patients benefit from?

Answer 49

Diuresis when evidence of fluid overload SGLT-2 i +/- mineralocorticoid antagonist

Question 50

HFimEF: How do you Tx?

Answer 50

Studies conflict

Question 51

Describe non-pharmacologic treatment for HF

Answer 51

1) Multidisciplinary team treatment – reduce all cause mortality & hospitalizations, & HF related hospitalizations 2) Exercise training/regular physical activity Improves function and QOL 3) Lifestyle recommendations are challenged by limited evidence Limit NaCl < 2,300 mg/day

Question 52

Symptom management: 1) What should you use for fluid retention? What kind?

Answer 52

**Diuretic** (improve symptoms and reduce symptom progression): 1) To reduce electrolyte abnormalities, a combination of a thiazide and loop diuretic should be limited to patients who have symptoms that do not improve with moderate or high dose loop diuretic monotherapy 2) If on thiazide diuretic for HTN, may use PRN loop diuretic, but if using schedule loop diuretic for fluid overload, stop thiazide diuretic.

Question 53

Implantable devices for HF include what 2 things?

Answer 53

1) Cardioverter-defibrillation -Reduce all cause mortality in symptomatic HF patients and EF < 35%, asymptomatic EF < 30% 2) Cardiac resynchronization therapy

Question 54

Describe the evaluation of right-sided HF

Answer 54

1) When evaluating patients for left-sided heart failure (HF), consider right-sided HF as well. 2) There is significant crossover in symptoms, and these conditions frequently are seen together 3) Management of underlying conditions is vital to restoring function regardless of whether the right-sided HF is acute or chronic - consider fluid status, preload and afterload

Question 55

__________HF is seen in approximately 47.2% of patients with HFrEF and in 19% of patients with HFpEF

Answer 55

Right-sided

Question 56

Management RHF reversible causes includes what?

Answer 56

1) Management of the underlying causes 2) Assessment of volume status with management of preload and afterload 3) Ensuring continued forward perfusion of the circulatory system 4) In the setting of acute RV myocardial infarction, reperfusion is vital 5) In cases of pulmonary embolism, anticoagulation or thrombolytic therapy is key