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Heart Failure Flashcards

1
Q

BNP levels & NT Pro BNP levels in normal subjects

A

10 pmol/L ( Not pg/ml)- Normal levels same for both. All below values are I pg/ ml.

HF- BNP- <100pg/ml very high negative predictive value
100-400–not sensitive or specific
>400– heart failure

NT Pro BNP- <300 —means no heart failure
<50 yrs- 450 pg/ ml
50-75 yrs- 900 pg/ml
>75 yrs- 1800 pg/ ml

UPTODATE 2018

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2
Q

NT pro BNP of —– is roughly equivalent to BNP of >100pg/ml for diagnosis of HF

A

> 900 pg/ml

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3
Q

—% of RV pressure rise is accounted by LV

A

63% ie almost 2/3 rd

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4
Q

Pulmonary vascular congestion in CXR means

A

ill defined plump vessels

Also increased interstitial markings
Peri bronchial cuffing etc

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5
Q

Entresto should be given only after ……..hours of an ACE inhibitor

A

36 hrs

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6
Q

Heart failure with reduced ejection fraction is EF less than

A

40%

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7
Q

Sacubitril is given if EF less than

A

40%

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8
Q

Minimum BP to start Sacubitril

A

100 mm Hg

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9
Q

Gold standard for salt intake estimation at individual level

A

24 hr urine sodium extraction

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10
Q

Sub categorization of Class B and Class C level of evidence started from

ACC/AHA

A

2015

B R& B NR

C LD & C EO

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11
Q

Class 2b ACCAHA recommendation means

A

Benefit EQUAL to or MORE THAN risk ( WEAK Recommendation)

2a is MODERATE recommendation

Class1 is STRONG recommendation

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12
Q

Benefit = Risk means COR will be

A

Class 3 (Moderate) ie No benefit

Class 3 ( Harm) is Risk > Benefit

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13
Q

Stage C Heart Failure is

A

Once symptoms develop

Can never go back to stage B

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14
Q

The rationale for developing ARB

A

Angiotensin 2 production continue s through alternate enzyme pathways with ACEI

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15
Q

NEPRILYSIN inhibitors inhibit

A

Neprilysin 😜( enzyme that degrades natriuretic peptides, bradykinin, adrenomedullin and other vasoactive peptides)

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16
Q

ARNI vs ARB reduces

A

Death or hospitalization by 20%- similar extent of benefit in both

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17
Q

Best ACEI for heart failure

A

All are same

2017 ACC/ AHA

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18
Q

ACEI to be cautious if K

A

More than 5

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19
Q

ACEI can cause cough in up to

A

20%

2017 ACC/AHA

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20
Q

Abrupt withdrawal of ACEI should be avoided -which guideline

A

ACC/AHA 2017 Heart Failure

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21
Q

Patient on ARB for HTN can continue same if Heart Failure develops - which guidelines

A

2017 ACC/AHA

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22
Q

ARNI is superior than ACEI which Guidelines

A

2017 ACC/AHA

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23
Q

Guidelines on ARNI as per ACC/AHA 2017

A
  1. Chronic 2. symptomatic HFrEF
  2. Class 2/3

REPLACE with ARNI to further reduce morbidity and mortality

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24
Q

COR for LVAD in refractory HF

A

2a

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25
The BNP/ NT Pro BNP cut off used in the PARADIGM-HF study for giving ARNI
BNP> 150: NTPro BNP> 600 | or 100 & 400 If history of hospitalization within 12 months
26
Target dose of ARNI
200 BD slowly uptitrate
27
Time gap between ARNI and ACEI should be at least
36 hours
28
Neprilysin PLUS ACEI was
Omapatrilat- High Angioedema-3 fold increase compared to Enalapril. Single molecule with ACE , Neprilysin inhibition unlike ARNI
29
HFrEF means EF of
40% or less More than 40% is preserved EF
30
Role of Ivabradine in HF-ACC AHA 2017
1. Stable chronic HF (EF-35 or less)- For 4 weeks stable on GDEM 2. Symptomatic Gd2/3 3. On GDEM ( on max tolerated beta blockers ) 4. Sinus rhythm 5. Rate> 70 Pts enrolled in study included a small no of Paroxsmal AF and PPI But predominantly in Sinus rhythm MI within 2 months were excluded Only 25% were on optimal BB. In view of MORTALITY benefits of BB first uptitrate them then only add Ivabradine
31
The benefit of Ivabradine in HF is mainly driven by reduced
Hospitalization | Not much by mortality
32
Level C evidence categories
C- LD- Limited data | C -EO- Expert Opinion
33
Obesity and BNP
Associated with lower BNP values in HF
34
BNP level assay in ARNI therapy
Unreliable for HF as BNP levels will be high due to ARNI NT- Pro BNP can be used BNP is a substrate for Neprilysin but not NT-pro BNP. So BNP will increase
35
Markers which provide additional prognostic value over BNP in HF
Galectin 3, Soluble ST 2, hscrp etc-(considered as markers of myocardial fibrosis or injury)
36
A non cardiac cause of high BNP
Bacterial sepsis
37
Class of recommendation For checking BNP in Stage A HF
2a 50 pg/ml or more benefits from more aggressive therapy-reduces incidence of HF( Asymptomatic) ACC 2017
38
BNP recommendations in HF
Admission BNP-1a Predischarge BNP-2a ACCHA2017
39
How ACEI increase bradykinin
They inhibit Kininase enz
40
Angio edema with ACE is more in
Blacks and Women <1% incidence
41
ACEI to be used Cautiously if K is
5 or more | Aldactone also same 5
42
Therapies for Class 4 HF patients
Spiranolactone Hydralazine-Nitrate in Blacks CRT And ACEI/ARB/BB/Diuretics All others are in Class 2-3
43
ICD in HF
1. EF-35 or less 2. > 40 days post MI 3. Class 2-3
44
Therapies in 2-3 HF only
ARNI, ICD,Ivabradine ,IV Iron
45
EF in CRT and ICD in HF
EF- 35 or less in both CRT-QRS 150 or more with LBBB pattern —COR 1
46
COR of Aldosterone antagonist in HFpEF
IIb. 1. EF45 or more 2. BNP-increased or 3. HF admission in a year These drugs will reduce hospitalization From TOPCAT study ACC/AHA 2017
47
Role of coronary revasc in HFpEF
COR II a ACCHA2017
48
IV Iron in HF
1. Ferritin <100 2. Or 100-300 If Transferrin saturation less than 20% 3. Class 2-3
49
Role of Nitrate therapy in HFrEF
Reduce Pulmonary congestion and Improve exercise tolerance
50
PDE 5 inhibitors augment nitric oxide by
Increasing cGMP
51
Role of correction of Anemia with Erythropoietin stimulating agents in HF
COR Class 3- No benefit Found also to have a significant increase in thromboembolic events and NS increase in strokes
52
ACCHA 2017 stand on ARNI in hfPef for control of HTN
RAAS inhibition with ACEI/ARB/MRA and possibly ARNI
53
Sleep Apnea treatment with ———— is harmful in HF
Adaptive Servo Ventilation in Central sleep Apnea. -Higher mortality rate
54
Incidence of sleep Apnea in HF
60% ACCHA 2017
55
Use of. CPAP in HF plus OSA
Improves sleep quality No benefit on CVS events (A.F. progressing to permanent AF less likely- in a trial with A.F. and OSA)
56
ARB and Angioedema
Some patients have developed. So caution advised when giving ARB in a patient who had angioedema with ACEI
57
After starting ARB check RFT after
1-2 weeks of starting ACCHA 2013
58
Why only Metoprolol succinate, bisoprolol and Carvedilol only should be used in HF
ACCHA 2017 All B.B. are not equal in HF Eg. Studies with Bucindolol and Metoprolol tartarate was not as effective as others in studies . Nebivolol didn’t affect mortality
59
When can you start beta blockers in hospitalized
Once they are out of intravenous INOTROPIC therapy ACCHA 2013
60
How to reduce hypotension risk with ACE plus B.B. in HF
Give at different times of the day ACCHA 2013
61
Causes of fatigue in heart failure
Sleep Apnea Overdiuresis Depression Also Beta blocker
62
When to use MRA Post MI
1. LVEF-40% or less 2. Symptoms of HF 3. Or Diabetes Mellitus
63
MRA in HF to be used if
1. EF-35% or less 2. NYHA 3/4 3. If NYHA 2- should have high BNP or history of prior hospitalization ACCHA 2013
64
Few Non HF causes of high BNP
LVH Anemia Obstructive Sleep Apnea Valvular diseases
65
The new ACCHA COR/LOE is from the year
2015
66
Creatinine cut off for MRA
2.5 creatinine-STOP ( But 2 in women) Or GFR-30 -STOP
67
Role of MRA in HFpEF is
to reduce hospitalization
68
Hepcidin is
Protein which shifts Iron to the intravascular compartment Levels are low in HF. This is the rationale for IV Iron therapy in HF- 2b ACCHA 2017
69
GFR calculation inSPRINT trial was with
MDRD equation
70
In HF pEF HTN is preferably treated with (ACCHA2017)
RAAS inhibitors- ACE/ARB/MRA and possibly ARNI- ACCHA 2017 And target SBP<130
71
SPRINT said target BP of 120/80 or less which was modified to an office setting value of ——by ACCHA 2017
130/80- they say office BP is 5-10 mmHg high than research setting
72
2015 SPRINT trial was basically
Targeting a new BP target for pts at high cardiovascular risk This reduced HF and cardiac death
73
The upper limit of normal in non acute settings for BNP and NT-pro BNP is ESC 2016 guidelines
35 pg/ ml and 125 pg / ml respectively 2016 ESC HF guidelines In Acute settings <100 and 300pg/ml

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