Heart failure and cardiomyopathy

Question 1

Risk factor for HF

Answer 1

AGE
HTN +++ = 39% of HF in men and 59% in women
MI
Valvular lesions
thyrotoxicosis
Arrhythmias

Question 2

Pathophysiology of heart failure

Answer 2

Index event - MI, HTN, Valvular disease –> myocyte injury

Myocyte injury:

• > Neurohormonal activation
• > Peripheral vasoconstriction
• > Fluid retention
• > Decreased contractility

–> progressive heart failure

Question 3

NYHA Criteria

Answer 3

Class 1 = asymptomatic
Class 2 = Symptoms with exercise
Class 3 = Symptoms during everyday activities
Class 4 = Symptoms at rest

Question 4

Signs of chronic heart failure

Answer 4

Orthopnoea = most reliable

90% of patients with PCWP >22

Question 5

What is diastolic heart failure

Answer 5

Disordered filling of the ventricle
Stiffening ventricle –> need for increased pressures to fill
Can be isolated but most commonly with systolic HF
Caused by HTN and HOCM most commonly

Question 6

Treatment for Diastolic heart failure

Answer 6

NIL RCTs
Avoid fluid depletion and inotropes
Improve relaxation - beta blockers and calcium channel blockers
Rate control AF

Question 7

Use of BNP for heart failure diagnosis

Answer 7

>400pg/mL = CHF likely
<100 = unlikely
100-400 = patients history - LV dysfunction, cor pulmonale or PE = CHF

Question 8

Reducing heart failure in high risk patients

Answer 8

Risk factor reduction = Treat HTN, Diabetes, hyperlipidaemia
Education
ACE-Is in high risk groups and IHD

Question 9

Treatment of structural heart disease without symptoms

Answer 9

ACE-Is in all

Beta blockers in IHD cardiomyopathy

Question 10

Treatment of structural heart disease with symptoms for heart failure

Answer 10

Education
Heart failure MDT
ACE-Is and beta blockers for all
Aldosterone blockers
Diuretics = nil survival benefit 
Digoxin = nil survival benefit but decreases hospitalisations
Ivabradine if SR and HR >77
AICD if EF >35%
CRT if LBBB

Question 11

HF with refractory symptoms

Answer 11

Inotropes
LVAD
Transplant
Palliation

Question 12

Diuretic Resistance

Answer 12

Oral = gut oedema –> reduced uptake

IV resistance = an extension of cardiorenal syndrome –> frusemide infusion or dobutamine/levosemendan

Question 13

Which is the most potent B blocker?

Answer 13

Carvedilol

Question 14

Which is the most cardioselective B blocker?

Answer 14

Nebivolol

Question 15

Side effects of beta blockers?

Answer 15

Dizziness and dyspnoea

Worse in the short term 3 months prior to the onset of improved symptoms

Question 16

Benefits of beta blockers

Answer 16

Improved morbidity and mortality class 2-3 HF - heart failure and SCDs reduced
Class 4 requires stabilization and euvolaemia prior to commencement 

Dose related benefits

Question 17

Which betablockers have evidence

Answer 17

Carvedilol, bisoprolol and nebivolol

Question 18

Spironolactone and epleronone side effects

Answer 18

Hyperkalaemia

• -> temporary pacing
• -> renal insufficiency
• -> Discontinuation

Must monitor EUCs weekly for the first 4 weeks
Higher doses do not increase benefit

Question 19

What is the mechanism of action for Spironolactone and epleronone?

Answer 19

Aldosterone antagonist –> inhibits ENaC –> reduced reabsorption of sodium and water in the collecting duct

Question 20

What is the mechanism of action of ivabradine?

Answer 20

A sinus node funny/sodium channel inhibitor which slows the upstroke of depolarisation –> slower heart rate

Does not have neurohormonal effects

Question 21

What is the benefit of ivabradine?

Answer 21

Reduces hospitalisations for heart failure in class 2-4 heart failure
Reduces mortality for patients with HR <77bpm

NO SUBSTITUTE FOR BETA BLOCKERS
SHIFT trial

Question 22

What is LCZ696/Entresto

Answer 22

Valsartan + sacubitril

Question 23

What is sacubitril

Answer 23

A neprolysin inhibitor

Sacubitril is a prodrug that is activated to sacubitrilat by de-ethylation via esterases –> inhibits the enzyme neprilysin, a neutral endopeptidase that degrades vasoactive peptides, including natriuretic peptides, bradykinin, and adrenomedullin –> increases these peptides –> blood vessel dilation and reduction of ECF volume via sodium excretion

Question 24

Which treatments decrease symptoms but don’t improve mortality?

Answer 24

Digoxin and diuretics

Question 25

What is the mortality rate for advanced heart failure?

Answer 25

Advanced HF = symptoms despite max therapy 10% of CCF patients/yr 25% mortality at 1yr

Question 26

Lifestyle measures to reduce HF symptoms?

Answer 26

``` Education Lifestyle changes: - Salt restriction - Water restriction - Weight reduction - Cease smoking - Cease alcohol Rehab programs Manage co-morbidities ```

Question 27

Causes of death by NYHA class

Answer 27

Class 2 = Sudden death +++ Class 3 = Sudden death ++ Heart failure + Class 4 = Heart failure

Question 28

When is AICD indicated?

Answer 28

Class 2-3 with LVEF <35% with maximal medical therapy | If IHD = must wait at least 40 days

Question 29

When is CRT indicated?

Answer 29

Class 3-4 with LVEF <35% and QRS > 120ms Class 2 with LVEF <35% with LBBB + QRS >150 MUST be in SR and have ongoing symtpoms despite optimal medical therapy Aims to pace the ventricles constantly to prevent MR

Question 30

What about Bi-Ventricular pacing?

Answer 30

For patient with class1-3 and LVEF<50% Bi-V reduces death and HF hospitalizations

Question 31

Indications for Cardiac transplant?

Answer 31

Refractory class 3-4 HF VO2 max <14 mL/kg/min + anaerobic metabolism Severe ischaemia not amenable to treatment Recurrent refractory ventricular arrhythmias

Question 32

Disadvantages of Transplantation?

Answer 32

Donor shortage Long waiting times 10-20% wait list mortality Risks of immunosuppression Risk of rejection

Question 33

Mortality of transplant patients?

Answer 33

4%/yr

Question 34

Pathophysiology of HOCM?

Answer 34

Abnormal hypertrophy any any part of the ventricle +/- LV outflow obstruction + Diastolic dysfunction +++ Diastolic dysfunction --> LA dilation --> AF

Question 35

Presentation of HOCM?

Answer 35

``` Asymptomatic Palpitations and syncope SCD Endocarditis Angina ```

Question 36

Signs of HOCM?

Answer 36

Ejection systolic murmur which varies with contractility, preload and afterload Mitral regurgitation ECG = T wave inversion of Lateral leads

Question 37

Principles of management of HOCM

Answer 37

Treat heart failure - Beta blockers - ACEI-s - DO NOT use digoxin and diuretics Alcohol septal ablation Myomectomy Prevent SCD - Beta blockers - AICD Screen relatives

Question 38

Risk factors for SCD in HOCM

Answer 38

``` Family history Recurrent syncope NSVT Severe LVH Severe obstruction Abnormal BP response with exercise Specific genotype - ARG719TRP ```

Question 39

Restrictive Cardiomyopathy

Answer 39

Predominant right heart failure Preserved LVEF with diastolic dysfunction Atria dilated AV regurg TREATMENT = transplant and fluid balance Response usually poor