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Geriatrics > HF > Flashcards

HF Flashcards

1
Q

What is the most common discharge diagnosis for 65+ years?

A

HF

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2
Q

What are the changes in anatomy and physiology which contribute to HF?

A

Increased vascular stiffness
Decreased endothelial function
Diminished beta-adrenergic stimulation
Often preserved left ventricular function

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3
Q

What conditions can mimic HF?

A

Chronic deconditioning
Chronic lung disease
Peripheral edema

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4
Q

What are atypical presentations of HF?

A

Anorexia
Confusion
Fatigue
Generalized weakness

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5
Q

What is the best way to determine HF in elderly?

A

LV function echo is best

BNP is high in elderly (less specific test and unclear role in diagnosis)

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6
Q

What is the prognosis of HF?

A

5 year survival for those 80+ years <25%

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7
Q

What are the primary treatment goals for patients with HF?

A

Improve QOL
Reduce frequency of HF exacerbations
Extend survival

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8
Q

What are the secondary treatment goals for patients with HF?

A

Maximize independence
Increase exercise capacity
Enhance emotional well-being
Manage associated costs of care

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9
Q

Which CCBs do we avoid in HF and why?

A 
First generation (nifedipine, verapamil, diltiazem)
Increased adverse outcomes
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10
Q

What is stage A HF?

A

At high risk for HF but w/o structural disease or sx of HF

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11
Q

What is stage B HF?

A

Structural heart disease but w/o s/sx of HF

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12
Q

What is stage C HF?

A

Structural heart disease w/prior or current sx of HF

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13
Q

What is stage D HF?

A

Refractory HF

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14
Q

What do patients with stage A HF have?

A 
HTN
Atherosclerotic disease
DM
Obesity
Metabolic syndrome
OR
Using cardio toxins
FH of cardiomyopathy
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15
Q

What are the goals of therapy for stage A HF?

A

Heart healthy lifestyle
Prevent vascular/coronary disease
Prevent LV structural abnormalities

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16
Q

What are the medications for stage A HF?

A

ACE/ARB in appropriate patients for vascular disease/DM

Statins as appropriate

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17
Q

What do patients with stage B HF have?

A

Previous MI
LV remodeling including LVH and low EF
Asymptomatic valvular disease

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18
Q

What are the goals of therapy for patients with stage B HF?

A

Prevent HF sx

Prevent further cardiac remodeling

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19
Q

What are the medications for stage B HF?

A

ACE/ARB

BB

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20
Q

What select patients are qualified for stage B?

A

ICD

Revascularization or valvular surgery as appropriate

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21
Q

What do patients with stage C HF have?

A

Known structural heart disease and

HF s/sx

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22
Q

What are the goals of HFpEF therapy?

A

Control sx
Improve HRQOL
Prevent hospitalization
Prevent mortality

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23
Q

What is the treatment of HFpEF?

A

Diuresis to relieve sx of congestion

Follow guideline driven indications for comorbidities (HTN, AF CAD, DM)

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24
Q

What are the two types of HF?

A

HFpEF (reserved

HFrEF (reduced)

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25
Q

What are the goals of therapy in HFrEF?

A

Control sx
Patient education
Prevent hospitalization
Prevent mortality

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26
Q

What drugs are used in HFrEF?

A

Diuretics for fluid retention
Entresto (ACE/ARB)
BB
Aldosterone antagonists

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27
Q

What do patients have in stage D HF?

A

Marked HF sx at rest

Recurrent hospitalizations despite GDMT

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28
Q

What are the goals of therapy in stage D HF?

A

Control sx
Improve HRQOL
Reduce hospital readmissions
Establish patient’s end-of-life goals

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29
Q

What are treatment options for stage D HF?

A 
Advanced care measures
Heart transplant
Chronic inotropes
Temporary/permanent MCS
Experimental surgery/drugs
Paliative care/hospice
ICD deactivation
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30
Q

How do ARNIs work compared to enalapril?

A

Decreased CV death or HF hospitalizations

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31
Q

What trials were there for BBs?

A

SENIORS
MERIT-HF
COLA II
OPTIMIZE-HF

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32
Q

What drugs did the SENIORS trial compare?

A

Nebivolol vs PBO

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33
Q

What was the patient population in the SENIORS trial?

A

> /= 70 years any EF

34
Q

What were the results of the SENIORS trial?

A

Nebivolol decreased mortality and CV hospitalization

No difference between 75-85 or > 85 years

35
Q

What drugs did the MERIT-HF trial compare?

A

Metoprolol succinate vs PBO

36
Q

What patients did the MERIT-HF trial study?

A

> /= 65 years

37
Q

What were the results of the MERIT-HF trial?

A

Post hoc: decreased mortality, sudden death, and hospitalization
Significant benefit > 75 years

38
Q

What drugs were observed in the COLA II trial?

A

Carvedilol

39
Q

What patients were studied in the COLA II trial?

A

> /= 70 years

40
Q

What are the results of the COLA II trial?

A

Majority of patients tolerated for at least 3 months

41
Q

What drugs did the OPTIMIZE-HF trial compare?

A

BBs

42
Q

What type of trial is the OPTIMIZE-HF trial?

A

Retrospective

43
Q

What type of patients were studied in the OPTIMIZE-HF trial?

A

Patient registry and medicare claims data; hospitalized for HF

44
Q

What were the results of the OPTIMIZE-HF trial?

A

HFrEF: BB decreased mortality
HFpEF: BB no mortality benefit

45
Q

What trials were done on ACEi?

A

Gambassi et al
Flather et al
PEP-CHF

46
Q

What drugs were studied in the Gambassi et al trial?

A

ACEi or digoxin

47
Q

What type of trial was Gambassi et al?

A

Retrospective

48
Q

What patients were studied in the Gambassi et al trial?

A

Nursing home
Avg age 84 (ACEi), 85 (dig);
Enknown EF

49
Q

What were the results of the Gambassi et al trial?

A

ACEi decreased mortality vs digoxin

50
Q

What drugs were studied in the Flather et al trial?

A

ACEi

51
Q

What patients were studied in the Flather et al trial?

A

Systemic overview of 5 prospective trials

HF and post MI

52
Q

What were the results of the Flather et al trial?

A

> /= 75 years had smaller mortality benefit than younger patients but still decreased mortality

53
Q

What drug did the PEP-CHF trial study?

A

Perinopril

54
Q

What patients were studied in the PEP-CHF trial?

A

> /= 70 years with HFpEF?

55
Q

What were the results of he PEP-CHF trial?

A

“Trend” towards decreased mortality and hospitalization (did not meet power)

56
Q

What was the ARNI trial?

A

PARADIGM-HF

57
Q

What drugs were investigated in PARADIGM-HF trial?

A

Valsartan/sacubitril vs enalapril

58
Q

What were the patients in the PARADIGM-HF trial?

A

Avg age 63 +/- 1 1 yo
LVEF 29%
70% NYHA class II

59
Q

Is there any relevant PK difference in ARNIs when given to elderly?

A

Yes

60
Q

What would be the results if an ARNI is given with NSAIDs in patients with volume-depleted, compromised renal function?

A

Possible worsening of renal function, including possible acute renal failure

61
Q

What trial was used for ivabradine?

A

SHIFT

62
Q

What drugs did the SHIFT trial study?

A

Ivabradine vs PBO

63
Q

What were the patients studied in the SHIFT trial?

A

Avg age 60 +/11 yo
NYHA Class II-III
LVEF 29%
Optimized, stable regimen

64
Q

What were the results of the SHIFT trial?

A

Decreased composite endpoint (CV death and HF hospitalization) BUT only hospitalization showed benefit individually
No mortality benefit
>/= 65: no clear benefit for composite endpoint

65
Q

Which elderly patients are more likely to have CIs?

A

Pacemaker dependence

Use of strong 3A4 inhibitors

66
Q

What are the trials that study digoxin?

A

DIG (ACC)
DIG (JAMA)
DIG substudy-Ahmed et al (AJC)

67
Q

What was digoxin compared to in the DIG (ACC) trial?

A

PBO

68
Q

What patients were studied in the DIG (ACC) trial?

A

Stratified by age
Main study: LVEF = 45%
Ancillary: LVEF > 45%

69
Q

What were the results of the DIG ACC trial?

A

InHFrEF: Dig = no mortality benefit, decreased hospitalization, applies to all age groups
Older age = increased toxicity, withdrawal
Insufficient evidence to recommend dig in HFpEF, especially in very old

70
Q

What patients were in the DIG (JAMA) trial?

A

Evaluating dig levels

71
Q

What were the results of the DIG JAMA trial?

A

Low mortality at 0.5-0.8 mg/dl versus higher concentrations

72
Q

What drugs were studied in the DIG substudy-Ahmed et al (AJC)?

A

Digoxin continuation at low SDC vs d/c

73
Q

What was the patient population of the DIG substudy-Ahmed, et al (AJC)

A

Avg age = 63 yo
N = 1666 continued on dig
N - 1699 d/c
Low SDC = 0.0 - 0.9 ng/ml

74
Q

What were the results of the DIG substudy-Ahmed et al (AJC)

A 
Continuation = decreased all-cause mortality, all cause and HF hospitalization
Discontinuation = increased all cause and HF hospitalization, no effect on mortality
75
Q

What is the serum digoxin level?

A

0.5-0.8 mg/dl

76
Q

What drugs for HF are on the Beers List?

A

Spironolactone

Digoxin

77
Q

What are the renal adjustments with spironolactone?

A

Avoid if CrCl < 30

78
Q

How does spironolactone impact potassium levels?

A

Increased risk of hyperkalemia (especially with ACEi/ARB)

79
Q

What is the max digoxin daily dose?

A

Avoid greater than 0.125mg daily

80
Q

Why do we avoid higher digoxin doses in the elderly?

A

Increased toxicity with no additional benefit

May be associated with increased mortality

81
Q

What drugs do we avoid in HF d/t increased risk of fluid retention and/or HF exacerbations?

A 
TZDs
NSAIDs
COX-2 inhibitors
Cilostazol
Dronedarone (if severe/decompensated HF)
non-DHP CCB (if HFrEF)

Geriatrics (15 decks)

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