Flashcards in MKSAP 3: Heart Failure Deck (48):
What is the most important diagnostic test for evaluating heart failure?
What are the general ranges of BNP is someone with decompensated HF?
Most common causes of HFpEF?
HFpEF: HTN, CAD
HFrEF: HTN, CAD, myocarditis, drugs (doxorubicin, trastuzumab, cyclophosphomide
What is the general approach to a patient with acute exacerbation of heart failure?
Manage the acute exacerbation with diuretics and ACEi and then get them on a stable long-term medication regimen to reduced mortality and symptoms
List the NYHA Functional Classes:
I: no limitation of physical exercise
II: Slight limitation of physical exercise
III: Marked limitation of physical activity
IV: Unable to carry on any physical activity without symptoms
therapies that decrease mortality in Heart failure
Aldosterone antagonists (NYHA II-IV)
Hydralazine/nitrates (blacks with NYHA III/IV)
therapies that improve symptoms in heart failure
All HFrEF patients should be started on an ACEi up to what level creatinine?
what is the underlying pharmacologic benefit of BB therapy in HFrEF
block the adverse effects of chronic neurohormonal activation on cardiac function
What 3 beta blockers are approved for HFrEF and what dosages?
carvedilol (25mg BID)
metoprolol succinate (NOT tartrate) (200mg QD)
bisoprolol (10mg QD)
What are the recommendations in terms of initiating ACEi and BB therapy inpatient vs outpatient?
A short acting ACEi like captopril can be started inpatient to make sure patient doesn't experience orthostatic hypotension.
Beta blocker should only be initiated once the patient is euvolemic and should be started on lowest possible dose with titration OUTPATIENT on a 1-2 week interval
What therapy can be added to a loop diuretic in decompensated, volume overload systolic heart failure?
What adverse effects do you need to watch for during diuretic therapy?
hypokalemia, hypomagnesemia, worsening kidney function
What populations do you need to be cautious in with digoxin therapy for HFrEF?
Patients with kidney impairment, low body mass, and older age
What subgroup of HFrEF patients have aldosterone antagonists been studied in?
NYHA II-IV symptoms
What is the principal side effect of aldosterone antagonists?
What are the lab cut offs (Scr and K+) for use of aldosterone antagonists in patients with HFrEF? When should you check electrolytes after starting these drugs?
Scr below 2.5 in men and 2.0 in women
K+ below 5.0
Check electrolytes one week after starting med
What are the dosages for spironolactone and epleronone in HFrEF?
spironolactone 12.5-25 mg/d
What therapy combination can be used in black patients and/or renal dysfunction patients that limit ACEi/ARB therapy with HFrEF?
isosorbide dinitrate and hydralazine
But this should only be instituted if ACEi or ARB and BB therapy is maximized
What are the nondihydropyridine CCBs and what should you do if a patient with a new diagnosis of HFrEF is on these meds?
diltiazem and verapamil -> cause myocardial depression in treatment of HTN so should be stopped in new diagnosis of HFrEF
What are the dihydropyridine CCBs and are they indicated for HFrEF?
amlodipine and felodipine -> yes, shown to be safe in patients with HFrEF
What is the general therapeutic knowledge and approach to patients with HFpEF?
ACEi, ARBs, BB and aldosterone antagonists have all been studied in HFpEF. But none have demonstrated clinical benefit compared to placebo. Currently, NO MEDS have demonstrated a reduction in mortality. Tx causes and symptoms -> HTN and HR control
What is the only reliable predictor of an arrhythmic event in heart failure patients?
left ventricular ejection fraction
What is the indication for device therapy in heart failure for primary prevention according to ACC/AHA?
NYHA class II or III while taking GDMT AND expected survival > 1 year AND either: (1) ischemic CM > 40 days post MI or nonischemic CM with EF < 35% OR (2) Hx of hemodynamically significant ventricular arrhythmia or cardiac arrest
What should you do after patient has recent onset heart failure to evaluate for device therapy?
Wait 6 months on GDMT in patients with a reasonable chance of recovery
What is the indication for BiV pacing (cardiac re-synchronization therapy in heart failure?
All of the following:
NYHA Class II - IV
Ventricular dyssynchrony (LBBB with QRS duration > 150 msec)
What are the recommendations for serial BNP monitoring for outpatient evaluation of chronic HF?
Serial BNP monitoring does not predict progression of disease and no evidence of benefit to using BNP to assess volume status or dose adjustment of meds
What are the recommendations for Echo for chronic heart failure?
Recheck after 6 months of initiating GDMT -> recommended
Chronic heart failure patients who are clinically stable or annual repeats -> not recommended
Decompensated heart failure requiring admission -> repeat TTE is reasonable
What is the overall therapeutic and diagnostic approach to acute decompensated heart failure?
Therapy is focused on diuresis. Diagnostic approach is focused on reason for decompensation: review of meds, and echo and evaluation of ischemia
What should be done with patient's ACEi and BB on admission for AECHF?
Continue them unless evidence of low output heart failure: hypotension, worsening kidney function, worsening liver function, cool extremities
What are the objective markers of decongestion in treatment for AECHF?
net urine output, weight loss, evidence of hemoconcentration and reduction in BNP levels
Define cardiogenic shock
Persistent, symptomatic hypotension and end organ dysfunction
What are the reversible causes of cardiogenic shock that must be quickly ruled out?
ventricular wall or free wall rupture
Acute valvular regurgitation - papillary muscle rupture, infection or ascending aortic arch aneurysm with dissection of the aortic valve
What are the vasoactive meds usually indicated for in cardiogenic shock?
sodium nitroprusside (pure vasodilator)
What is considered after vasoactive meds in patients with cardiogenic shock not responsive to meds?
Consider a right heart catheter and mechanical assist devices
Why is heart transplant the best option for advanced refractory heart failure?
50% survival rates approaching 13 years, but only 2,000 heart transplants performed in US annually
What are the exclusion criteria for heart transplant?
Upper age limit: 65-70 yrs
kidney dysfunction, diabetes with end organ manifestations, malignancy, chronic infection or other comorbidities are often denied transplant
What are the data on inotropic therapy in patients with advanced refractory heart failure?
May actually increase mortality. <10% survival at 1 year
What are the common complications related to LVADs?
ischemic and hemorrhagic stroke
driveline related infections
GI bleeding related to AV malformations
What is the typical 3 drug regimen following heart transplant?
calcineurin inhibitor (cyclosporine or tacrolimus)
antiproliferative agent (mycophenolate mofetil, sirolimus or everolimus)
What are the signs of rejection in heart transplant patients?
heart failure and atrial arrythmias
What are the long term complications of heart transplant?
cardiac allograft vasculopathy
What is cardiac allograft vasculopathy and why is PCI not helpful to treat it?
occurs in 50% of patients by 5 years. diffuse intimal thickening of the coronary arteries that start distally and progresses proximally. This is why PCI is not helpful
What are the malignancies associated with heart transplant?
lymphoproliferative disorders and skin cancer
What is Takotsubo cardiomyopathy and what is the treatment
Stress induced cardiomyopathy, thought to be sympathetic mediated myocyte injury. ACEI and BB are indicated acutely but can be stopped with recovery of systolic function, unless it doesn't recover which is rare
What is the typical time course for acute myocarditis? What is the typical presentation? What are the common viral causes and pathogenesis? What is the typical time course for recovery?
Myocarditis usually presents with HF symptoms over a few days to weeks. Viral prodrome of fever, myalgia, and upper respiratory symptoms. Adenovirus, coxsackievirus and enterovirus. May involve direct infection of the myocardium or an immune system response. Typical heart failure therapy is indicated. Patients often take 6-12 months to recover.
What are the indications for biopsy of acute myocarditis?
ventricular arrhythmia, high grade conduction block, lack of response to typical heart failure therapy