15.3 (15.3) advanced heart disease Flashcards
2 types of CHF and the EF associated
HFrEF (HF with reduced ejection fraction) - EF </= 40% - systolic HF
HFpEF (HF with preserved ejection fraction) - EF > 50% - diastolic HF
Name 2 ways to classify CHF severity
NYHA (New York Heart Assoc) class
AHA (American Heart Assoc) stage
List three barriers to palliative care provision in patients with advanced heart disease
Disease:
- Prognosticating difficult*
- Patients with HF are medically complex and require multiple specialists which complicates integration of best practices in cardiology and PC
Cardiologists:
-Misperception that PC is only EOL *
-Concern that PC specialists may potentially discourage needed interventions due to lack of knowledge of CHF
Palliative:
-Lack of PC services for people with HF*
List four positive benefits of medical management in patients with advanced heart disease
slow disease progression
help patients live longer
improve QOL
avoid hospitalization
How long should CHF patients continue cardiac medications?
Close to death
List five classes of medication used in the management of heart failure with reduced ejection fraction (systolic)
ACEI/ARB
BB
Spironolactone
SGLT2 inhibitors (new CCS guideline, not in oxford)
Digoxin, dobutamine
Diuretics
Nitro
AB - SS - DD - N
Name 3 ways to administer diuretics in patients with gut edema
Combine loop diuretic (lasix) with a thiazide diuretic (HCTZ)
Use alternative loop diuretics such as bumetanide or torsemide
Give IV
At what additional weight should pts be advised to take extra dose of loop diuretic? How long should they take extra?
1kg over baseline weight - take extra diuretics daily until return to baseline weight
List 3 side effects of ACEI
cough
hypotension
renal insufficiency
hyperkalemia
angioedema
What happens if patients remain symptomatic after optimal ACEI or ARB?
Trial of ARNI (sacubitril-valsartan) - improve mortality, QOL and hosp rate
What to do if patients cannot tolerate ACEI/ARB/ARNI?
Combination of hydralazine + isosorbide dinitrate
What medication can be added to improve symptoms and reduce hosp. if ACEI/ARB + BB + mineralocorticoid antagonist + diuretics are optimized?
Digoxin (inotrope)
SGLT2 inhibitors
When patients are admitted with hospital with CHF and also presents with hypotension - what medication can be used to improve cardiac function and symptoms?
What to do if patients cannot tolerate dose tapering of this medication (i.e. hypotension recurs)?
IV inotrope - dobutamine or milrinone
Mechanical circulatory support (LVAD)
Heart transplant
Palliative approach
List three medications to avoid in patients with HF
NSAIDs
Thiazolidinediones “TZD” (eg rosiglitazone for diabetes)
QTc prolonging meds - methadone, TCAs, venlafaxine
Name 3 key non-pharm management of CHF
Daily fluid restriction (1.5-2L per day)
Salt restriction (<2-3g daily) - little evidence to support this
Exercise
List 3 implantable devices that may be used for patient’s with heart failure.
Implantable cardioverter defibrillator (ICD)
cardiac resynchronization therapy (CRT)
Left ventricular assist device (LVAD)
Who should be considered for ICD?
Besides defibrillation, all ICDs are also capable of?
Pts with prior arrest
Selected pts with HFrEF + EF <30% despite 3 months of optimal med tx
Pacemaking to treat bradycardia (pts can choose to turn off defibrillating function of ICD while leaving pacing functions on)
uptodate: indications for ICD
(1) Primary prevention - in pts with previous V tach or V fib
(2) Secondary prevention - in pts with high risk of V tach of V fib
- Prior MI + LVEF </= 30
- Cardiomyopathy + NYHA 2-3 + LVEF </= 35% (despite 3 months trial of meds)
- Congenital long QT syndrome
How does CRT work?
When is it indicated? 3 reasons
What is it commonly combined with?
BIVENTRICULAR PACEMAKER to synchronize contraction of the ventricles (via 3 leads - atrial, R ventricular, L ventricular leads) -> improve ventricular function and symptoms -> slow HF progression + extend life
Indications:
- ECG indicating L ventricular dyssynchrony (wide L BBB pattern)
- persistent low EF < 35%
- NYHA class II-IV symptoms
Commonly combined with ICD
What does LVAD stand for and what are the 2 indications?
Left ventricular assist device
- Bridge to transplantation (BTT)
- Destination therapy (DT) - older and more symptomatic patients
Complications of LVAD - name 3
Bleeding
Driveline infections
Thrombosis
Embolic stroke
Device failure
Death
List four common symptoms in patients with advanced HF
pain
breathlessness
edema
depression
Fatigue
Name 3 pharm and 4 non-pharm ways to manage SOB in CHF
Meds:
Lasix
Nitro
Inotrope
Opioids
Non-meds:
O2
Exercise
Thoracentesis for large pleural eff despite optimized tx
FS - similar to lung SOB management
Breathlessness
Self management
Equipment
Education, rehab, support
Meds
Surgery
WP - ? split card
Name 4 ways to manage fatigue in CHF
Optimized CHF medical management
Tx comorbidities (e.g. anemia, OSA, obesity)
Caffeine (e.g. 2 cups of coffee) - avoid psychostimulant drugs
Exercise
Energy conservation (e.g. pacing, using shower chair)
What anti-depressant class should be avoided in CHF?
TCA - increase tachycardia and arrhythmia (also prolong QTC)
List 5 markers of poor prognosis in a patient with HF
CHF related:
Multiple hospitalization*
Higher NYHA class*
hypotension
Patient related:
advanced age*
Frailty*
weight loss/cachexia*
Comorbidities:
CKD, COPD*
hyponatremia
history of sudden death
Name 2 prognostic tools for HF?
Name 3 domains does both tools look at
Seattle Heart Failure Model
MAGGIC risk calculator
3 domains:
demographic characteristics (age, gender, BMI)
cardiac status (NYHA class, sBP, EF)
meds (ace, arb, beta-blocker)
SHFM also looks at:
- devices (ICD)
- lab values (hbg, lymphocytes, sodium, uric acid, total cholesterol)
What is the gold standard tx for advanced CHF? What is median survival with this intervention?
Cardiac transplant - median survival > 12 years
