15.3 (15.3) advanced heart disease

Question 1

2 types of CHF and the EF associated

Answer 1

HFrEF (HF with reduced ejection fraction) - EF </= 40% - systolic HF
HFpEF (HF with preserved ejection fraction) - EF > 50% - diastolic HF

Question 2

Name 2 ways to classify CHF severity

Answer 2

NYHA (New York Heart Assoc) class
AHA (American Heart Assoc) stage

Question 3

List three barriers to palliative care provision in patients with advanced heart disease

Answer 3

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*

Question 4

List four positive benefits of medical management in patients with advanced heart disease

Answer 4

slow disease progression
help patients live longer
improve QOL
avoid hospitalization

Question 5

How long should CHF patients continue cardiac medications?

Answer 5

Close to death

Question 6

List five classes of medication used in the management of heart failure with reduced ejection fraction (systolic)

Answer 6

ACEI/ARB
BB
Spironolactone
SGLT2 inhibitors (new CCS guideline, not in oxford)
Digoxin, dobutamine
Diuretics
Nitro

AB - SS - DD - N

Question 7

Name 3 ways to administer diuretics in patients with gut edema

Answer 7

Combine loop diuretic (lasix) with a thiazide diuretic (HCTZ)

Use alternative loop diuretics such as bumetanide or torsemide

Give IV

Question 8

At what additional weight should pts be advised to take extra dose of loop diuretic? How long should they take extra?

Answer 8

1kg over baseline weight - take extra diuretics daily until return to baseline weight

Question 9

List 3 side effects of ACEI

Answer 9

cough

hypotension
renal insufficiency
hyperkalemia

angioedema

Question 10

What happens if patients remain symptomatic after optimal ACEI or ARB?

Answer 10

Trial of ARNI (sacubitril-valsartan) - improve mortality, QOL and hosp rate

Question 11

What to do if patients cannot tolerate ACEI/ARB/ARNI?

Answer 11

Combination of hydralazine + isosorbide dinitrate

Question 12

What medication can be added to improve symptoms and reduce hosp. if ACEI/ARB + BB + mineralocorticoid antagonist + diuretics are optimized?

Answer 12

Digoxin (inotrope)
SGLT2 inhibitors

Question 13

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)?

Answer 13

IV inotrope - dobutamine or milrinone

Mechanical circulatory support (LVAD)
Heart transplant
Palliative approach

Question 14

List three medications to avoid in patients with HF

Answer 14

NSAIDs
Thiazolidinediones “TZD” (eg rosiglitazone for diabetes)
QTc prolonging meds - methadone, TCAs, venlafaxine

Question 15

Name 3 key non-pharm management of CHF

Answer 15

Daily fluid restriction (1.5-2L per day)

Salt restriction (<2-3g daily) - little evidence to support this

Exercise

Question 16

List 3 implantable devices that may be used for patient’s with heart failure.

Answer 16

Implantable cardioverter defibrillator (ICD)
cardiac resynchronization therapy (CRT)
Left ventricular assist device (LVAD)

Question 17

Who should be considered for ICD?

Besides defibrillation, all ICDs are also capable of?

Answer 17

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

Question 18

How does CRT work?

When is it indicated? 3 reasons

What is it commonly combined with?

Answer 18

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

Question 19

What does LVAD stand for and what are the 2 indications?

Answer 19

Left ventricular assist device

1. Bridge to transplantation (BTT)
2. Destination therapy (DT) - older and more symptomatic patients

Question 20

Complications of LVAD - name 3

Answer 20

Bleeding
Driveline infections
Thrombosis
Embolic stroke
Device failure
Death

Question 21

List four common symptoms in patients with advanced HF

Answer 21

pain
breathlessness
edema
depression
Fatigue

Question 22

Name 3 pharm and 4 non-pharm ways to manage SOB in CHF

Answer 22

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

Question 23

Name 4 ways to manage fatigue in CHF

Answer 23

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)

Question 24

What anti-depressant class should be avoided in CHF?

Answer 24

TCA - increase tachycardia and arrhythmia (also prolong QTC)

Question 25

List 5 markers of poor prognosis in a patient with HF

Answer 25

CHF related:
Multiple hospitalization*
Higher NYHA class*
hypotension

Patient related:
advanced age*
Frailty*
weight loss/cachexia*

Comorbidities:
CKD, COPD*

hyponatremia
history of sudden death

Question 26

Name 2 prognostic tools for HF?

Name 3 domains does both tools look at

Answer 26

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)

Question 27

What is the gold standard tx for advanced CHF? What is median survival with this intervention?

Answer 27

Cardiac transplant - median survival > 12 years