38 - Heart Failure

Question 1

What defines HFrEF?

Answer 1

LVEF < 40%

Question 2

symptoms of heart failure

Answer 2

dyspnea, fatigue, fluid retention

Question 3

non-pharms

Answer 3

• management concomitant disease states
• moderate physical activity in stable patients
• no more than 1 alcoholic drink/day
• restrict sodium intake
• restrict fluid intake
• annual flu vaccine
• pneumococcal vaccine
• monitor daily weight

Question 4

Who are ICDs for? (implantable cardioverter defibrillators)

Answer 4

for those with NYHA class 2-3 and LVEF < 35% or NYHA class 1 & LVEF < 30%

Question 5

Who are CRTs for? (cardiac resynchronization therapy)

Answer 5

for those with NYHA class 2-4 despite optimal medication therapy

Question 6

When using LVADs (left ventricular assist devices) use ____ bridge to transplantation

Answer 6

ASA

Question 7

When do you use CPAP (continuous positive airway pressure) ?

Answer 7

for those with obstructive sleep apnea

Question 8

Patients with HFrEF need long-term tx with ____ and ___

Answer 8

ACEi and BB

Question 9

HFrEF:
What class of drug may be preferred to an ACEi in select patients with mild-mod HFrEF ?

Answer 9

ARNI (combined angiotensin receptor/neprilysin inhibitor) such as valsartan/sacubitril

Question 10

HFrEF:

You can add _____ if patients are still symptomatic despite ACEi and BBs.

Answer 10

MRAs (mineral receptor antagonists) such as spironolactone or eplerenone

Question 11

HFrEF:

____ can control symptoms of hypervolemia

Answer 11

diuretics

Question 12

HFrEF:

Recommend ____ for all patients. Start at low doses and titrate at 7-14 day intervals.

Answer 12

ACEi

Question 13

HFrEF:

What do you need to monitor with ACEi?

Answer 13

SCr, K+ and BP before starting and changing doses.

Question 14

HFrEF:

When you start an ACEi, an increase of SCr up to ___% is expected and acceptable

Answer 14

30%

Question 15

HFrEF:

In the ARNI combo valsartan/sacubitril, how does sacubitril affect valsartan?

Answer 15

it increases the bioavailability of valsartan

Question 16

HFrEF:

If switching between ACEi/ARNI how long do you need to wait and why?

Answer 16

Must wait 36 hours between ACEi and ARNI (and vice versa) to decrease risk of angioedema

Question 17

HFrEF:

How often do you titrate dose of ARNI’s?

Answer 17

every 2-4 weeks

Question 18

HFrEF:

Which BBs are indicated for heart failure?

Answer 18

bisoprolol, carvedilol, metoprolol succinate (not in Canada)

Question 19

HFrEF:

points about BBs?

Answer 19

• start at low dose
• titrate every 2-4 weeks
• monitor BP and HR
• BBs should not be stopped abruptly

Question 20

HFrEF:

Thiazide diuretics for ____ fluid retention

Answer 20

fluid

Question 21

HFrEF:
\_\_\_\_ diuretics (ex. furosemide) are required in most patients

Answer 21

loop

Question 22

HFrEF:

Need to ____ doses of furosemide for patients with renal dysfunction

Answer 22

increase

Question 23

HFrEF:

Thiazide diuretics have poor efficacy if CrCl < ____

Answer 23

50 mL/min

Question 24

HFrEF:

Monitor what while on diuretics?

Answer 24

SCr and electrolytes

Question 25

HFrEF:

What do thiazide and loop diuretics deplete?

Answer 25

K+ and Mg2+

Question 26

HFrEF:

What to keep K+ > _____ while on diuretics?

Answer 26

4 mmol/L

Question 27

HFrEF:

What can you add to help with hypokalemia and hypomagnesemia?

Answer 27

potassium-sparing diuretics (eplerenone or spironolactone)

Question 28

HFrEF:

ARBs are an alternative to ACEi if ____ or _____ present

Answer 28

cough or angioedema

Question 29

HFrEF:

What are MRAs for?

Answer 29

for patients who remain symptomatic despite use of ACEi and BB.

Question 30

HFrEF:

Do not use MRAs if ???

Answer 30

K+ > 5 mmol/L, sCr > 221 umol/L or CrCl < 30

Question 31

HFrEF:
Which MRA (spironolactone or eplerenone) can cause gynecomastia?

Answer 31

spironolactone

Question 32

HFrEF:

Who is ivabradine used for?

Answer 32

for those with LVEF < 35% who present with NHYA class 2-3 symptoms, resting HR > 77 despite using BBs or if they cant use BBs

*Target HR 50-60 bpm

Question 33

HFrEF:

____ can help improve HF symptoms

Answer 33

digoxin

Question 34

HFrEF:

When should you check digoxin levels and what is the target?

Answer 34

Check digoxin serum levels at least 8 hours after drug administration (target 0.6 - 1 nmol/L)

Question 35

HFrEF:

Who is ISDN/hydralazine for?

Answer 35

black patients or those who can’t tolerate other options

*nitrates alone do not reduce mortality

Question 36

HFrEF:

Can use omega 3 FAs but high doses > 3g/day increases risk for ___

Answer 36

bleeds

Question 37

HFrEF:

Which CCB is safe?

Answer 37

amlodipine is safe but does not decrease mortality/morbidity

Question 38

HFrEF:

Which anti-arrhythmic can be used to maintain sinus rhythm if they also have A. Fib?

Answer 38

amiodarone

Question 39

HFrEF:

Reasonable to also consider ____ as add on for cardioprotection

Answer 39

statins

Question 40

HFpEF:

How do we manage this?

Answer 40

• focus tx on control of risk factors
• consider ACEi or ARB for HRN, esp if DM
• should use MRA.
• Can use BB or diuretics if indicated
• can use verapamil or diltiazem

Question 41

How do you handle decompensated HF ?

Answer 41

• furosemide
• can add a vasodilator such as nitroglycerin
• for low cardiac output, add milrinone or dobutamine if systolic > 90
• dobutamine is preferred if systolic < 90
• limit use of vasopressors (dopamine or NE)
• may have short-term vasopressin antagonist Tolvaptan