6: HF Treatment

Question 1

What stage of HF (A, B, C, or D) is usually seen in primary care?

Answer 1

Stage C

Question 2

At what stage (A, B, C, or D) do patients become symptomatic and focus shifts from primary and secondary prevention to tertiary prevention?

Answer 2

Stage C

Question 3

Stage A, B, C, or D?

Patients with HTN

Answer 3

Stage A

Question 4

Stage A, B, C, or D?

Patients with atherosclerotic disease

Answer 4

Stage A

Question 5

Stage A, B, C, or D?

Patients with metabolic syndrome

Answer 5

Stage A

Question 6

Stage A, B, C, or D?

Patients using cardiotoxins

Answer 6

Stage A

Question 7

Stage A, B, C, or D?

Patients with HFx CM

Answer 7

Stage A

Question 8

Stage A, B, C, or D?

Patients with previous MI

Answer 8

Stage B

Question 9

Stage A, B, C, or D?

Patients with LV remodeling

Answer 9

Stage B

Question 10

Stage A, B, C, or D?

Patients with LVH and low EF

Answer 10

Stage B

Question 11

Stage A, B, C, or D?

Patients with asymptomatic valvular disease

Answer 11

Stage B

Question 12

Stage A, B, C, or D?

Patients with known structural heart disease and fatigue, SOB, reduced exercise tolerance

Answer 12

Stage C

Question 13

Stage A, B, C, or D?

Patients who have marked symptoms at rest despite maximal medical therapy

Answer 13

Stage D

Question 14

What are the goals for this stage?

Stage A

Answer 14

Treat HTN
Smoking cessation
Treat lipid disorders
Encourage regular exercise
Discourage alcohol, drugs
Control metabolic syndrome

Question 15

What are the goals for this stage?

Stage B

Answer 15

Same as Stage A

Question 16

What are the goals for this stage?

Stage C

Answer 16

Same as Stages A/B plus:
Dietary salt restriction
Drugs for routine use
Diuretic for fluid retention
ACEs
BBs

Question 17

What are the goals for this stage?

Stage D

Answer 17

Same as Stages A/B/C plus:
Control fluid retention
Referral to HF program for appropriate patients
Decision regarding appropriate level of care
Information regarding inactivating previously implanted defibrillator

Question 18

At what stage might implantable defibrillators be used?

Answer 18

Selected patients in Stages B and C

Question 19

What drugs might be used in this stage?

Stage A

Answer 19

ACE or ARB in appropriate patients for vascular disease or diabetes

Question 20

What drugs might be used in this stage?

Stage B

Answer 20

ACE or ARB in appropriate patients

BB in appropriate patients

Question 21

What drugs might be used in this stage?

Stage C

Answer 21

Aldosterone antagonist
ARB
Digitalis
Hydralazine/Nitrates

Question 22

When do options like hospice, heart transplants, experimental measures, and chronic inotropes come into play?

Answer 22

Stage D

Question 23

Stage A, B, C, or D?

At high risk for HF but without structural heart disease or symptoms of HF.

Answer 23

Stage A

Question 24

Stage A, B, C, or D?

Structural heart disease but without symptoms of HF.

Answer 24

Stage B

Question 25

Stage A, B, C, or D? | Structural heart disease with prior or current symptoms of HF.

Answer 25

Stage C

Question 26

Stage A, B, C, or D? | Refractory HF requiring specialized interventions.

Answer 26

Stage D

Question 27

What classification of recommendation (1, 2a, 2b, or 3)? | Benefit greatly outweighs risk.

Answer 27

Class 1

Question 28

What classification of recommendation (1, 2a, 2b, or 3)? | Benefit outweighs risk; additional studies with focused objectives needed.

Answer 28

Class 2a

Question 29

What classification of recommendation (1, 2a, 2b, or 3)? | Benefit and risk roughly equal; additional data would be helpful.

Answer 29

Class 2b

Question 30

What classification of recommendation (1, 2a, 2b, or 3)? | Risk greatly outweighs the benefit.

Answer 30

Class 3

Question 31

What classification of recommendation (1, 2a, 2b, or 3)? | Procedure or treatment should be performed or administered.

Answer 31

Class 1

Question 32

What classification of recommendation (1, 2a, 2b, or 3)? | It is reasonable to perform the procedure or administer treatment.

Answer 32

Class 2a

Question 33

What classification of recommendation (1, 2a, 2b, or 3)? | Procedure or treatment may be considered.

Answer 33

Class 2b

Question 34

What classification of recommendation (1, 2a, 2b, or 3)? | Procedure or treatment should not be performed or administered as it is not helpful and may be harmful.

Answer 34

Class 3

Question 35

What level of evidence (A, B, C)? | Data derived from multiple randomized clinical trials.

Answer 35

A

Question 36

What level of evidence (A, B, C)? | Data derived from a single randomized trial, or nonrandomized studies.

Answer 36

B

Question 37

What level of evidence (A, B, C)? | Consensus opinion of experts.

Answer 37

C

Question 38

These diuretics are typically used in patients with acute volume overload to rapidly diurese them.

Answer 38

Loop Diuretics Bumetanide Furosemide Torsemide

Question 39

Weaker diuretics used for maintenance therapy or for hypertensive properties.

Answer 39

``` Thiazide Diuretics Chlorothiazide Chlorthalidone Hydrochlorothiazide Indapamide Metolazone ```

Question 40

Diuretic that is a mainstay in HF patients.

Answer 40

Potassium-Sparing Diuretics Amiloride Spironolactone Triamterene

Question 41

Diuretic that can be added to loop diuretics for an additional boost.

Answer 41

Sequential Nephron Blockade Diuretics Metolazone Hydrochlorothiazide Chlorothiazide

Question 42

ACE inhibitors are a Class 1 recommendation in Stage C HF with a level of evidence A. When could they not be used?

Answer 42

Severe renal failure | Hx of hyperkalemia

Question 43

What is an example of a drug combination that is a Class 3 recommendation with level of evidence C?

Answer 43

Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.

Question 44

When might an ARB be used in place of an ACE?

Answer 44

If the patient is already taking an ARB | Patient develops ACE cough

Question 45

Should ACEs and ARBs be combined?

Answer 45

No, combination has not shown any benefits and should not be routinely done.

Question 46

When are aldosterone antagonists (spironalactone) usually added?

Answer 46

After you've already been put on ACEs and BBs to help prevent fluid volume overload in the future.

Question 47

Which ARBs should be used in Stage C?

Answer 47

Candesartan | Valsartan

Question 48

Which ARB is preferred in Stage C for patients who are also post MI?

Answer 48

Valsartan

Question 49

Which aldosterone antagonist is suggested in Stage C?

Answer 49

Spironolactone

Question 50

Which aldosterone antagonist is suggested for patients who are post MI?

Answer 50

Eplerenone

Question 51

Which BBs are recommended in Stage C?

Answer 51

Bisoprolol Carvedilol Metoprolol Succinate

Question 52

Which BB is recommended in Stage C for those who are also post MI?

Answer 52

Carvedilol

Question 53

At what stage is Digoxin recommended in HF?

Answer 53

Stage C

Question 54

Why is BB use recommended in Stage C?

Answer 54

Reduce mortality

Question 55

What are some contraindications or cautions for carvedilol?

Answer 55

Nonselective BB with alpha blocking properties so caution in: Sever pulmonary disease that requires bronchodilators (like COPD) as it can impair bronchodilators

Question 56

Why is metoprolol succinate (XL) commonly used in HF?

Answer 56

It's a selective BB

Question 57

T/F Digoxin is first-line treatment in HF.

Answer 57

False. It used to be. Now it used more selectively and in low doses.

Question 58

After other meds (ACEs, BBs, etc) have reached target doses, what 2 meds have been shown to be beneficial in the AA population?

Answer 58

Hydralazine | Isosorbide Dinitrate

Question 59

What med should not be continued in patients with significant symptoms of volume overload or fluid retention?

Answer 59

CCBs