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oral boards > AHA: HF / MCS / transplant > Flashcards

AHA: HF / MCS / transplant Flashcards

1
Q

CPET discriminator for cardiac transplant benefit

A

VO2max≤14
(or ≤12 if +β-blocker)

“Peak exercise oxygen consumption/oxygen uptake (VO2) is often used to risk stratify patients and make decisions about timing of advanced HF therapies, including heart transplantation and LVAD. In a landmark article, investigators divided patients referred for heart transplantation into groups based on their peak VO2. Patients with peak VO2 <14 mL/kg/min were listed for transplant, while those with higher peak VO2 values were deferred for being too well. Patients with peak VO2 >14 mL/kg/min who were deferred had 1- and 2-year survival of 94% and 84%, respectively, which was similar to survival after heart transplant. As such, the authors proposed peak VO2 ≤14 mL/kg/min as a cutoff to distinguish patients who may derive survival benefit from heart transplant. Patients tolerating beta blockers may have improved survival with an equivalent VO2 compared with patients who do not tolerate beta blockers. For patients on beta blockers, a peak VO2 ≤12 mL/kg/min has been suggested as a more appropriate cutoff to consider cardiac transplant listing.”

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2
Q

VO2max threshold for heart transplant benefit

A

≤14
(≤12 if +β-blocker)

“Peak exercise oxygen consumption/oxygen uptake (VO2) is often used to risk stratify patients and make decisions about timing of advanced HF therapies, including heart transplantation and LVAD. In a landmark article, investigators divided patients referred for heart transplantation into groups based on their peak VO2. Patients with peak VO2 <14 mL/kg/min were listed for transplant, while those with higher peak VO2 values were deferred for being too well. Patients with peak VO2 >14 mL/kg/min who were deferred had 1- and 2-year survival of 94% and 84%, respectively, which was similar to survival after heart transplant. As such, the authors proposed peak VO2 ≤14 mL/kg/min as a cutoff to distinguish patients who may derive survival benefit from heart transplant. Patients tolerating beta blockers may have improved survival with an equivalent VO2 compared with patients who do not tolerate beta blockers. For patients on beta blockers, a peak VO2 ≤12 mL/kg/min has been suggested as a more appropriate cutoff to consider cardiac transplant listing.”

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3
Q

6MWT threshold for heart transplant benefit

A

<300m
(~NYHA III)

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4
Q

GDMT for HFrEF (EF≤40% & +sx)

A
  • statin if h/o MI/ACS ⇒ ￬HF,MACE
  • ARNi for NYHA II-III ⇒ ￬M&M
    / ACEi>ARB for NYHA IV ⇒ ￬HF,death
  • β-blocker ⇒ ￬hosp,death
  • MRA for NYHA ≥II ⇒ ￬M&M
  • SGLT2i ⇒ ￬hosp,CVdeath
  • ± diuretics PRN ⇒ ￬sx,HF progression
  • hydral + isosorbide dinitrate for NYHA ≥III in Blacks ⇒ ￬sx,M&M

(device tx discussed separately)
β-blockers proven ⇒ ￬death = bisoprolol, carvedilol, metoprolol XL
ARNi = angiotensin receptor-neprilysin inhibitor
MRA = mineralocorticoid antagonist = spironolactone, eplerenone
SGLT2i = Na-Glc co-transporter 2 inhibitor (regardless of ±DM) = -gliflozins (e.g. empagliflozin)

all class 1 recommenations

AHA HF guideline
Figure 6. Treatment of HFrEF Stages C and D
https://drive.google.com/file/d/138w94HQ7XSt4VLuN5b-5RdDJA0SYFthv/view

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5
Q

device tx for HFrEF (EF≤40% & +sx)

A
  • EF≤30% + NYHA I ≥40d post-MI:
    ICD ⇒ ￬SCD,death (1)
  • non-ischemic dilated CM OR isch heart dz ≥40d post-MI
    EF≤35% + NYHA II-III:
    ICD ⇒ ￬SCD,death (1)
  • EF≤45% + high-risk features of sudden death:
    ICD ⇒ ￬SCD (2a)
  • EF≤35% + NYHA ≥II + sinus + QRS≥150ms ⊕LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (1)
  • EF≤35% + NYHA ≥II + sinus + QRS≥150ms ⊖LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2a)
  • EF≤35% + NYHA ≥II + QRS=120-150ms ⊕LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2a)
  • EF≤35% + NYHA ≥III + QRS=120-150ms ⊖LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2b)
  • isch HF + EF≤30% + NYHA I + QRS≥150ms ⊕LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp (2b)
  • EF≤35% + afib + req Vpacing OR AVN ablation will allow ~100% Vpacing with CRT ⊕GDMT:
    CRT ⇒ ￪LVEF,QOL, ￬sx,death (2a)
  • EF≤35% + concomitant device proc + req >40% Vpacing:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2a)
  • EF=35-50% + high-degree or complete heart block:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2a)

⊕GDMT & life expect >1y

AHA HF guideline
Figure 6. Treatment of HFrEF Stages C and D
https://drive.google.com/file/d/138w94HQ7XSt4VLuN5b-5RdDJA0SYFthv/view
Figure 8. Algorithm for CRT Indications in Patients With Cardiomyopathy or HFrEF
https://drive.google.com/file/d/13PyWc53WxKqJ5dqDfX42hgud4M-hKiYM/view

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6
Q

GDMT for pre-HF (EF≤40% but asx or NYHA I)

A
  • if h/o MI/ACS: statin ⇒ ￬sxHF,MACE
  • if h/o MI/ACS: β-blocker ⇒ ￬death
  • β-blocker (no h/o MI/ACS) ⇒ ￬sxHF
  • ACEi>ARB for NYHA IV ⇒ ￬sxHF,death

all class 1 recommenations

AHA HF guideline
Figure 5. Recommendations (Class 1 and 2a) for Patients at Risk of HF (Stage A) and Those With Pre-HF (Stage B)
https://drive.google.com/file/d/13GzOiIvRfnFGZavNcJgT0Iu7l8eOLbZW/view

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7
Q

device tx for pre-HF (EF≤40% but asx or NYHA I)

A

≥40d post-MI + EF≤30% + NYHA I ⊕GDMT:
ICD ⇒ ￬SCD,death
⊕GDMT & life expect >1y

all class 1 recommenations

AHA HF guideline
Figure 5. Recommendations (Class 1 and 2a) for Patients at Risk of HF (Stage A) and Those With Pre-HF (Stage B)
https://drive.google.com/file/d/13GzOiIvRfnFGZavNcJgT0Iu7l8eOLbZW/view

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8
Q

big picture/broad category indications for device tx for HF

A

pre-HF (EF≤40% + NYHA I)
≥40d post-MI:
ICD ⇒ ￬SCD,death

EF≤30% + NYHA I ≥40d post-MI:
ICD ⇒ ￬SCD,death (1)

HFrEF (EF≤35% + NYHA ≥II)
- non-ischemic dilated CM OR isch heart dz ≥40d post-MI:
ICD ⇒ ￬SCD,death
- + sinus + QRS≥150ms ⊕LBBB:
CRT ⇒ ￪QOL, ￬sx,hosp,death

⊕GDMT & life expect >1y

AHA HF guideline
Figure 5. Recommendations (Class 1 and 2a) for Patients at Risk of HF (Stage A) and Those With Pre-HF (Stage B)
https://drive.google.com/file/d/13GzOiIvRfnFGZavNcJgT0Iu7l8eOLbZW/view
Figure 6. Treatment of HFrEF Stages C and D
https://drive.google.com/file/d/138w94HQ7XSt4VLuN5b-5RdDJA0SYFthv/view
Figure 8. Algorithm for CRT Indications in Patients With Cardiomyopathy or HFrEF
https://drive.google.com/file/d/13PyWc53WxKqJ5dqDfX42hgud4M-hKiYM/view

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9
Q

indications for CRT in HF

A
  • _EF≤35% + NYHA ≥II + sinus + QRS≥150ms ⊕LBBB:_
    CRT ⇒ ￪QOL, ￬sx,hosp,death (1)
  • EF≤35% + NYHA ≥II + sinus + QRS≥150ms ⊖LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2a)
  • EF≤35% + NYHA ≥II + QRS=120-150ms ⊕LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2a)
  • EF≤35% + NYHA ≥III + QRS=120-150ms ⊖LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2b)
  • isch HF + EF≤30% + NYHA I + QRS≥150ms ⊕LBBB:
    CRT ⇒ ￪QOL, ￬sx,hosp (2b)
  • EF≤35% + afib + req Vpacing OR AVN ablation will allow ~100% Vpacing with CRT ⊕GDMT:
    CRT ⇒ ￪LVEF,QOL, ￬sx,death (2a)
  • EF≤35% + concomitant device proc + req >40% Vpacing:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2a)
  • EF=35-50% + high-degree or complete heart block:
    CRT ⇒ ￪QOL, ￬sx,hosp,death (2a)

⊕GDMT & life expect >1y

AHA HF guideline
Figure 8. Algorithm for CRT Indications in Patients With Cardiomyopathy or HFrEF
https://drive.google.com/file/d/13PyWc53WxKqJ5dqDfX42hgud4M-hKiYM/view

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10
Q

indications for & additional therapies for HF after optimizing GDMT ± ICD/CRT

A
  • EF≤35% & suitable coronary anatomy (AHA SIHD) ⇒ CABG (1)
  • NYHA ≥II + severe 2° MR (AHA valve) ⇒ optimize GDMT before considering MVR (1)
  • NYHA ≥II + severe 2° MR + suitable anatomy + EF=20-50% + LVESD≤70mm + PASP≤70mmHg (AHA valve) ⇒ TEER (2a)
  • NYHA III + h/o HF hosp OR ￪BNP ⇒ wireless PA pressure monitoring (2b)

AHA HF guideline
Figure 9. Additional Device Therapies https://drive.google.com/file/d/13TYZfVBFCsTkO6FL-xfMOamII1wiS8hl/view
Figure 10. Treatment Approach in Secondary Mitral Regurgitation
https://drive.google.com/file/d/13gmu5poAjH1uaXcl3H9ia_M7DhjFxqJ9/view

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11
Q

indications for LVAD in HF

A
  • adv HF + NYHA IV + dependent on cont IV inotropes or temp MCS: LVAD ⇒ ￪fxnal status,QoL,OS (1)
  • adv HF + NYHA IV: durable MCS ⇒ ￪fxnal status, ￬sx,death (2a)
  • adv HF + hemodynamic compromise/shock: temp MCS reasonable as bridge to recovery/decision (2a)
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12
Q

anticipated 1-/2-year survival + OS after LVAD

A

[median OS of adv HF without advanced txs = <2y]
1y: ???
2y: >80% (approaches early survival after transplant)
OS: destination = >4y, bridge = >5y
BUT risk of death becomes greater than survival between 3 and 4 years on an LVAD

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13
Q

median OS of adv HF without advanced txs

A

<2y

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14
Q

median OS after heart transplant

A

>12y

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15
Q

indication(s) for transplant in HF

A

AHA: “select” adv HF (1)
UpToDate:
- cardiogenic shock req cont IV inotropes OR IABP OR MCS to maintain adequate organ perfusion
- NYHA IV on maximal med/device tx
- ???

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