B P6 C48 Approach to the Patient with Heart Failure

Question 1

Heart failure (HF) is a complex clinical syndrome resulting from _____.

Answer 1

Structural and functional impairment of ventricular filling or ejection of blood

Question 2

Risk factors for HF include:

Answer 2

Ischemic heart disease
Incident or prevalent MI
Myocarditis
Valvular heart disease
Tachycardia
Diabetes mellitus
Structural heart disease related to CHD
Sleep apnea
Excessive drug or alcohol use
Obesity

Question 3

HFpEF is generally defined as a left ventricular EF ____, whereas HFrEF is generally defined as an EF _____.

Answer 3

HFpEF >/= 50%

HFrEF <40%

Question 4

The prevalence of HFpEF increases dramatically with age and is much more common in _____ at any age

Answer 4

Women

Question 5

Patients in this category (HFrecEF) have somewhat characteristic demographics, in that they are more likely to be _____.

Answer 5

Younger
Female
Have nonischemic HF
Shorter duration of HF
Have less remodeling of their left ventricle at the time of diagnosis

Question 6

A working definition of HFrecEF that is consistent with the majority of studies in the literature includes: ______ These improvements in LVEF are typically accompanied by a reduction in LV volumes.

Answer 6

(1) Documentation of a decreased LVEF less than 40% at baseline
(2) 10% absolute improvement in LVEF
(3) a second measurement of LVEF greater than 40%

Question 7

Although demonstrating improvement in LVEF, many of these patients may have persistent biochemical signs of HF pathophysiology with abnormal concentrations of natriuretic peptides, and a recent study suggested that discontinuation of GDMT for HF was accompanied by an unacceptably high rate (___%) of recrudescent HFrEF.

Answer 7

44%

Question 8

When the diagnosis of HF is suspected, the goals of the clinical assessment are to _____.

Answer 8

(1) Determine whether HF is present
(2) Define the underlying cause and the type of HF (HFrEF vs. HFpEF)
(3) Assess the severity of HF
(4) Identify comorbidities that can influence the clinical course and response to treatment

Question 9

ACC/AHA stages of HF

Answer 9

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

B
Structural heart disease but without signs or symptoms of heart failure.

C
Structural heart disease with prior or current symptoms of heart failure.

D
Refractory heart failure requiring specialized interventions.

Question 10

NYHA Functional Classification

Answer 10

I
No limitation of physical activity.
Ordinary physical activity does not cause symptoms of heart failure.

II
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical activity results in symptoms of heart failure.

III
Marked limitation of physical activity.
Comfortable at rest, but less than ordinary activity causes symptoms of heart failure.

IV
Unable to carry on any physical activity without symptoms of heart failure, or symptoms of heart failure at rest.

Question 11

_____ is a cardinal symptom of HF, and is typically related to increases in cardiac filling pressures but also may represent restricted cardiac output.

Answer 11

Worsening dyspnea

Question 12

_____ is often mentioned by patients hospitalized with HF and has a high-diagnostic sensitivity and significant prognostic ramifications in this population. However, it is also cited by patients with many other medical conditions, so that the specificity and positive predictive value of this symptom alone are low.

Answer 12

Dyspnea at rest

Question 13

Patients may sleep with their heads elevated to relieve dyspnea while recumbent (_____); additionally, dyspnea while lying on the left side (_____) may occur.

Answer 13

Orthopnea

Trepopnea

Question 14

_____, shortness of breath developing while recumbent, is one of the most highly reliable indicators of HF.

Answer 14

PND

Question 15

______ respiration (also referred to as periodic or cyclic respiration) is common in advanced HF and is usually associated with low cardiac output and sleep-disordered breathing. The presence of this respiration is generally indicative of an adverse prognosis.

Answer 15

Cheyne-Stokes respiration

Question 16

While nonspecific, _____due to congestion of the liver is common in those with significant right HF, and may be incorrectly attributed to other conditions

Answer 16

RIght upper quadrant pain

Question 17

Another cardinal symptom of HF is _____, generally held to be reflective of reduction in cardiac output as well as abnormal skeletal muscle metabolic responses to exercise.

Answer 17

Fatigue

Question 18

Other causes of fatigue in HF may include _____.

Answer 18

Major depression
Anemia
Renal dysfunction
Endocrinologic abnormalities
Side effects to medications

Question 19

Unintended weight loss, often leading to _____, may be prominent and is a major prognostic indicator.

Answer 19

Cachexia

Question 20

Physical examination findings in HF which are indicative of more severe diseaase:

Answer 20

Narrow pulse pressure or thready pulse
Pulses alternans
Cool and/or mottled extremities
Anasarca

Question 21

The presence of _____ is particularly helpful because these conditions account for approximately 90% of the population attributable risk for HF in the United States

Answer 21

Hypertension, CAD, and/or DM

Question 22

This class of agents is well recognized to lead to HF through their ability to worsen renal function, trigger hypertension, and lead to fluid retention, particularly in older adults.

Answer 22

NSAIDS

Question 23

The skin exam may show pallor or cyanosis due to under perfusion, stigmata of alcohol abuse (such as _____), _____ due to sarcoidosis, _____ due to hemachromatosis, or _____ from amyloidosis; additional findings supporting amyloidosis include _____.

Answer 23

Alcohol abuse: spider angiomata or palmar erythema

Sarcoidosis: erythema nodosum

Hemachromatosis: Bronzing

Amyloidosis: easy bruising + deltoid muscle infiltration (leading to the “shoulder pad sign”), tongue hypertrophy, and bilateral thenar wasting from carpal tunnel syndrome

Question 24

The presence of a third heart sound is a crucially important finding and suggests increased ______; while difficult to identify, a third heart sound is highly specific for HF, and carries a substantial prognostic meaning

Answer 24

Increased ventricular filling volume

Question 25

A fourth heart sound usually indicates _____.

Answer 25

Reduced ventricular compliance

Question 26

In advanced HF, the third and fourth heart sounds may be superimposed, resulting in a _____.

Answer 26

Summation gallop

Question 27

The most definitive method for assessing a patient’s volume status by physical examination is by the measurement of _____.

Answer 27

JVP

Question 28

An elevated JVP has good sensitivity (____%) and specificity (____%) for elevated left-sided filling pressure

Answer 28

Sensitivity: 70%
Specificity: 79%

Question 29

Changes in JVP with therapy usually parallel changes in _____.

Answer 29

Left sided filling pressures

Question 30

Increase in the JVP may lag behind left heart filling pressures or may not rise at all if ______ is increased to the extent that right ventricular failure or tricuspid insufficiency occur.

Answer 30

Pulmonary pressure is increased

Question 31

Conversely, the JVP may be elevated without an increase in left ventricular filling pressures in patients with _____.

Answer 31

Pulmonary arterial hypertension
Isolated right ventricular pressure
Isolated severe TR

Question 32

_____ pleural effusions are most common but when an effusion is present unilaterally, it is usually _____ sided with only approximately 10% occurring exclusively on the left side.

Answer 32

Most common: Bilateral
Unilateral: Right-sided

Question 33

Importantly, rales or rhonchi may be absent in congested patients with advanced HF; this may reflect compensatory _____.

Answer 33

Increase in local lymphatic drainage

Question 34

The occurrence of so-called “cardiac asthma” is due to the _____, and can commonly result in an incorrect diagnosis of obstructive airways disease exacerbation, with consequent mis-triage and incorrect therapy with bronchodilators; such incorrect management may be associated with increased risk for mortality.

Answer 34

(1) Physical presence of fluid in the bronchial wall
(2) Secondary bronchospasm

Question 35

Lower-extremity edema is a common finding in volume-overloaded HF patients but may commonly be the result of:

Answer 35

(1) Venous insufficiency (particularly after saphenous veins have been harvested for coronary artery bypass grafts)

(2) Side effect of medications (e.g., calcium channel blockers)

Question 36

Many patients with systolic blood pressure in the range of _____ mm Hg (or even lower) may have adequate perfusion while others with reduced cardiac output may maintain blood pressure in the normal range at the expense of tissue perfusion by greatly increasing systemic vascular resistance.

Answer 36

80 mm Hg

Question 37

Findings suggesting reduced cardiac output include _____. Of these, ______ are the most broadly useful.

Answer 37

Poor mentation
Reduced urine output
Mottled skin
Cool extremities - most useful

Question 38

Categorize based on hemodynamic profile:

No congestion, adequate perfusion at rest

Answer 38

Warm and dry

Question 39

Categorize based on hemodynamic profile:

(+) congestion, but adequate perfusion at rest

Answer 39

Warm and wet

Question 40

Categorize based on hemodynamic profile:

No congestion, but low perfusion at rest

Answer 40

Cool and dry

Question 41

Categorize based on hemodynamic profile:
(+) congestion, and low perfusion at rest

Answer 41

Cool and wet (Cardiogenic shock)

Question 42

The classical chest X-ray pattern in patients with pulmonary edema is a _____ pattern of interstitial and alveolar opacities bilaterally fanning out to the periphery of the lungs.

Answer 42

Butterrfly pattern

Question 43

Many patients, however, present with more subtle findings, in which increased interstitial markings including _____ are the most prominent findings.

Answer 43

(1) Kerley B lines (thin horizontal linear opacities extending to the pleural surface caused by accumulation of fluid in the interstitial space)

(2) Peribronchial cuffing

(3) Evidence of prominent upper lobe vasculature (indicating pulmonary venous hypertension)

Question 44

_____ due to sympathetic nervous system activation is seen with advanced HF or during episodes of acute decompensation; beside increasing the likelihood for the diagnosis finding of elevated heart rate it is a prognostic finding in HF as well.

Answer 44

Sinus tachycardia

Question 45

Increased _____ identifies a patient at risk for sudden death, particularly when the EF is very low (e.g., <30%).

Answer 45

Increased ventricular ectopy

Question 46

The presence of increased QRS voltage may suggest left ventricular hypertrophy; in the absence of a prior history of hypertension, such a finding might be caused by valvular heart disease or by hypertrophic cardiomyopathy, particularly if _____ patterns are noted

Answer 46

Bizarre repolarization patterns

Question 47

If right ventricular hypertrophy is present, _____ should be considered.

Answer 47

Primary or secondary pulmonary hypertension

Question 48

_____ suggests the presence of an infiltrative disease or pericardial effusion.

Answer 48

Low QRS voltage

Question 49

The presence of _____ suggests that HF may be due to ischemic heart disease, while _____ identify acute coronary ischemia is present even when chest pain is absent.

Answer 49

Q waves: IHD

New or reversible ST changes: ACS

Question 50

_____ interval is common in patients in this setting, and may be due to intrinsic conduction disease, but may also be seen in patients with infiltrative cardiomyopathy such as amyloidosis.

Answer 50

Prolongation of the PR interval

Question 51

The QT interval is often prolonged in patients with HF, and may be due to:

Answer 51

Electrolyte abnormalities
Myocardial disease
Effects of commonly used drugs, such as antiarrhythmics

Question 52

A lengthened QT interval may identify patients at risk for _____ and is thus an important variable to consider when utilizing therapeutic agents with effects on ventricular repolarization.

Answer 52

Torsades de pointes

Question 53

Patients with new-onset HF and those with acute decompensation of chronic HF should have a panel of _____ measured.

Answer 53

Electrolytes
Blood urea nitrogen
Serum creatinine
Hepatic enzymes
Fasting lipid profile
Thyroid stimulating hormone
Transferrin saturation
Uric acid
Complete blood count
Urinalysis

Question 54

When the diagnosis of cardiac amyloidosis is entertained, _____ may be measured to screen for the AL form of the diagnosis, however no reliable blood tests exist for diagnosis of the transthyretin form of cardiac amyloidosis, which typically requires imaging for its evaluation

Answer 54

Serum-free light chains

Question 55

Low-sodium concentrations in HF may be due to:

Answer 55

Worsening volume retentio

Use of diuretics, including thiazides

Question 55

Studies have shown that hyponatremia (defined as serum sodium values below 135 mmol/L) may be found in up to ___% of patients with acute HF, and hyponatremia may also be seen in patients with indolently worsening HF without obvious decompensation.

Answer 55

25%

Question 56

_____natremia, although uncommon, is also prognostic for mortality in patients with HF.

Answer 56

Hypernatremia

Question 57

Hypokalemia occurs commonly in HF patients who are treated with diuretics. Besides increasing the risk of cardiac arrhythmias, low potassium may also lead to _____.

Answer 57

Leg cramps and muscle weakness

Question 58

Conversely, hyperkalemia is less common, and most often is due to effects of medications such as _____.

Answer 58

ACEi and MRA

Question 59

Abnormalities of renal function are common in patients with HF, and occur due to _____. In addition, HF therapies such as _____ can increase blood urea nitrogen and creatinine

Answer 59

Renal congestion
Inadequate cardiac output
Consequence of comorbid condition

ACE, ARBs, diuretics

Question 60

In patients hospitalized with acutely decompensated HF, registry data suggest that _____% have a reduced estimated glomerular filtration rate; among such patients, the initial blood urea nitrogen and serum creatinine concentrations are both independently predictive of death.

Answer 60

60-70%

Question 61

Following admission, approximately 30% of patients with acute HF may also develop an increase in serum creatinine by ____ mg/dL, which is similarly prognostic for mortality.

Answer 61

0.3 mg/dL

Question 62

Following admission, approximately 30% of patients with acute HF may also develop an increase in serum creatinine by 0.3 mg/dL, which is similarly prognostic for mortality. The causes of this so-called “cardiorenal” syndrome are complex, but include the _____.

Answer 62

(1) Severity of right heart congestion
(2) Increased intraabdominal pressure
(3) Renal hypoperfusion from inadequate cardiac output

Question 63

An unexpected increase in prothrombin time in patients receiving warfarin therapy may be an early harbinger of decompensation as it may reflect _____.

Answer 63

Impaired synthetic capacity of a congested liver

Question 63

On the other hand, worsening renal function may also occur from aggressive decongestion strategies; such decline in renal function has been linked to _____ prognosis, as it presumably indicates a more thorough treatment for congestion, the trigger for acute HF hospitalization

Answer 63

Improved (rather than worse)

Question 64

Lastly, improvement in renal function may follow therapies improving the severity of congestion, although such a finding is still associated with _____ long-term prognosis.

Answer 64

Poor

Question 65

Albumin levels are an indication of the patient’s nutritional status and they may be depressed due to poor appetite or impaired absorption across an engorged bowel wall; _____ is prognostic for mortality in acute and chronic HF.

Answer 65

Hypoalbuminemia

Question 66

Hematologic abnormalities are exceedingly common in HF, affecting nearly 40% of affected patients. Low hemoglobin levels have been associated with:

Answer 66

(1) More severe HF symptoms
(2) Reduced exercise capacity and quality of life
(3) Increased mortality

Question 67

While anemia may be a consequence of chronic disease in HF patients, a low hemoglobin level should trigger an evaluation to detect treatable causes, particularly _____.

Answer 67

Iron deficiency

Question 68

Increasing attention has also been given to the red cell distribution width as a prognostic variable in ____ HF.

Answer 68

Acute and chronic HF

Question 69

The ______ is helpful in detecting the presence of infection that is responsible for destabilizing a previously well-compensated patient and could provide a clue that HF is due to uncommon cause such as eosinophilic infiltration of the myocardium.

Answer 69

WBC and differentials

Question 70

Biomarkers Used in Assessing Patients with Heart Failure: Inflammation

Answer 70

C-reactive protein
Tumor necrosis factor
Fas (APO-1)
Interleukins 1, 6, and 18

Question 71

Biomarkers Used in Assessing Patients with Heart Failure: Oxidative Stress

Answer 71

Oxidized low-density lipoproteins Myeloperoxidase
Urinary biopyrrins
Urinary and plasma isoprostanes
Plasma malondialdehyde

Question 72

Biomarkers Used in Assessing Patients with Heart Failure: Extracellular-matrix remodelling

Answer 72

Matrix metalloproteinases
Tissue inhibitors of metalloproteinases
Collagen propeptides
Propeptide procollagen type I
Plasma procollagen type III

Question 73

Biomarkers Used in Assessing Patients with Heart Failure: Neurohormones

Answer 73

Norepinephrine
Renin
Angiotensin II
Aldosterone
Arginine vasopressin
Endothelin

Question 74

Biomarkers Used in Assessing Patients with Heart Failure: Myocyte Injury

Answer 74

Cardiac-specific troponins I and T
Myosin light-chain kinase I
Heart-type fatty-acid protein
Creatine kinase MB fraction

Question 75

Biomarkers Used in Assessing Patients with Heart Failure: Myocte stress

Answer 75

B-type natriuretic peptide/N-terminal pro-B type natriuretic peptide Midregional proadrenomedullin
ST2

Question 76

Biomarkers Used in Assessing Patients with Heart Failure:
New biomarkers

Answer 76

Chromogranin
Galectin 3
Osteoprotegerin
Adiponectin
Growth differentiation factor 15
Insulin-like growth factor binding protein 7

Question 77

The most commonly measured natriuretic peptides are _____ and its amino-terminal cleavage pro-peptide equivalent, _____; these two biomarkers are released from cardio- myocytes in response to stretch, and highly precise assays exist for their detection in blood

Answer 77

B-type natriuretic peptide (BNP)

NT-proBNP

Question 78

____ is another member of the class of natriuretic peptides and is synthesized and secreted from atrial tissue; a _____ assay is now available and appears to deliver comparable results to BNP and NT-proBNP when tested in HF patients.

Answer 78

Atrial natriuretic peptide (ANP)

mid- regional pro-ANP

Question 79

Due to the differences in their clearance BNP and NT-proBNP have considerably different half-lives (BNP: __ minutes; NT-proBNP: __ minutes), and thus they circulate with very different concentrations.

Answer 79

BNP: 20 mins
NT-proBNP: 90 mins

Question 80

Patients with acute HF most often have higher values for BNP and NT-proBNP, compared to chronic stable patients, however this is by no means a universal finding, and knowledge of an individual’s natriuretic peptide value when _____ may be useful to better interpret a change when a change in symptoms occurs.

Answer 80

Stable

Question 81

When using BNP or NT-proBNP, the clinician should remember that beyond left ventricular systolic and diastolic dysfunction, concentrations of both peptides are higher in patients with:

Answer 81

VHD
Pulmonary hypertension
Ischemic heart disease
Atrial arrhythmias
Pericardial processes such as constriction

Question 82

Elevation of BNP or NT-proBNP—often marked—is nearly ubiquitous in infiltrative cardiomyopathies such as cardiac _____; these elusive diagnoses should be considered in a patient with significant elevation of natriuretic peptide but without obvious congestion.

Answer 82

Amyloidosis

Question 83

Additionally, numerous relevant medical covariates with effects on natriuretic peptide values must also be kept in mind. Examples are:

Answer 83

(1) Age - identify accumulating structural heart disease in older patients
(2) Renal failure - partially reflective of slower clearance, but also similarly identifying heart disease in this population of patients with prevalent cardio- vascular risk factors
(3) Hyperdynamic states - sepsis
(4) RV dysfunction sec to PE
(5) ARNI - not universal and may be transient
(6) Obesity is strongly linked to lower-than-expected BNP or NT-proBNP values, despite comparable or higher wall stress in heavier patients. Represents suppression of natriuretic peptide gene expression or post-translational modification.

Question 84

In the Breathing Not Properly, a BNP concentration of _____ pg/mL was highly accurate for the diagnosis of acutely decompensated HF; in PRIDE, an NT-proBNP cutoff of _____ pg/mL provided comparable performance to a BNP of 100 pg/mL.

Answer 84

BNP (Breathing Not Properly): 100 pg/mL

NT-proBNP (PRIDE) : 900 pg/mL

Question 85

Subsequently, the International Collaborative of NT-proBNP (ICON) investigators showed that age stratification improved positive predictive value of NT-proBNP in acutely dyspneic patients; as well, an NT-proBNP concentration below _____ pg/mL was useful to exclude acutely decompensated HF

Answer 85

NT-proBNP (ICON): 300 pg/mL

Question 86

Knowledge of natriuretic peptide levels in the emergency department is associated with:

Answer 86

(1) More rapid diagnosis
(2) Lower admission rate
(3) Shorter length of hospital stay
(4) Reduced cost

Question 87

While one natriuretic peptide measurement is prognostically meaningful, _____ measurements add incrementally important prognostic information.For example, in patients with acute HF, those who do not show a robust reduction in BNP or NT-proBNP by the time of hospital discharge tend to have considerably higher rates of morbidity and mortality.

Answer 87

Serial Follow-up

Question 88

It has thus been suggested that a BNP or NT-proBNP decrease of _____% or more by hospital discharge is desirable. Similarly, in ambulatory HF, chronically elevated or rising natriuretic peptide values identify a particularly high-risk patient population. HF therapies may lower concentrations of BNP and NT-proBNP; when this finding occurs, prognosis is improved.

Answer 88

Decrease of >/= 30%

Question 89

Concentrations of _____ (a member of the interleukin receptor family) have been shown to be strongly linked to progressive HF and death in patients across the four ACC/AHA stages of HF.

Answer 89

Soluble ST2

Question 90

Class I indications for the use of biomarkers in HF

Answer 90

For Diagnosis: BNP or NT-proBNP
(1) ACC/AHA Stage C/D HF (Ambulatory patient with new onset dyspnea)
(2) ACC/AHA Acute /Hospitalized HF (Acute dyspnea to ED)

For Prognosis or added risk stratification:
(1) ACC/AHA stage C/D HF (NYHA Class II-IV) BNP or NT-proBNP
(2) ACC/AHA Acute/Hospitalized HF (Acute dyspnea to ED and hospitalized for ADHF) BNP or NT-proBNP and Cardiac Troponin

Question 91

The myofibrillar proteins, _____, are indicators of cardiomyocyte injury and may be elevated in HF patients in the absence of an acute coronary syndrome or even significant coronary artery disease

Answer 91

Troponin T and I

Question 92

Other novel biomarkers are emerging and may have a role in the com- prehensive evaluation of the patient with HF; many of these novel markers reflect systemic stress or disarray of organs outside of the heart. For example, the mid-regional fragment of _____ is a biomarker reflective of vascular and systemic stress and is powerfully prognostic for short-term adverse outcome

Answer 92

Pro-adrenomedullin

Question 93

In a similar fashion, _____, another marker of cardiovascular stress, strongly predicts outcomes not only in established HF, but may also be prognostic for new-onset HF in apparently well subject

Answer 93

Growth differentiation factor-15

Question 94

Lastly, novel biomarkers of renal dysfunction are emerging as strong predictors of cardiovascular risk beyond the standard measures of blood urea nitrogen or serum creatinine. _____ (a ubiquitous protein found in all nucleated cells whose clearance is directly related to glomerular filtration) and _____ are two renal function markers whose values are tightly related to outcomes in HF, while _____ are promising biomarkers of acute renal injury whose values rise well before renal function is perceived to be worsening, and impart important prognostic information in HF patients

Answer 94

Cystatin C and B trace protein - related to HF outcomes

Neutrophil gelatinase-associated lipocalin, N-acetyl-B-D-glucosaminidase, and kidney injury molecule-1

Question 95

For patients hospitalized with acute symptoms, the model developed by the Acute Decompensated Heart Failure National Registry (ADHERE) incorporates three routinely measured variables upon hospital admission (_____), and partitions subjects into categories with a 10-fold difference in risk (from 2.1% to 21.9%)

Answer 95

SBP
BUN
Creatinine

Question 96

For this purpose, natriuretic peptide results may be of more use, particularly when measured after in-patient treatment, just prior to discharge; a lack of BNP or NT-proBNP reduction by _____% during in-patient treatment may identify those at higher risk for short-term death or rehospitalization.

Answer 96

30%

Question 97

Nonetheless, as right heart catheterization affords unequivocal assessment of hemodynamics and filling pressures, it is particularly useful in cases where there is uncertainty about the cause of a patient’s symptoms and in situations where precise measurements are required to guide therapy or decision making (e.g.,selection of patients for heart transplantation). In addition, right heart catheterization is of value (and should be considered) in those with HF complicated by:

Answer 97

(1) Clinically significant hypotension
(2) Systemic hypoperfusion, dependence on inotropic infusions, or persistently severe symptoms despite adjustment of recommended therapies.

Question 98

An invasive assessment with right heart catheterization is important to assess the _____, a necessary part of the evaluation for heart transplantation.

When pulmonary artery pressures are found to be elevated, response to _____ can be determined in this context, and provides important information determining whether a patient with pulmonary hypertension will be acceptable for cardiac transplantation.

Answer 98

PVR

Pulmonary arterial vasodilating agents

Question 99

In addition, obtaining the pulmonary artery wedge pressure is useful for assessing volume status.The pulmonary artery wedge pressure usually estimates the _____ if no obstruction to flow between the left atrium and left ventricle exists.

Answer 99

LVEDP

Question 100

Use of hemodynamic monitoring to guide therapy was evaluated in patients with advanced HF in the _____ trial. The results did not show any clear benefit on morbidity and mortality of pulmonary artery-guided management compared to care- ful clinical assessment. The failure to affect postdischarge outcomes appears to be related to the fact that the hemodynamic improvements that were affected during hospitalization reverted back toward baseline within a relatively short period of time. Consequently, “tailored ther- apy” of HF is used less commonly now than in the past, but has a role particularly in patients with HF complicated by hypotension, systemic hypoperfusion, and end-organ dysfunction.

Answer 100

Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE)

Question 100

The sensitivity of endomyocardial biopsy may vary,depending on the cause of HF; for example, sensitivity is higher in more diffuse disease states such as _____, while more patchy disease states such as _____ may be less easily detected using biopsy.

Answer 100

Diffuse states: myocarditis or amyloidosis

Patchy states: sarcoidosis

Question 101

HF has a profound effect on quality of life, and _____ is a powerful predictor of adverse prognosis in HF patients.

Answer 101

Poor health-related quality of life

Question 102

Determinants of poor quality of life in HF include:

Answer 102

Female gender
Younger age
Higher body-mass index
Worse symptoms
Presence of depression and sleep apnea

Question 103

Improved quality of life has been reported following:

Answer 103

(1) Standard HF drug treatment intensification
(2) Cardiac resynchronization therapy
(3) Disease management programs

Question 104

Given its importance, at the initial and subsequent visits, consideration should be given for quality-of-life assessment, whether through standard history or through the use of validated tools for its estimation such as the _____.

Answer 104

Kansas City Cardiomyopathy Questionnaire

Question 105

When more precise information is needed, _____ is often used because it allows for identification of causes of exercise intolerance and quantification of exercise capacity, and delivers important physiologic information not routinely available from standard stress testing.

Answer 105

Cardiopulmonary exercise testing (CPX)

Question 106

The _____ is the standard expression of capacity for endurance, based on the Fick equation, which states that VO2 = cardiac output × [oxygen content arterial − oxygen content venous].

Answer 106

Maximum VO2

Question 107

Use of CPX is a standard part of the routine evaluation prior to heart transplantation; moderate to severely reduced maximal VO2 values (e.g., <___mL O2/kg−1/min−1) are often used as a prognostic threshold in this setting, while maximal VO2 values less than 10 mL O2/kg−1/min−1 are considered severe, and particularly prognostic when the VE/VCO2 slope is >/= 45.0.

Answer 107

<14 mL O2/kg−1/min−1

Question 108

For example, concentric LV hypertrophy with _____ raises the possibility that HF is due to an infiltrative process such as amyloidosis, particularly in the absence of a prior diagnosis of hypertension; in cases such as this, strain imaging may be helpful to evaluate for the characteristic “_____” seen in patients with amyloid cardiomyopathy

Answer 108

Severe bi-atrial enlargement

Question 109

Ratio of early mitral valve inflow to mitral valve annulus velocity determined using tissue Doppler (E/e’) is particularly helpful to determine presence and severity of diastolic dysfunction; a ratio of _____ or greater is abnormal.

Answer 109

15

Question 110

______ in patients without significant systolic dysfunction or pulmonary disease suggests that diastolic dysfunction may be present

Answer 110

Pulmonary hypertension

Question 111

_____ IVC diameter and inspiratory collapse of at least ____% are associated with normal RA pressures, while increased IVC diameter and smaller inspiratory changes indicate elevated RA pressure.

Answer 111

Normal RAP: Normal IVC diameter, at least 50% inspiratory collapse

Question 112

Lung ultrasound (LUS) has become increasingly used to evaluate patients presenting to the emergency department setting; it has been found to be useful to diagnose interstitial pulmonary edema and fluid overload through the detection of vertical reverberation artifacts, known as _____.

Answer 112

B-lines

Question 113

Also known as “_____,” in the appropriate setting, such B-lines may be highly sensitive and specific for presence of HF, particularly when incorporated with clinical judgment and other tools such as chest radiography and natriuretic peptide testing.

Answer 113

Comets

Question 114

_____ provides high-quality imaging of the heart and involves no radiation, which is a significant advantage over CT

Answer 114

MRI

Question 115

MRI can characterize myocardial tissue and assess myocardial viability. Cardiac MRI can distinguish ischemic from nonischemic cardiomyopathies based upon the pattern of delayed gadolinium enhancement from T1-weighted images: ischemic cardiomyopathies usually show characteristic _____, while nonischemic dilated cardiomyopathies most commonly have either _____.

Answer 115

Ischemic CMP: sub-endocardial enhancement at the sites of prior infarctions

NIDCMP: no enhancement, mid-wall enhancement, or other patterns depending upon the cause

Question 116

The current role of cardiac CT in HF is mainly to help determine whether or not obstructive coronary artery disease is present via the use of CT angiography , an important application particularly for patients with _____likelihood for coronary artery disease

Answer 116

Lower

Question 117

A wide array of nuclear imaging techniques have been developed for the assessment of HF. In particular, _____ technologies are well-suited for assessing myocardial ischemia and viability, and for evaluating myocardial function

Answer 117

SPECT and PET

Question 118

18F-fluorodeoxyglucose (18F-FDG) PET scanning may be particularly helpful for diagnosis prognosis, and management of cardiac sarcoidosis; a characteristic _____ pattern in the myocardium may be seen in patients with cardiac sarcoidosis in contrast to _____ uptake seen in DCM and normal subjects. Following successful treatment with immunosuppressive medication, 18F-FDG uptake may normalize

Answer 118

Sarcoidosis: Heterogeneous uptake pattern

DCM/normal subjects: Diffuse uptake

Question 119

99m Technicium pyrophosphate (99mTc-PYP) scanning has become a major imaging modality for diagnosing _____. Although 99mTc-PYP scans are more frequently positive in patients with this disease, they can also be modestly positive in patients with AL amyloid

Answer 119

Transthyretin amyloidosis

Question 120

Lastly, cardiac scans using 123 I-metaiodobenzylguanidine (MIBG) may provide objective evaluation of cardiac _____ function; this imaging strategy may predict risk for sudden death due to arrhythmia in NYHA class II or III HFrEF when the heart-to-mediastinal ratio of 123I-MIBG is _____

Answer 120

Sympathetic function

123I-MIBG heart-to-mediastinal ratio: LOW

Question 121

Among patients with advanced HFrEF, early identification and timely referral of select patients to a HF specialist is critical so that those with advanced disease can be considered for heart transplantation or mechanical circulatory support. This window of opportunity is missed if referral is delayed until multiorgan failure develops, as such patients may no longer be candidates for these therapies

High-risk features include:

Answer 121

(1) Need for intravenous inotropic agents
(2) Worsening NYHA symptom severity or congestion refractory to diuretic use
(3) Rising natriuretic peptide concentrations
(4) End-organ dysfunction
(5) EF less than 35%, ventricular arrhythmias
(6) Recurrent hospitalizations
(7) Progressive intolerance to HF therapies
(8) Low blood pressure/high heart rate

Question 122

To exclude acutely decompensated HF

BNP
NT pro BNP

Answer 122

BNP - < 30 - 50 pg/ml
NT proBNP - <300 pg/ml

Question 123

Outpatient application cut offs

BNP
NT proBNP

Answer 123

BNP - < 40 pg/ml (symptomatic), < 20 pg/ml (asymptomatic)
NT proBNP - <125 pg/ml for age <75 years old