Cardio- CHF

Question 1

CHF Characteristics

Answer 1

• inability to effectively pump blood
• eleveated BNP (or pro-BNP)
• SOB, cough
• Fatigue, weakness
• Edema
• HFrEF
• SOB
• Fatigue, weakness
• Edema
• HFrEF

Question 2

New York Heart Association Classification- Patient Symptoms (4)

Answer 2

Class 1: Asymptomatic
Class 2: Become winded with exertion
Class 3: Trouble with regular activities
Class 4: Most severe, symptoms even at rest

Question 3

ACC/AHA Classification (4)

Answer 3

Class A- At risk for heart failure but no evidence of heart dx or symptoms of heart failure
Class B- Evidence of structural dx, but no signs and symptoms of heart failure
Class C- Structural heart dx with symptoms of heart failure
Class D- Refractory heart failure not responsive to treatments

Question 4

What meds are currenrly used in CHF? (2 categories)

Answer 4

• Diuretics (Loops, K+ sparing MRAs, Thiazide-like
• Quadruple Tx (ARNI, BB, SGLT2-inhibitors, MRAs)

Question 5

Loops Diuretic Important Characteristics

Answer 5

furosemide, torsemide, bumetanide, ethacrynic acid
- Ethacrynic acid (no sulfa group)
- ototoxicity (rare)
- IV to oral dosing ratio is approximately 1:2

Question 6

Aldosterone Antagonists Characteristics

Answer 6

• Spironolactone, Elperenone (mortality benefit)
  NYHA Class II-IV w/ EF of 35% or left
• Gynecomastia
• Avoid in eGFR < 30 ml/min, K+>5
• 100 mg spironolactone/40 mg furosemide

Question 7

Thiazide Like Characteristics

Answer 7

• Metolazone: 1-hour before lasix
  used to agument furosemide
• HCTZ: generally not used in CHF/fluid loss
  Likely not beneficial with CrCl < 30 ml/min

Question 8

BB/ACE-inhibitors with proven mortality benefit

Answer 8

Coreg
Toprol XL
Bisoprolol
ARNI (Entresto- sacubitril/valsartan)

Question 9

Important ARNI (Entresto- sacubitril/valsartan) Characteristics?

Answer 9

• AVOID with angioedema
• 36-hour washout period when switching from ACEi
• reduces morbidity/mortality
• NYHA Class 2-4
• More hypo-TN than ACE/ARB (<100 mm Hg SBP avoid)
• Enalapril 10 mg or valsartan 160 mg or higher- may start higher dose (49/51 mg)

Question 10

SGTL-2 Inhibitor Characteristics

Answer 10

• Benefit in HFrEF even in patients WITHOUT DM
• dapagliflozin (first FDA approval)
• SGLT2I- 2a recommendation with MRAs, ARBs and ARNI (2b)

Question 11

Other Chronic Managment Options (2)

Answer 11

• Ivabradine: reduction in hospitalization
• Hydralazine/ISDN (consideration in AA or those with intolerant of angiotensin blocking agent)

Question 12

Classic Drugs that Exacerbate CHF (5 drug classes)

Answer 12

NSAIDs (Sodium retention,
CCBs
TZDs
Pregabalin
Cilostazol