Cardiology – Heart Failure Flashcards
Clinical differences in HFrEF vs HFpEF?
HFpEF patients will have
#higher heart rate to maintain normal cardiac output #More sensitive to volume due to small LV
Role for serial BNPs?
None
Initial labs for heart failure should include?
BMP UA Lipids LFTs TSH
Do not do any more labs unless suggested by history or physical
Most important diagnostic test in the evaluation of heart failure?
Potentially better test? Advantages?
ECHO
cMRI #Can assess wall motion abnormalities, global wall function, #Viability #Tissue perfusion #Tissue injury (inflammation, necrosis, fibrosis, infiltration, iron deposition)
Valve abnormality that is secondary to heart failure?
Mitral regurgitation
Left ventricular hypertrophy magnitude in HFpEF (vs HFrEF)?
LVH in HFpEF is generally due to?
Mild to moderate (under 15 mm in any region)
Hypertension
When to perform endomyocardial biopsy for acute heart failure?
Goal of biopsy?
#Progressive heart failure on #medical therapy with #malignant arrhythmias
Evaluate for Giant cell myocarditis
Infiltrative disease that is least likely to be discovered on endomyocardial biopsy?
Sarcoidosis (patchy)
Role for routine right heart catheterization in patients with heart failure?
However, it may be useful for?
None
#Patients with heart failure refractory to medical therapy #Transplant candidates #Before using inotropic agents or more aggressive diuresis
Medications that decrease mortality in patients with HFrEF?
Therapies that improve symptoms?
#ACE inhibitors/ARBs #Beta blockers #Aldosterone antagonist #Hydralazine/isosorbide dinitrate (for black patients in NYHA class III/IV)
Digoxin
Diuretics
Iontropic agents
Vasodilators
Benefit of high dose versus low dose ACE inhibitor? (Interval of uptitrating)
Beta-blocker?
Decreased hospital admissions but no difference in mortality (up to daily)
Mortality reduction and heart failure symptoms (uptitrating q1-2 weeks)
In patient with HFrEF, when to reconsider starting ACE inhibitor?
Creatinine over 3.0
Side effect of ACE inhibitors that warrant switching to angiotensin receptor blocker? Side effect that rules out both?
Cough
Angioedema
Therapeutic doses of beta blockers for treatment of HFrEF?
Metoprolol Succinate 200
Carvedilol 25 BID
Bisoprolol 10
Digoxin- benefits?
In Short-term, improved symptoms, quality-of-life, and exercise tolerance
Digoxin - patients at risk to develop toxic levels?
Level associated with increased risk of mortality?
#Elderly #Low body mass #Kidney impairment
Over 1 ng/mL
Aldosterone antagonists have mortality/mobility benefits in NYHA Class II if?
Prior hospitalization or elevated BNP
Lab values that prohibit the use of aldosterone antagonists?
#Creatinine above 2.5 in men or above 2 in women #Potassium over 5
Pathophysiology of HFrEF vs HFpEF?
Abnormality of myocardio contraction (reduced systolic function result in progressive ventricular dilation)
Abnormality in diastolic relaxation (results in restricted feeling and High filling pressures)
Antihypertensives that should be discontinued once a diagnosis of heart failure has been made?
Dihydropyridine’s (diltiazem or verapamil)
Amlodipine or felodipine can be continued
Medications with a mortality benefit in HFpEF?
None
How common is sudden cardiac death in patients with heart failure? Only reliable predictor of an arrhythmic event is?
50%
LVEF
Indications for ICD for primary prevention in heart failure?
For secondary prevention?
#NYHA class II or III on medical therapy #Expected survival over one year
And one of the following for primary prevention: #Ischemic cardiomyopathy over 40 days post MI #Nonischemic cardiomyopathy with EF under 35
For secondary prevention: #History of Hemodynamically significant ventricular arrhythmia or cardiac arrest
Should only place ICD in patients with reduced life expectancy if?
#Awaiting transplantation #Awaiting placement of mechanical circulatory device
Pacing lead in ICD is placed?
Additional pacing lead in CRT is placed?
Apex of right ventricle
Coronary sinus
CRT indications?
#LVEF under 35% #LBBB with QRS>150 #NYHA Class III or IV (maybe II) on medical therapy
Valve abnormality that arise after CRT?
Tricuspid regurgitation
Bad prognostic signs in patients with heart failure?
Bad prognostic signs on cardiopulmonary exercise testing?
#NYHA class IV #Repeat hospitalizations #Hyponatremia under 133 #Worsening kidney function #Intolerance of ACE inhibitors or beta blockers #Arrhythmias resulting in ICD firings
#Low oxygen consumption (under 14 ml/kg/min) #High ratio of ventilation-to-carbon dioxide production (over 34)
Patient with acute decompensated heart failure. When to discontinue beta blocker?
Low output heart failure: #Hypotension #Worsening kidney/liver function #Cool extremities
Ultrafiltration versus IV diuretics in decompensated heart failure?
Worsened kidney function
Drug that can be used for the treatment of hyponatremia in patients with heart failure?
Vasopressin antagonists
Cardiogenic shock - drugs that increase inotropy and vasodilate?
Drugs that increase inotropy and vasoconstrict?
Drug that increases inotropy and can either vasodilate or vasoonstrict?
Milrinone (PDE inhibitor)
Dopamine
Norepinephrine
Dobutamine (dilates at low doses, constricts at high doses)
Cardiogenic shock – drugs that purely vasodilate?
Sodium nitroprusside
Nitroglycerin
Nesiritide (Natriuretic peptide receptors)
Cardiogenic shock – drug that is a negative inotrope and Vasoconstricts?
Vasopressin
Complications related to LVADs?
#Driveline related infections #G.I. bleeding from AV malformation's #Ischemic/hemorrhagic stroke
Three drug immunosuppressive regimen after heart transplant?
#Calcineurin inhibitor (cyclosporine or tacrolimus) #Antiproliferative agent #Mycophenolate, sirolimus, everolimus) Prednisone
Signs of rejection after transplant? Rate of rejection in the first year? subsequently?
Heart failure and atrial arrhythmias (atrial flutter)
20%
Nonexistent if medication compliant
Long term Complications of heart transplant?
Cardiac allograft vasculopathy (diffuse intimal thickening of the cornary arteries from distally to proximally)
Malignancy (lymphoproliferative disorders and skin cancer)
Cardiac transplant patients do not experience typical ischemic chest pain because?
Because of this, resting heart rate is usually between?
Also, patients are not responsive to these drugs?
Transplanted heart is denervated
90-110 (no vegal innervation)
Atropine or digoxin
