Cardiology – Heart Failure

Question 1

Clinical differences in HFrEF vs HFpEF?

Answer 1

HFpEF patients will have

#higher heart rate to maintain normal cardiac output
#More sensitive to volume due to small LV

Question 2

Role for serial BNPs?

Answer 2

None

Question 3

Initial labs for heart failure should include?

Answer 3

BMP
UA
Lipids
LFTs
TSH

Do not do any more labs unless suggested by history or physical

Question 4

Most important diagnostic test in the evaluation of heart failure?

Potentially better test? Advantages?

Answer 4

ECHO

cMRI
#Can assess wall motion abnormalities, global wall function,
#Viability
#Tissue perfusion
#Tissue injury (inflammation, necrosis, fibrosis, infiltration, iron deposition)

Question 5

Valve abnormality that is secondary to heart failure?

Answer 5

Mitral regurgitation

Question 6

Left ventricular hypertrophy magnitude in HFpEF (vs HFrEF)?

LVH in HFpEF is generally due to?

Answer 6

Mild to moderate (under 15 mm in any region)

Hypertension

Question 7

When to perform endomyocardial biopsy for acute heart failure?

Goal of biopsy?

Answer 7

#Progressive heart failure on
#medical therapy with 
#malignant arrhythmias

Evaluate for Giant cell myocarditis

Question 8

Infiltrative disease that is least likely to be discovered on endomyocardial biopsy?

Answer 8

Sarcoidosis (patchy)

Question 9

Role for routine right heart catheterization in patients with heart failure?

However, it may be useful for?

Answer 9

None

#Patients with heart failure refractory to medical therapy
#Transplant candidates
#Before using inotropic agents or more aggressive diuresis

Question 10

Medications that decrease mortality in patients with HFrEF?

Therapies that improve symptoms?

Answer 10

#ACE inhibitors/ARBs
#Beta blockers
#Aldosterone antagonist
#Hydralazine/isosorbide dinitrate (for black patients in NYHA class III/IV) 

Digoxin
Diuretics
Iontropic agents
Vasodilators

Question 11

Benefit of high dose versus low dose ACE inhibitor? (Interval of uptitrating)

Beta-blocker?

Answer 11

Decreased hospital admissions but no difference in mortality (up to daily)

Mortality reduction and heart failure symptoms (uptitrating q1-2 weeks)

Question 12

In patient with HFrEF, when to reconsider starting ACE inhibitor?

Answer 12

Creatinine over 3.0

Question 13

Side effect of ACE inhibitors that warrant switching to angiotensin receptor blocker? Side effect that rules out both?

Answer 13

Cough

Angioedema

Question 14

Therapeutic doses of beta blockers for treatment of HFrEF?

Answer 14

Metoprolol Succinate 200
Carvedilol 25 BID
Bisoprolol 10

Question 15

Digoxin- benefits?

Answer 15

In Short-term, improved symptoms, quality-of-life, and exercise tolerance

Question 16

Digoxin - patients at risk to develop toxic levels?

Level associated with increased risk of mortality?

Answer 16

#Elderly
#Low body mass
#Kidney impairment

Over 1 ng/mL

Question 17

Aldosterone antagonists have mortality/mobility benefits in NYHA Class II if?

Answer 17

Prior hospitalization or elevated BNP

Question 18

Lab values that prohibit the use of aldosterone antagonists?

Answer 18

#Creatinine above 2.5 in men or above 2 in women
#Potassium over 5

Question 19

Pathophysiology of HFrEF vs HFpEF?

Answer 19

Abnormality of myocardio contraction (reduced systolic function result in progressive ventricular dilation)

Abnormality in diastolic relaxation (results in restricted feeling and High filling pressures)

Question 20

Antihypertensives that should be discontinued once a diagnosis of heart failure has been made?

Answer 20

Dihydropyridine’s (diltiazem or verapamil)

Amlodipine or felodipine can be continued

Question 21

Medications with a mortality benefit in HFpEF?

Answer 21

None

Question 22

How common is sudden cardiac death in patients with heart failure? Only reliable predictor of an arrhythmic event is?

Answer 22

50%

LVEF

Question 23

Indications for ICD for primary prevention in heart failure?

For secondary prevention?

Answer 23

#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

Question 24

Should only place ICD in patients with reduced life expectancy if?

Answer 24

#Awaiting transplantation
#Awaiting placement of mechanical circulatory device

Question 25

Pacing lead in ICD is placed? Additional pacing lead in CRT is placed?

Answer 25

Apex of right ventricle Coronary sinus

Question 26

CRT indications?

Answer 26

``` #LVEF under 35% #LBBB with QRS>150 #NYHA Class III or IV (maybe II) on medical therapy ```

Question 27

Valve abnormality that arise after CRT?

Answer 27

Tricuspid regurgitation

Question 28

Bad prognostic signs in patients with heart failure? Bad prognostic signs on cardiopulmonary exercise testing?

Answer 28

``` #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) ```

Question 29

Patient with acute decompensated heart failure. When to discontinue beta blocker?

Answer 29

``` Low output heart failure: #Hypotension #Worsening kidney/liver function #Cool extremities ```

Question 30

Ultrafiltration versus IV diuretics in decompensated heart failure?

Answer 30

Worsened kidney function

Question 31

Drug that can be used for the treatment of hyponatremia in patients with heart failure?

Answer 31

Vasopressin antagonists

Question 32

Cardiogenic shock - drugs that increase inotropy and vasodilate? Drugs that increase inotropy and vasoconstrict? Drug that increases inotropy and can either vasodilate or vasoonstrict?

Answer 32

Milrinone (PDE inhibitor) Dopamine Norepinephrine Dobutamine (dilates at low doses, constricts at high doses)

Question 33

Cardiogenic shock – drugs that purely vasodilate?

Answer 33

Sodium nitroprusside Nitroglycerin Nesiritide (Natriuretic peptide receptors)

Question 34

Cardiogenic shock – drug that is a negative inotrope and Vasoconstricts?

Answer 34

Vasopressin

Question 35

Complications related to LVADs?

Answer 35

``` #Driveline related infections #G.I. bleeding from AV malformation's #Ischemic/hemorrhagic stroke ```

Question 36

Three drug immunosuppressive regimen after heart transplant?

Answer 36

``` #Calcineurin inhibitor (cyclosporine or tacrolimus) #Antiproliferative agent #Mycophenolate, sirolimus, everolimus) Prednisone ```

Question 37

Signs of rejection after transplant? Rate of rejection in the first year? subsequently?

Answer 37

Heart failure and atrial arrhythmias (atrial flutter) 20% Nonexistent if medication compliant

Question 38

Long term Complications of heart transplant?

Answer 38

Cardiac allograft vasculopathy (diffuse intimal thickening of the cornary arteries from distally to proximally) Malignancy (lymphoproliferative disorders and skin cancer)

Question 39

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?

Answer 39

Transplanted heart is denervated 90-110 (no vegal innervation) Atropine or digoxin