Cardiology - Heart Failure: Chronic Management

Question 1

What is Stage A Heart Failure?

Answer 1

Stage A = at risk BUT no structural disease or symptoms

Question 2

What is Stage B Heart Failure?

Answer 2

Stage B = Structural disease BUT no symptoms

Question 3

What is Stage C Heart Failure?

Answer 3

Stage C = structural disease WITH previous or current symptoms

Question 4

What is Stage D Heart Failure?

Answer 4

Refractory heart failure requiring specialist interventions with marked symptoms at rest despite maximum medial therapy

Question 5

ACEi benefit?

Answer 5

Reduces mortality
Reduces hospitalisation

(has never been studied in symptomatic hypotension)

NO CHANGE TO SCD

Question 6

ACEi plus beta blocker versus ACEi alone

Answer 6

Better to use lower dose ACEi plus beta blocker than either alone
- additional 35% mortality benefit if beta blocker added

Question 7

Which ARBs have trial evidence in heart failure?

Answer 7

Losartan
Valsartan
Candesartan

Question 8

Which ARB has been looked at in EF >40% (HFpEF)

Answer 8

Candesartan

• TREND to decreased CV deaths
• REDUCED hospitalisation for HF
• REDUCED new diabetes

Question 9

What salt restriction should HF patients be on?

Answer 9

<2g per day of salt

Question 10

Which beta blockers have been studied in heart failure?

Answer 10

Carvedilol
Bisoprolol
Nebivolol
Metoprolol succinate

Question 11

Which is the most cardioselective beta blocker?

Answer 11

Nebivolol

Question 12

Which beta blocker has evidence for reducing sudden cardiac death?

Answer 12

Bisoprolol

Question 13

Which beta blocker has been studied in seniors?

Answer 13

Nebivolol

in patients >70yrs with HFrEF

Question 14

Role of aldosterone antagonists in HFrEF?

Answer 14

Spironolactone in HFrEF <35% (mortality and hospitalisation and symptom benefit)

Eplerenone in EF<35% NYHA Class II reduced mortality and hospitalisation

Question 15

What side effects of aldosterone antagonists in HFrEF

Answer 15

1 in 10 gynecomastia

Increased hyperkalaemia BUT study with eplerenone showed no increase in hospitalisations due to hyperkalaemia

Question 16

Which aldosterone antagonist would you use post MI and when?

Answer 16

Eplerenone in patients 3-14 days post acute MI with LVEF <40%

• reduced mortality
• reduced SCD
• increased hyperkalaemia

Question 17

Role of aldosterone antagonists in HFpEF?

Answer 17

Spironolactone in EF>45%

• reduced HOSPITALISATIONS for HF
• no change to mortality
• increased hyperkalaemia and AKI

Spironolactone in EF >50%
- improved echo measures of diastolic dysfunction but no other changes

Question 18

Mechanism of hydralazine plus nitrates in heart failure?

Answer 18

Hydralazine: direct smooth muscle relaxation causing systemic peripheral vasodilation

Nitrates: in smooth muscle cells nitrates are transformed to nitric oxide which stimulates cGMP production and therefore vasodilation

Question 19

Role for hydralaxine plus nitrates in heart failure?

Answer 19

IN African Americans has mortality benefit, hospitalisation benefit and improved QoL

Question 20

Ivabradine role in heart failure?

Answer 20

Alters SINUS node rate
Inhibits If channels in SINUS NODE and RETINA

If LVEF <35%, symptoms and a sinus rhythm >77bpm has mortality benefit but only is ADEQUATE beta blockage dose or unable to use beta blocker

Question 21

Where are the If receptors found?

Answer 21

Sinus node and retina

Question 22

Role of digoxin in heart failure?

Answer 22

Mild inotropic effects
Attenuates carotid sinus baroreceptor activity
Sympathoinhibitory
Reduces plasma renin and reduces noradrenaline levels

In LVEF <45% improves hospitalisation but not mortality or QoL

Question 23

Mech of neprolysin inhibitors?

Answer 23

Degrades natriuretic peptides (ie BNP, bradykinin, CNP and Substance P)
Which causes: 
- Diuresis
- Natriuresis
- Vasodilation
- Decreased fibrosis and hypertrophy

Question 24

Why does neprolysin need to be added to RAAS blockade?

Answer 24

Neprolysin also breaks down Angiotensin I and II
–> neprolysin inhibition will therefore increase levels of angiotensin II which counteracts the other benefits of it

So you need to combine with an ARB

Question 25

Benefit of Neprolysin Inhibitors?

Answer 25

In HFrEF <40%

• reduced CVS mortality
• reduced HF hospitalisation

Question 26

Role of fish oil in HF?

Answer 26

Long chain omega 3 polyunsaturated fatty acids have associated with modest improvement in outcomes and HFrEF mortality

Question 27

Role for thiamine in HF?

Answer 27

Selenium and thiamine deficiency lead to HF

Some SMALL evidence for thiamine in chronic HFrEF

Question 28

Role of Graded External Pneumatic Compression (Enhanced External Counterpulsion) (EECP)

Answer 28

• improved ET and QoL

Question 29

Role of exercise in HFrEF?

Answer 29

Improved QoL
No adverse outcomes
TREND to mortality reduction
Improved peak O2 consumption at 12 months

Question 30

Indications for biventricular pacing in HF?

Answer 30

• NYHA Class III-IV
• NYHA Class II with LBBB QRS >150ms
• LBBB QRS >120ms (BEST evidence if >150)
• EF <35% with ischaemic or dilated CM
• on guideline maxmum medical therapy
• sinus rhythm

MORTALITY BENEFIT

Question 31

Indications for ICD in HF?

Answer 31

• NYHA II-III with LVEF <35%
• Post MI with EF <30% at >40 days post MI
• Post CABG with LVEF <30% and >3 months post CABG

Question 32

Role of CABG for HF?

Answer 32

Best role for ongoing angina in ischaemic cardiomyopathy with multivessel disease

• no change to all-cause mortality
• reduced CV-death and reduced COMBINED all-cause mortality+hospitalisation