Cardiovascular

Question 1

What does HFpEF stand for?

Answer 1

Heart failure with preserved left ventricular ejection fraction

Question 2

What was heart failure with preserved left ventricular ejection fraction (HFpEF) previously known as?

Answer 2

Diastolic heart failure

Question 3

What is HFpEF classified as?

Answer 3

Heart failure with a left ventricular ejection fraction of greater than 40%.

Question 4

Describe the prevalence of HFpEF

Answer 4

HFpEF is more common in certain population groups, including older women and patients with elevated blood pressure.

Question 5

What is 1 principle of treatment for a patient with HFpEF?

Answer 5

1. Diagnose and treat the cause (eg hypertension)

Question 6

What are 2 principles of treatment for a patient with HFpEF?

Answer 6

1. Diagnose and treat the cause (eg hypertension)
2. Identify and treat precipitating factors (eg arrhythmias such as atrial fibrillation)

Question 7

What are 3 principles of treatment for a patient with HFpEF?

Answer 7

1. Diagnose and treat the cause (eg hypertension)
2. Identify and treat precipitating factors (eg arrhythmias such as atrial fibrillation)
3. Treat the symptoms (eg diuretics to treat congestion)

Question 8

What are 4 principles of treatment for a patient with HFpEF?

Answer 8

1. Diagnose and treat the cause (eg hypertension)
2. Identify and treat exacerbating conditions (eg atrial fibrillation)
3. Treat the symptoms (eg diuretics to treat congestion)
4. Recognise and treat comorbidities (eg hypertension, ischaemic heart disease, diabetes).

Question 9

Describe the evidence for drug therapy in HFpEF.

Answer 9

The drugs that have proven outcome benefits in heart failure with reduced ejection fraction (HFrEF) have not been studied for outcomes in HFpEF. However, the drugs used to treat HFrEF are often used to treat HFpEF.

Question 10

Describe the role of ACE inhibitor therapy in HFpEF.

Answer 10

While patients with HFpEF may benefit from angiotensin converting enzyme inhibitor (ACEI) therapy (which is often indicated for a comorbidity), there is insufficient evidence to recommend routine ACEI therapy in patients with HFpEF.

Question 11

Describe the role of beta-blocker therapy in HFpEF.

Answer 11

Beta-blocker therapy may also be beneficial in patients with HFpEF, particularly in patients with atrial fibrillation with a fast resting ventricular rate, or with coexisting ischaemic heart disease.

Question 12

Name 1 class of drug which can cause harm in patients with HFpEF

Answer 12

1. Diuretics

Question 13

Name 2 classes of drugs which can cause harm in patients with HFpEF

Answer 13

1. Diuretics
2. Venodilators

Question 14

Name 3 classes of drugs which can cause harm in patients with HFpEF

Answer 14

1. Diuretics
2. Venodilators
3. Powerful arterial vasodilators

Question 15

Name 4 classes of drugs which can cause harm in patients with HFpEF

Answer 15

1. Diuretics
2. Venodilators
3. Powerful arterial vasodilators
4. Digoxin and other inotropic drugs

Question 16

Why are diuretics potentially harmful for patients with HFpEF?

Answer 16

Patients with HFpEF generally have normal left ventricular volume and are sensitive to diuretics. Excessive diuresis can lead to a severe reduction in cardiac output and blood pressure

Question 17

Name an example of a venodilator

Answer 17

Isosorbide dinitrate

Question 18

Why are venodilators (such as isosorbide dinitrate) potentially harmful in HFpEF?

Answer 18

They can cause a severe reduction in cardiac output and blood pressure.

Question 19

Name an example of a powerful arterial vasodilator

Answer 19

Hydralazine

Question 20

Why are powerful arterial vasodilators (such as hydralazine) potentially harmful in HFpEF?

Answer 20

They can cause dynamic left ventricular outflow obstruction

Question 21

Describe the role of digoxin and other inotropic drugs in HFpEF

Answer 21

They should be avoided unless the patient is in atrial fibrillation.

Question 22

Which SGLT2 inhibitor has more evidence for HFpEF?

Answer 22

Empagliflozin

Question 23

What is are 3 good signs a patient can use to determine they may be accumulating fluid?

Answer 23

1. Orthopnoea
2. Loss of appetite
3. Peripheral oedema

Question 24

What should you always remember about cardioversion in heart failure patients?

Answer 24

We try to get patients as dry and as stable as possible before cardioversion as this makes it most likely they will maintain normal rhythm post cardioversion.

Question 25

What should you always remember about 1.5 litre fluid restrictions?

Answer 25

We want patients to get as close to their fluid targets as possible as this gives us the best chance to optimise their medication regime.

Question 26

What is the renal function cutoff for apixaban?

Answer 26

15 mL/minute

Question 27

How does the bleeding risk of warfarin compare to the bleeding risk of DOACs?

Answer 27

Warfarin has a higher risk of bleeding than DOACs even when INR is within therapeutic range.

Question 28

How does the bleeding risk of apixaban compare to the bleeding risk of dabigatran?

Answer 28

Dabigatran causes more bleeds than apixaban.

Question 29

Can you switch straight from an ARB to Entresto?

Answer 29

No. You still need your 36-hour washout period.

Question 30

Are pulmonary hypertension and PAH the same?

Answer 30

No

Question 31

What is the difference between pulmonary hypertension and PAH?

Answer 31

Pulmonary hypertension (PH) is a general term used to describe high blood pressure in the lungs from any cause. Pulmonary arterial hypertension (PAH) is a chronic and currently incurable disease that causes the walls of the arteries of the lungs to tighten and stiffen

Question 32

Describe the requirements around pregnancy in patients with PAH.

Answer 32

Pregnancy is contraindicated in PAH, so patients should use at least two concurrent forms of effective contraception.