Cards-Heart Failure Flashcards
What are some common things that impact BNP?
BNP levels increase with age and worsening kidney function and are reduced in patients with an elevated BMI. So fat people have a low BNP
How is CMR used for assessment in heart failure?
Cardiac magnetic resonance (CMR) imaging is used increasingly in the evaluation of patients with heart failure. CMR imaging can be used to assess wall motion abnormalities, global wall function, and viability. Additionally, it can be used to assess tissue perfusion, tissue injury (inflammation or necrosis), fibrosis, infiltration (sarcoid or amyloid), or iron deposition.
When is a biopsy indicated for the assessment of heart failure?
Patients with progressive heart failure on medical therapy who have malignant arrhythmias should undergo biopsy to evaluate for giant cell myocarditis. Biopsy is also reasonable for patients with new-onset heart failure unresponsive to standard medical therapy. Endomyocardial biopsy can assist in the diagnosis of amyloidosis and hemochromatosis, which are diffuse processes amenable to diagnosis by biopsy techniques; sarcoidosis, on the other hand, can be quite patchy and is less likely to be discovered on endomyocardial biopsy.
Who should get a right heart Cath? What are the indications?
- Advanced heart failure who are refractory to medical therapy
- Symptomatic hypotension and worsening kidney function may be suggestive of low cardiac output but could also be caused by infection or progression of disease. A right heart catheterization directly measuring cardiac output and filling pressures can guide therapy toward improving hemodynamics (higher stroke volume and lower filling pressures) with inotropic agents and/or more aggressive diuresis if the filling pressures are high.
- patients being evaluated for heart transplantation. Pulmonary hypertension is a risk factor for poor outcomes following heart transplantation because the right ventricle of the donor heart is not accustomed to pumping against high pulmonary pressures and may fail.
Therapy for heart failure
The initial therapy for patients presenting with acute heart failure and volume overload is a diuretic. An ACE inhibitor, angiotensin receptor blocker (ARB), or angiotensin receptor–neprilysin inhibitor (ARNI) should also be started unless the patient has symptomatic hypotension. Once the acute heart failure episode has stabilized, all patients should be treated with a β-blocker.
What is longterm heart failure therapy based on?
The long-term therapy of heart failure is based on the patient’s functional status as measured by New York Heart Association (NYHA) functional class
What medications have been shown to reduce mortality in heart failure?
Main ones: ACE inhibitors, ARBs, angiotensin receptor neprilysin inhibitor (ARNIs; sacubitril-valsartan), and β-blockers
Other treatments for heart failure that have been shown to decrease mortality and future hospitalizations include…. aldosterone antagonists, ivabradine, and, specifically for black patients, hydralazine–isosorbide dinitrate
What is the role of ivabradine in heart failure treatment?
The 2016 ACC/AHA/HFSA Focused Update on Pharmacological Therapy for Heart Failure recommends ivabradine to reduce heart failure–associated hospitalizations in patients with:
- chronic symptomatic heart failure with
- left ventricular ejection fraction less than or equal to 35%
- who are in sinus rhythm and taking guideline-directed medical therapy, including a β-blocker
Ivabradine is an inhibitor of the If or “I-funny” channel, which contributes to normal sinus node function. Its sole effect is in slowing the heart rate by decreasing sinus node automaticity.
When should you consider the ARNI over an ACEI?
he ARNI valsartan-sacubitril has been proved to be more effective than the ACE inhibitor enalapril in reducing cardiovascular death, heart failure hospitalization, and all-cause mortality in symptomatic patients with HFrEF. Consequently, the 2016 ACC/AHA/HFSA heart failure focused update recommends that an ARNI be substituted for an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF (NYHA functional class II or III) who have tolerated ACE inhibitor or ARB therapy well. It is important to note that concomitant use of an ARNI and ACE inhibitor is contraindicated because of an increased risk of angioedema. ARNI use has also been associated with hypotension.
What is the treatment for HFrEF?
- ACE-I (give to ALL): start in acute heart failure and when has volume overload
- B-blocker: after acute decompensation is treated and pt is HD stable
- Diuretics: loop diuretic for acute HF, maybe lower dose for chronic, sometimes need to add a thiazide to help out
Who is at risk for high digoxin levels?
Patients with kidney impairment, low body mass, and older age have reduced metabolism of digoxin and can quickly develop a toxic level. It is important to check a digoxin level in patients with worsening kidney function.
What follow-up labs should you order for spironolactone or eplerenone?
Additionally, if the patient is on potassium supplementation, this should be discontinued when therapy is initiated. Electrolytes and kidney function should be checked 1 week after initiation of therapy and be closely monitored over time.
When do you use a nitrate/nitrite in heart failure?
The combination of isosorbide dinitrate and hydralazine is an alternative therapy for patients with heart failure who have kidney dysfunction that limits therapy with either ACE inhibitors or ARBs.
What CCB are unsafe in heart failure? What should you do with them?
Because of their vasodilating effects, calcium channel blockers have been closely studied for their potential role in the management of heart failure. Unfortunately, the non-dihydropyridine calcium channel blockers (for example, diltiazem or verapamil) also have myocardial depression activity and have been demonstrated to either have no benefit or worse outcomes in patients with heart failure. Patients who have been treated for hypertension with diltiazem or verapamil should have those agents discontinued once a diagnosis of heart failure has been made. The second-generation dihydropyridine calcium channel blockers, such as amlodipine and felodipine, have been shown to be safe in patients with heart failure, but do not reduce morbidity or mortality
What medications have proven benefit for HFpEF?
ACE inhibitors, ARBs, β-blockers, and aldosterone antagonists have been studied in patients with HFpEF. Unfortunately, none of these agents have demonstrated any clinical benefit compared with placebo. At this time, no medications have demonstrated a reduction in mortality in this patient population. Therapy for HFpEF should instead be based on treating the causes and symptoms of the heart failure.
