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RCE Guidelines Studying > CCS HF (2021 + 2017) > Flashcards

CCS HF (2021 + 2017) Flashcards

1
Q

When should patients be fully uptitrated for LV enhancement therapy?

A

3-6 months

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2
Q

When to consider Vericiguat?

A

LVEF < 40% and symptoms with recent hospitalization

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3
Q

What level of K+ would you hold or reduce MRA?

A

> 5.6

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4
Q

What renal function was excluded in EMPEROR reduced? DAPA HF?

A

-20
-30

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5
Q

What level of GFR drop would you expect after SGLT2 inhibitor start?

A

15% (reversible, good for renal function in long term)

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6
Q

What eGFR was excluded in VICTORIA trial? LVEF?

A

> 45%

<15

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7
Q

When should Digoxin be used in HF?

A

1) Afib control

2) Sinus but with symptoms despite maximal medical therapy

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8
Q

When to assess LVEF after titration of LV enhancement therapy?

A

3 months

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9
Q

5 markers/Diagnostic tests that predict HF?

A

-Abnormal ECG
-BNP
-Increased CXR ratio
-Elevated resting HR
-Microalbuminuria

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10
Q

When to get echo after HF presentation? After clinical significant event?

A

-2 weeks
-30 days

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11
Q

6 toxic agents for CMO?

A

-Heavy metals
-Chemotherapy
-ETOH
-Cocaine
-Amphetamines
-Steroids
-Radiation

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12
Q

6 Endocrine causes of CMO?

A

-Thyrotoxicosis
-DM
-Adrenal insufficiency
-Cushing’s
-Pheochromocytoma
-Acromegaly

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13
Q

4 nutritional causes of CMO?

A

Thiamine
Selenium
Carnitine
Vitamin D

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14
Q

Name 5 Chemotherapeutic agents that cause CMO?

A

-Anthracycline
-Tratzumab
-Bleomycin
-Cyclophosphamide
-Adriamcyin

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15
Q

What are 6 heavy metals that can cause CMO?

A

-Gold
-Silver
-Mercury
-Cobalt
-Iron
-Chromium

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16
Q

BNP HF likely vs unlikely ? NT Pro BNP?

A

<100 or >400

< 50 -> < 300, >450
50-75 -> < 300, > 900
>75 -> < 300, >1800

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17
Q

What are BNP rule out for outpatient? NT BNP?

A

BNP < 50

NT BNP < 125

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18
Q

Target dose of Carvedilol? Ivabradine?

A

-Carvedilol 25mg BID (50 bid if weight > 85kg)

-Ivabradine 7.5mg bid

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19
Q

How to manage K5.5-5.9? >5.9

A

-Continue RAAS inhibition at half of previous dose, recheck in 72 hours. If still > 5.5 -> stop at least one agent. restart when less than 5.

-Stop all, go get ECG/ER, restart less than 5

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20
Q

What are the 7 INTERMACS stages?

A

1) Crashing and Burning

2) Progressive decline on inotropes

3) Stable but inotrope dependent

4) Resting symptoms

5) Exertional intolerant

6) Exertional limited

7) Advanced NYHA III

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21
Q

Exclusions for K, SBP and eGFR for PARADIGM trial?

A

K > 5.2

SBP < 100mmhg

eGFR < 30

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22
Q

What is histopathology of ARVC according to revised task force criteria?

A

-Residual myocytes < 60%, with fibrous replacement of the RV free wall myocardium in 1 or more sample, with or without fatty replacement of tissue on EMB

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23
Q

What is echo + MRI criteria for ARVC with task force?

A

-Echo: Regional RV akinesia/dyskinesia, RV dilatation, FAC < 33%

-CMR: RVEDV > 110, RVEF 40%

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24
Q

ECG criteria for ARVC by revised task force? (2)

A

-Inverted T waves in right precordial leads (V1-V3) in individuals (need V4 too if RBBB present)

-Epsilon wave

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25
Q

What trial showed that omega 3 (PUFAs) in HF NYHA II-IV resulted in 8-9% RRR in death/hospitalization?

A

-GISSI 3

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26
Q

What is side effect of PUFA?

A

bleeding

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27
Q

5 differences between LVH/HCM vs. RCM (Demographics, Prevalence, Comorbidities, changes on biopsy)

A

LVH/HCM: Female > male, higher prevalence, comorbidities (HTN, DM), mild DD vs severe), no changes on biopsy

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28
Q

What are 4 mechanisms of Anthracycline induced CMO?

A
  1. ROS generation
  2. Transcriptional change in myocyte ATP pathway
  3. Decreased mRNA expression, reduced contractility
  4. Toposiomerase IIB interference
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29
Q

6 therapy associated risk factors for anthracycline CMO?

A

-Doxorubicin (not epirubicin)

-IV administration

-High peak concentrations

-Irradiation

-Concurrent use of toxic med (Tratzumab, Paclitaxel)

-Cumulative dose: Doxo cut offs- 400, 550 , 700,

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30
Q

What is the mechanism of CMO for Tratzumab?

A

-Inhibition of HER2 signalling might interfere with growth and signalling of cardiomyocytes and might induce mitochondrial damage

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31
Q

5 criteria to have Primary prevention ICD?

A

-LVEF < 35%
-NYHA II-III
-1 month post MI
-3 month post revascularization
-3 months post GDMT

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32
Q

List 8 criteria for DC from Heart Function clinic (need 2 for DC)

A

-NYHA 1 or 2 for 6-12 months
-Optimal therapy
-Reversible causes of HF controlled
-Having access to FP with expertise in HF management
-Adherence to optimal HF therapy
-No hospitalization for > 1 year
-LVEF > 35%
-Primary care provider has access to urgent specialist reassessment

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33
Q

Name 3 indications for CRT?

A

-LVEF < 35%, NYHA II-IV, SR, LBBB > 130 msec

-NYHA II-IV, LVEF < 35% and WRS > 150msec with non LBBB

-Chronic RV pacing if LVEF < 50%

34
Q

10 reasons to consider MCS/Transplant?

A

-LVEF < 25%

-VO2 < 14

-Recurrent HF hospitalizations

-Progressive end organ failure

-Diuretic refractoriness associated with worsening renal function

-6MWT < 300m

-Cardiac Cachexia

-Inability to perform activities of daily living

-20-25% mortality by scoring systems

-Need to take off LV enhancement therapies

35
Q

Criteria for revasc based on MIBI? PET? DSE? CMR

A

-Reversible ischemia > 30% on MIBI?

-Reversible ischemia > 7% on PET

-Reversible ischemia > 20% on Echo

-Less than 50% wall thickness scarring shown by LGE on CMR imaging

36
Q

What is prevalence of ARVC? Men:women?

A
  • 1/5000

-1.3:1

37
Q

What 3 outcomes have been improved with iron replacement in HF? What studies?

A

-Exercise capacity, HF hospitalization, quality of life

-FAIR HF, IRON OUT

38
Q

When should Tolvaptan be considered?

A

Na < 130 mmol/l for the short term correction of hypo na and associated symptoms

39
Q

What EF drop in chemo patients is important?

A

> 10% to less than 53%

40
Q

What are three scenarios where myocarditis should be suspected?

A

-Cardiogenic shock due to LV dysfunction with no other etiology

-Acute/subacute development systolic dysfunction in patients whom etiology is not apparent

-Evidence of myocardial damage not attributable to epicardial CAD or another cause

41
Q

What are 4 indications for EMB?

A

1) New onset (< 2 weeks) HF with no etiology with HD compromise

2) HF and high grade heart block

3) HR with recurrent ventricular arrhythmias

4) HF unresponsive to medical therapy

42
Q

What are two hallmarks of histology of myocarditis?

A

-Presence of inflammatory cell infiltrate
-Positive viral genome signal on examination of EMB specimens

43
Q

What is the indication for Mitra clip?

A

Symptomatic HFrEF and severe MR on maximal GDMT including CRT if indicated

44
Q

5 indications for SGLT2 inhibitors?

A

-T2DM + ASCVD

-T2DM, age > 50 and additional RFs

-> 30 with T2DM and microalbumineric renal disease

  • LVEF < 40% with t2DM
  • LVE < 40% with no t2DM
45
Q

How much increase in Cr OK with SGLT2 start?

A

20%

46
Q

When should Vericiguat be added?

A

LVEF < 40% with worsening HF symptoms in the last 6 months (to reduce hospitalization risk)

47
Q

When should Entresto be started? (3)

A

Symptomatic HFrEF despite GDMT

Hospitalization HFrEF despite GDMT

New onset HFrEF

48
Q

When to repeat echo in Stable HF?

A

q1-3 years

49
Q

Name 5 CMO’s where LV enhancement can be withdrawn?

A

-ETOH CMO: Normal LVEF and Volumes, NYHA 1, Abstinence of ETOH

-TCM: Above + control or arrhythmia

-Chemo: Above and no more exposure to drug

-PPCM

-Valve replacement surgery

50
Q

2 indications for MRA post MI?

A

LVEF < 40% and HF symptoms OR Diabetes

51
Q

What is Exercise intensity recommendation for HF patients NYHA I-III? (3; Based on RPE, Max HR and VO2)

A

-RPE 3-5

-65-85% Max HR

-50-75% VO2

52
Q

Which patients with HFrEF to refer for angiography?

A

-Angina/Equivalent IF revascularization candidate

-No Angina but LVEF < 35% and Revasc candidate

-No Angina but LVEF < 35% and NIV positive

53
Q

Name 5 causes of Isolated Right Heart Failure

A

PAH/PH

Right sided Valve Disease

RV infarct

ARVC

Congenital Heart Disease

54
Q

What are the 3 classifications of etiologies for Restrictive cardiomyopathy?

A

-Infiltrative: Amyloidosis, Sarcoidosis, Gaucher, Fabry, Glycogen Storage Disease

-Myocardial: Scleroderma, HCM, Familial RCM, Diabetic CMO

-Endomyocardial: Hypereosinophilic syndrome, Endomyocardial fibrosis, Carcinoid, Radiation, chemo

55
Q

4 hemodynamic changes in Pregnancy?

A

-Increased HR
-Increased SV
-Increased CO (due to above)
-Increased Plasma Volume
-Decreased peripheral vascular resistance (Decreased BP)

56
Q

What are three classifications of Anthracycline toxicity effects?

A

-Acute: Myocarditis, QTc prolongation -> Reversible

-Early-Onset Chronic Progressive: irreversible CMO within 1 year

-Late-Onset Chronic Progressive: irreversibel CMO onset after 1 year

57
Q

5 cardiac consequences of Radiation therapy?

A

-CAD
-Pericardial Disease (CP)
-Conduction system disease
-Calcific/Stenotic Valve disease
-RCM

58
Q

Referral time for following- Emergent (CS, for MCS), Urgent (New onset decompensated), Semi-Urgent (New onset compensated), Routine (stable HF, chronic management or NYHA 1)

A

-Emergent: < 24h

-Urgent: < 2 weeks

-Semi-urgent: < 6 weeks

-Routine: < 12 weeks

59
Q

4 Indications for CRT in HF?

A

-LVEF < 35%, NYHA II-IVa despite GDMT, Sinus Rhythm, QRS > 130msec with LBBB morphology

-LVEF < 35%, NYHA II-IVa despite GDMT, Sinus Rhythm, QRS > 150msec with Non-LBBB morphology

-RV pacing required (With anticipated pacing > 40%) in patients with with LV dysfunction (LVEF < 40%) and symptoms

-Indication for CRT and Permanent AF with AV ablation or Rate control allowing for BiPacing % close to 100%

60
Q

Indications to consider Transplant/Advanced management strategies

A

Patients with advanced HF and NYHA III/IV symptoms despite GDMT with two or more of the following:

  • LVEF < 25%
  • VO2 max < 14
  • Progressive end organ damage due to reduced perfusion/high filling pressures
  • > 1 HF hospitalization in last year
  • Progressive Diuretic Refractoriness
  • Need to taper back LV enhancement therapy
  • Requirement for inotropic support
  • 6MWT < 300m
  • 1y mortality > 25% on risk scores
  • Inability to perform ADLs
    -Cardiac Cachexia
    -Hyponatremia < 134
61
Q

Benefits of Rehab in HF?

A

-Decreased HF Hospitalization

-Decreased Depression

-Improved QoL

-Decreased Symptoms

-Improved Exercise Capacity/VO2 max achieved

62
Q

Two populations that Dronedarone should be avoided in?

A

LVEF < 35%

Recent Hospitalization in last year

63
Q

4 patients populations that may experience LV systolic improvement based on: MPI, DSE, PET, CMR

A

-MPI: 30% area of Reversible Ischemia/Viable segment

-DSE: 20% shown as Viable on DSE

-PET: 7% Hibernating Myocardium

-CMR: Less than 50% scarring of wall thickness

64
Q

Target weight loss per day for ADHF management?

A

0.5-1 kg per day

65
Q

What three classes of medications is there High evidence for intiation on HF hospitalization or new onset HF

A

-ACEi/ARB

-BB

-MRA

Not Entresto (Moderate HF Hosp Pioneer HF)
Not SGLT2 (Updated since guidelines, SOLOIST shows lower composite of CV death/Hosp at follow up)

66
Q

Three indications for ARNI based on 2021 guidelines?

A

-New HFrEF with hospitalization

-Symptomatic HFrEF despite GDMT

-HF hospitalization with HFrEF despite GDMT

67
Q

Name 4 pathophysiologic mechanisms of PPCM?

A

-Increased Prolactin
-Oxidative stress
-Immune mechanisms
-Viral infections

68
Q

4 features of Restrictive CMO?

A

Disease of the myocardium with markedly stiff ventricles with:
-Restrictive ventricular filling
-Reduced diastolic filling volumes
-Near normal or normal systolic function

69
Q

how does Tolvaptan work?

A

Vasopressin receptor antagonist that blocks free water absorption in the collecting tubule

(Use in HF when symptomatic with fluid overload and Na < 130)

70
Q

What is recommended RPE , HR max and peak VO2 for HF NYHA I-III?

A

-RPE 3-5

-65-85% max HR

-50-75% peak VO2

71
Q

How to decide between temporary vs long term/durable ventricular assist?

A

Time period: Emergent -> Short, elective/urgent -> durable

Infection control: high risk -> short, lower risk -> durable

Type of support: 1 or both ventricles -> short, only left -> durable

72
Q

In what two situations in SGLT2 inhibitor contraindicated?

A

-EGFR < 20 Empa or < 30 Dapa

-Type 1 diabetes

73
Q

How long before you see the benefits of beta blockade?

A

3-6 months

74
Q

What is the incidence of euglycemic DKA in patients on SGLT2 inhibitors?

A

0.1%

75
Q

When should EF be assessed for ICD/CRT (Timing)

A

-3 months post achievement of GDMT/or maximally tolerated doses

76
Q

What 3 populations with ATTR CA should not be prescribed Tafamadis?

A

-NYHA IV, 6MWT < 100m, severe functional disability

These were excluded in ATTRACT trial

77
Q

2 indications for BNP measurement in HF?

A

-Diagnosis of HF or rule out when otherwise in doubt

-Prognosticate HF to optimize therapy

78
Q

5 reasons to admit for HF?

A

-NYHA III/IV

-SPO2 < 91%

-SBP < 90mmhg

-HR > 90 bpm

-RR > 20

79
Q

Name 5 criteria for discharge?

A

-NYHA II
-BP to baseline or > 100
-SPO2 > 92%
-RR < 20
-HR < 90 bpm

80
Q

When does peripheral vascular resistance and blood pressure nadir in pregnancy?

A

Second with gradual return to normal in third trimester

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