CCS HF (2021 + 2017) Flashcards
When should patients be fully uptitrated for LV enhancement therapy?
3-6 months
When to consider Vericiguat?
LVEF < 40% and symptoms with recent hospitalization
What level of K+ would you hold or reduce MRA?
> 5.6
What renal function was excluded in EMPEROR reduced? DAPA HF?
-20
-30
What level of GFR drop would you expect after SGLT2 inhibitor start?
15% (reversible, good for renal function in long term)
What eGFR was excluded in VICTORIA trial? LVEF?
> 45%
<15
When should Digoxin be used in HF?
1) Afib control
2) Sinus but with symptoms despite maximal medical therapy
When to assess LVEF after titration of LV enhancement therapy?
3 months
5 markers/Diagnostic tests that predict HF?
-Abnormal ECG
-BNP
-Increased CXR ratio
-Elevated resting HR
-Microalbuminuria
When to get echo after HF presentation? After clinical significant event?
-2 weeks
-30 days
6 toxic agents for CMO?
-Heavy metals
-Chemotherapy
-ETOH
-Cocaine
-Amphetamines
-Steroids
-Radiation
6 Endocrine causes of CMO?
-Thyrotoxicosis
-DM
-Adrenal insufficiency
-Cushing’s
-Pheochromocytoma
-Acromegaly
4 nutritional causes of CMO?
Thiamine
Selenium
Carnitine
Vitamin D
Name 5 Chemotherapeutic agents that cause CMO?
-Anthracycline
-Tratzumab
-Bleomycin
-Cyclophosphamide
-Adriamcyin
What are 6 heavy metals that can cause CMO?
-Gold
-Silver
-Mercury
-Cobalt
-Iron
-Chromium
BNP HF likely vs unlikely ? NT Pro BNP?
<100 or >400
< 50 -> < 300, >450
50-75 -> < 300, > 900
>75 -> < 300, >1800
What are BNP rule out for outpatient? NT BNP?
BNP < 50
NT BNP < 125
Target dose of Carvedilol? Ivabradine?
-Carvedilol 25mg BID (50 bid if weight > 85kg)
-Ivabradine 7.5mg bid
How to manage K5.5-5.9? >5.9
-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
What are the 7 INTERMACS stages?
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
Exclusions for K, SBP and eGFR for PARADIGM trial?
K > 5.2
SBP < 100mmhg
eGFR < 30
What is histopathology of ARVC according to revised task force criteria?
-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
What is echo + MRI criteria for ARVC with task force?
-Echo: Regional RV akinesia/dyskinesia, RV dilatation, FAC < 33%
-CMR: RVEDV > 110, RVEF 40%
ECG criteria for ARVC by revised task force? (2)
-Inverted T waves in right precordial leads (V1-V3) in individuals (need V4 too if RBBB present)
-Epsilon wave
What trial showed that omega 3 (PUFAs) in HF NYHA II-IV resulted in 8-9% RRR in death/hospitalization?
-GISSI 3
What is side effect of PUFA?
bleeding
5 differences between LVH/HCM vs. RCM (Demographics, Prevalence, Comorbidities, changes on biopsy)
LVH/HCM: Female > male, higher prevalence, comorbidities (HTN, DM), mild DD vs severe), no changes on biopsy
What are 4 mechanisms of Anthracycline induced CMO?
- ROS generation
- Transcriptional change in myocyte ATP pathway
- Decreased mRNA expression, reduced contractility
- Toposiomerase IIB interference
6 therapy associated risk factors for anthracycline CMO?
-Doxorubicin (not epirubicin)
-IV administration
-High peak concentrations
-Irradiation
-Concurrent use of toxic med (Tratzumab, Paclitaxel)
-Cumulative dose: Doxo cut offs- 400, 550 , 700,
What is the mechanism of CMO for Tratzumab?
-Inhibition of HER2 signalling might interfere with growth and signalling of cardiomyocytes and might induce mitochondrial damage
5 criteria to have Primary prevention ICD?
-LVEF < 35%
-NYHA II-III
-1 month post MI
-3 month post revascularization
-3 months post GDMT
List 8 criteria for DC from Heart Function clinic (need 2 for DC)
-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
Name 3 indications for CRT?
-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%
10 reasons to consider MCS/Transplant?
-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
Criteria for revasc based on MIBI? PET? DSE? CMR
-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
What is prevalence of ARVC? Men:women?
- 1/5000
-1.3:1
What 3 outcomes have been improved with iron replacement in HF? What studies?
-Exercise capacity, HF hospitalization, quality of life
-FAIR HF, IRON OUT
When should Tolvaptan be considered?
Na < 130 mmol/l for the short term correction of hypo na and associated symptoms
What EF drop in chemo patients is important?
> 10% to less than 53%
What are three scenarios where myocarditis should be suspected?
-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
What are 4 indications for EMB?
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
What are two hallmarks of histology of myocarditis?
-Presence of inflammatory cell infiltrate
-Positive viral genome signal on examination of EMB specimens
What is the indication for Mitra clip?
Symptomatic HFrEF and severe MR on maximal GDMT including CRT if indicated
5 indications for SGLT2 inhibitors?
-T2DM + ASCVD
-T2DM, age > 50 and additional RFs
-> 30 with T2DM and microalbumineric renal disease
- LVEF < 40% with t2DM
- LVE < 40% with no t2DM
How much increase in Cr OK with SGLT2 start?
20%
When should Vericiguat be added?
LVEF < 40% with worsening HF symptoms in the last 6 months (to reduce hospitalization risk)
When should Entresto be started? (3)
Symptomatic HFrEF despite GDMT
Hospitalization HFrEF despite GDMT
New onset HFrEF
When to repeat echo in Stable HF?
q1-3 years
Name 5 CMO’s where LV enhancement can be withdrawn?
-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
2 indications for MRA post MI?
LVEF < 40% and HF symptoms OR Diabetes
What is Exercise intensity recommendation for HF patients NYHA I-III? (3; Based on RPE, Max HR and VO2)
-RPE 3-5
-65-85% Max HR
-50-75% VO2
Which patients with HFrEF to refer for angiography?
-Angina/Equivalent IF revascularization candidate
-No Angina but LVEF < 35% and Revasc candidate
-No Angina but LVEF < 35% and NIV positive
Name 5 causes of Isolated Right Heart Failure
PAH/PH
Right sided Valve Disease
RV infarct
ARVC
Congenital Heart Disease
What are the 3 classifications of etiologies for Restrictive cardiomyopathy?
-Infiltrative: Amyloidosis, Sarcoidosis, Gaucher, Fabry, Glycogen Storage Disease
-Myocardial: Scleroderma, HCM, Familial RCM, Diabetic CMO
-Endomyocardial: Hypereosinophilic syndrome, Endomyocardial fibrosis, Carcinoid, Radiation, chemo
4 hemodynamic changes in Pregnancy?
-Increased HR
-Increased SV
-Increased CO (due to above)
-Increased Plasma Volume
-Decreased peripheral vascular resistance (Decreased BP)
What are three classifications of Anthracycline toxicity effects?
-Acute: Myocarditis, QTc prolongation -> Reversible
-Early-Onset Chronic Progressive: irreversible CMO within 1 year
-Late-Onset Chronic Progressive: irreversibel CMO onset after 1 year
5 cardiac consequences of Radiation therapy?
-CAD
-Pericardial Disease (CP)
-Conduction system disease
-Calcific/Stenotic Valve disease
-RCM
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)
-Emergent: < 24h
-Urgent: < 2 weeks
-Semi-urgent: < 6 weeks
-Routine: < 12 weeks
4 Indications for CRT in HF?
-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%
Indications to consider Transplant/Advanced management strategies
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
Benefits of Rehab in HF?
-Decreased HF Hospitalization
-Decreased Depression
-Improved QoL
-Decreased Symptoms
-Improved Exercise Capacity/VO2 max achieved
Two populations that Dronedarone should be avoided in?
LVEF < 35%
Recent Hospitalization in last year
4 patients populations that may experience LV systolic improvement based on: MPI, DSE, PET, CMR
-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
Target weight loss per day for ADHF management?
0.5-1 kg per day
What three classes of medications is there High evidence for intiation on HF hospitalization or new onset HF
-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)
Three indications for ARNI based on 2021 guidelines?
-New HFrEF with hospitalization
-Symptomatic HFrEF despite GDMT
-HF hospitalization with HFrEF despite GDMT
Name 4 pathophysiologic mechanisms of PPCM?
-Increased Prolactin
-Oxidative stress
-Immune mechanisms
-Viral infections
4 features of Restrictive CMO?
Disease of the myocardium with markedly stiff ventricles with:
-Restrictive ventricular filling
-Reduced diastolic filling volumes
-Near normal or normal systolic function
how does Tolvaptan work?
Vasopressin receptor antagonist that blocks free water absorption in the collecting tubule
(Use in HF when symptomatic with fluid overload and Na < 130)
What is recommended RPE , HR max and peak VO2 for HF NYHA I-III?
-RPE 3-5
-65-85% max HR
-50-75% peak VO2
How to decide between temporary vs long term/durable ventricular assist?
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
In what two situations in SGLT2 inhibitor contraindicated?
-EGFR < 20 Empa or < 30 Dapa
-Type 1 diabetes
How long before you see the benefits of beta blockade?
3-6 months
What is the incidence of euglycemic DKA in patients on SGLT2 inhibitors?
0.1%
When should EF be assessed for ICD/CRT (Timing)
-3 months post achievement of GDMT/or maximally tolerated doses
What 3 populations with ATTR CA should not be prescribed Tafamadis?
-NYHA IV, 6MWT < 100m, severe functional disability
These were excluded in ATTRACT trial
2 indications for BNP measurement in HF?
-Diagnosis of HF or rule out when otherwise in doubt
-Prognosticate HF to optimize therapy
5 reasons to admit for HF?
-NYHA III/IV
-SPO2 < 91%
-SBP < 90mmhg
-HR > 90 bpm
-RR > 20
Name 5 criteria for discharge?
-NYHA II
-BP to baseline or > 100
-SPO2 > 92%
-RR < 20
-HR < 90 bpm
When does peripheral vascular resistance and blood pressure nadir in pregnancy?
Second with gradual return to normal in third trimester
