CHF

Question 1

NYHA classes

Answer 1

1 = asymptomatic, no limit on physical activity
2 = symptoms w/ ordinary activity, slight limits
3 = symptoms w/ < ordinary activity, moderate limits
4 = symptoms at rest, severe limits

Question 2

Types of HF

Answer 2

HFpEF = LVEF >50%
HFmEF = LVEF 41-49%
HFrEF = LVEF <40%

Question 3

Causes of HF

Answer 3

Cardiac: tachycardia, valve disease, CAD, LVH
Toxins: alcohol, amphetamines, cocaine, steroids, radiation
Pregnancy: cardiomyopathy, pre-e, GDM
Inflammation/ infections: myocarditis, sarcoidosis
Metabolic: DM, thyroid, pheochromocytoma, Cushings
Nutritional: low thiamine, malnutrition, obesity, anemia

Question 4

RF

Answer 4

Older age
Fam hx
Smoking
Alcohol
Chemotherapy
Obesity
HTN
High lipids
IHD/ CAD
DM

Question 5

Precipitating factors

Answer 5

Forgetting meds
Arrhythmia
Anemia
Ischemia
Infection
Pregnancy
Hyperthyroidism
Renal failure
PE

Question 6

Prevention

Answer 6

Exercise
Treat dyslipidemia, HTN, DM
Smoking cessation

Question 7

Screening

Answer 7

BNP for at risk pts - identifies those that need an echo

Question 8

Sx

Answer 8

Fatigue, wt gain, weakness
Orthopnea, PND
Cough, SOBOE
Nocturia, edema, abdo distension

Question 9

Signs

Answer 9

Hypotension
Tachycardia
Hypoxia
Weight gain
Raised JVP
Displaced apex
S3 murmur
+AJR
Edema

Question 10

Ix + results

Answer 10

CBC, lytes, lipids, TSH, urinalysis, trop, BNP
CXR
Interstitial Edema
Kerley B Lines
Pleural Effusions
Cardiomegaly
Echo
Reduced LVEF
Increased LV end-systolic + diastolic dysfunction
LVH
Wall motion abnormalities
Valve dysfunction
ECG
Exercise stress test to assess functional capacity

Question 11

Management HFrEF

Answer 11

BB (bisoprolol)
Spironolactone (mineralcorticoid receptor antagonist)
ACEi (ramipril)
SGLT2i (empagliflozin)

If not working, switch ACEi for ARNI (scubitril)

If still symptomatic, consider
Ivabradine
ICD/ CRT
Heart transplant

Nitrates for SOB/ angina PRN
Loop diuretic for sx control

Omega 3 polyunsaturated fatty acids 1g daily

Question 12

Management HFpEF

Answer 12

ACEi/ ARB + BB
Consider spironolactone

Question 13

Monitoring

Answer 13

Weight, HR, orthostatic vitals, JVP, edema
Check lytes 1 week after adjusting diuretic, ACEi or ARB
Digoxin trough 12hrs post dose
Repeat echo 3 months after titrating meds + q1-3 yrs if stable
Check BNP after titrating triple therapy

Question 14

Patient education + self monitoring

Answer 14

Self-weighing
Monitoring sx: worsening cough, SOB at rest, edema, wt gain, diiziness
Healthy diet - restrict salt + fluids (<1.5L/d)
Flu shot + pneumococcal vaccine annually
Sleep in upright position
Medication adherence
Smoking cessation
Exercise that does not induce sx
Supervised cardiac rehab for NYHA 1-2
Supervised mod aerobic + resistance training for NYHA 2-3
Assess for cognitive impairment, dementia and depression

Question 15

Acute HF management

Answer 15

ECG, CXR, lytes, Cr, CBC, trop, BNP
Admit if NYHA 3-4, hypoxia, new dx, worsening renal function
BIPAP: 14/8 or 10/5
IV Lasix 20-80mg
If hypotensive, give inotropes like dobutamine milrinone

Question 16

When to refer

Answer 16

Initial HF dx
After hospitalisation
HF w/ ischemia, HTN, valve disease, syncope, renal dysfunction

Question 17

CHF acute management

Answer 17

oxygen, BiPAP, lasix, nitro if hypertensive

Question 18

CHF + hypotension = what? What do you do about it?

Answer 18

cardiogenic shock, urgent cardio referral, arrange transfer, norepi

Question 19

Steps prior to case turning up in ED

Answer 19

don PPE, call for help, call lab + XR in, assign roles

Question 20

Most common cause of CHF

Answer 20

ischemic cardiomyopathy

Question 21

When to refer pts for heart transplant or ICD?

Answer 21

NYHA class 3, 4, advanced HF, high risk

Question 22

When to refer pts for CRT or ICD?

Answer 22

LVEF <35%

Question 23

HFpEF rx

Answer 23

SGLT2i

Question 24

HFrEF rx

Answer 24

BB, ACEi, spironolactone, SGLT2i

Question 25

HFrEF triple therapy x3mo, no improvement, what to offer?

Answer 25

Entresto (Sacubitril / Valsartan i.e. angiotensin receptor-neprilysin inhibitor), vericiguat, digoxin, ICD/ CRT, transplant

Question 26

What to add in CHF w/ HR >75?

Answer 26

Ivabradine (HCN channel blocker)

Question 27

Indicators of advanced CHF

Answer 27

recurrent hospitalisations, cardiac cachexia, intolerance of BB, inability to walk 1 block on level ground, maximal diuretic therapy, frequent ICD shocks, progressive decline in renal function

Question 28

Physical exam in CHF

Answer 28

weight, volume status, peripheral vascular exam, leg edema, lung sounds, JVP, S3

Question 29

What score do you use to dx HFpEF + what are the components?

Answer 29

H2FPEF = heavy (BMI >35), hypertensive, aFib, pulmonary HTN, Elder >80, filling pressure

Question 30

What can you consider switching black pts or pts that are intolerant of ACEi/ ARBs to?

Answer 30

consider H-ISDN (hydralazine/ isosorbide dinitrate)

Question 31

What could you add for pts that have had a recent hospitalisation?

Answer 31

Vericiguat