Cole- advanced CHF and its treatment

Question 1

The majority of HF patients seeking treatment are in stage ___ of HF classification disease

Answer 1

Stage C

Question 2

Define Stage D of HF classification

Answer 2

• patient has refractory heart failure… requires special interventions

Question 3

describe patients who are at stage d

Answer 3

• have to stop medical therpies because they have low blood pressure, renal failure, or symptomatic intolerance
• frequent hospitalizations
• hyponatremia
• worsening renal function
• need diuretics
• low VO2 max with exercise testing
• dilated heart on echo

Question 4

what is prognosis for patients with stage D CHF

Answer 4

• POOR

- < 25% 1-year survival

Question 5

what are 4 options for treating stage D CHF

Answer 5

1. palliative care/hospice
2. inotropic infusions
3. heart transplantation
4. LVAD

Question 6

what do milirinone and dobutamine have in common? how do they differ?

Answer 6

• both decrease contractility
• milrinone: PDE inhibitor
• dobutamine: B1 antagonist

Question 7

T/F inotropes are not a good long term solution to stage D heart failure

Answer 7

True

Question 8

give indications of heart transplantation

Answer 8

• refractory heart failure of any cause, despite optimal medical and device therapy
• refractory angina/ischemia due to severe coronary artery dsiease with NO FURTHER TREATMENT OPTIONS
• refractory ventricular arrythmias
• end stage congenital heart disase
• re-transplantation

Question 9

absolute contraindications for HT

Answer 9

• <2 yr LE despite HT
• fixed pulmonary hypertension

AIDS with frequent opportunisitc infections

Question 10

relative contraindications

Answer 10

• age >72 yr
• any active infection
• morbid obesity
• active mental illness or psychosocial instability

Question 11

Name the 4 biggest post transplant hazarda

Answer 11

1. primary graft failure
2. infections
3. rejection (antibody mediated)
4. Late years: coronary vasculopathy and cancer

Question 12

give the two types of HT rejection

Answer 12

1. acute cellular/T cell mediated rejection
2. antibody/Bcell mediated
   - T cell incidence > B cell incidence

Question 13

Give 4 methods of preventing rejection

Answer 13

1. calcineurin inhibitors (like cyclosporine)
2. antimetaboiltes
3. steroids
4. mTOR inhibitor

Question 14

how do you survey for rejection post HT

Answer 14

• routine heart biopsy to detect subclinical rejection beofore it causes a problem

Question 15

what are risks of HT biopsy

Answer 15

• perforation/tamponade
• TV regurg
• arrythmias (RBBB on EKG)

Question 16

distinguish coronary afreter vasculopathy from coronary atherosclerosis

Answer 16

• HUGE problem with transplant patients
• concentric lesion with no lipid core and DIFFUSE narrowing
• normal coronary atherosclerosis is cholesterol mediated with lipid deposits and focal distribution

Question 17

how can we slow the progression of coronary artery vasculopathy

Answer 17

1. statins
2. mTOR inhibitors
3. risk factor modificatino

Question 18

what malignancies are most common for HT patients?

Answer 18

• skin cancers and hematological malignancies

Question 19

what are two broad categorical indications of LVAD

Answer 19

1. bridge to transplant (buy time)

2. Destination therapy… cant do HT)

Question 20

List complications of LVAD

Answer 20

• infection, bleeding, device malfunction, stroke, or death