Congestive Heart Failure Flashcards
1
Q
Mortality rate/prognostication/role of palliative care in heart failure
A
- Worsen than many metastatic cancers
- Prognostication can be difficult as patients can decline and recover repeatedly
- Integrated palliative care can result in a survival benefit for advanced heart failure patients
2
Q
Pathophysiology of Heart Failure symptoms
A
- Dyspnea/Fatigue/Limited Exercise tolerance
- Fluid overload and pump failure
- Hormonal and cytokine alterations resulting in sarcopenia in skeletal, respiratory, and cardiac muscles
- Sleep disordered breathing and desats - Anorexia/Nausea/Constipation/Cachexia
- Catabolic state secondary to neurohormonal activation - Pain
- May be anginal or due to muscle weakness with pain in legs and joints
- Procedures (implants/cardiac surgery)
- Comorbidities (e.g. peripheral neuropathy etc.) - Cognitive impairment/Dep/Anxiety
- Sleep disordered breathing and desats
- Depression is commonly comorbid
3
Q
NYHA Heart Failure Classification
A
Stage I
- No limitations
Stage II
- Slight limitation of physical activity
- Comfortable at rest, but symptoms with ordinary physical activity (palps, fatigue, dyspnea)
Stage II
- Marked limitation of physical activity
- Comfortable at rest, but symptoms with less than ordinary physical activity
Stage IV
- Dyspnea at rest
- Unable to participate in any physical activity without discomfort
4
Q
Natural history of CHF
A
Stage I
- After diagnosis and treatment with life style modifications, most patients have a period of being relatively asymptomatic
Stage II
- Eventually, patients become symptomatic (NYHA II-III) and are at risk of sudden death due to arrhythmias and may benefit from an ICD
Stage III
- Increasing loss of function with exacerbations that may require hospitalization (NYHA III-IV)
- Response to ‘rescue’ treatment)
- Opioids may be helpful
Stage IV
- Refractory heart failure with severe symptoms (NYHA IV)
- Prognosis may still be challenging
- Palliative Care involvement is most helpful
5
Q
ICDs for CHF
A
- Secondary prevention
- Hemodynamically significant or sustained ventricular arrhythmia - Primary prevention
- Ischemic or non-ischemic cardiomyopathy, NYHA class II-III AND EF ≤ 35%
- Ischemic cardiomyopathy, NYHA Class I and EF ≤ 30%
- EF should be measured at least 1 month post MI, and at least 3 months post coronary revascularization procedure - Recommend AGAINST ICD implantation in patients with NYHA IV without anticipated improvement with further therapy and are not candidates for transplant or LVAD
As per CBD:
- Life expectancy > 1 year and reasonable quality of life
- EF < 30% with or without symptoms
Note that they do not improve QOL and sudden death may be a preferable mode of death for those with comorbidities or progressive HF
6
Q
Deactivation of an ICD
A
- By patient request
- Discussed in the context of functional decline or deteriorating cardiac function requiring several shocks of ICD
- Avoid painful shocks during active phase of dying
- Simple and quick to do (magnet placed over the device to deactivate)
7
Q
Prognostication in Heart Failure
A
- Should be a discussion early in the illness trajectory and there should be discussion of code status and SDM
- Prognostic models estimate death risk at 1, 2, and 3 years from measurement
- Seattle Heart Failure Model is well validated in a variety of patients
8
Q
Predictive factors of death in CHF
A
- Frequent hospital admissions
- Poor function
- Weight loss > 10%
- Low albumin
- High BNP
- Renal function (ESRD)
- EF < 20%
- Symptoms at risk
- Previous embolic stroke
- Previous cardiac arrest
9
Q
HFrEF treatment - Foundational
A
EF < 40%
- ARNI or ACE
- ARNI favoured over ACEi/ARB
- reduces CV death and hospitalizations
- Renal function may limit use - BB
- Reduction in mortality and hospitalizations
- Start low and go slow with more severe symptoms - Mineralocorticoid antagonist
- EF <40% and DM or MI with symptoms
- Reduces mortality and hospitalizations
- Avoid for GFR < 30% - SGLT2 inhibitor (empagiflozins, canagiflozin)
- Benefit regardless of DM status
- Improves QOL, Symptoms, and reduces hospitalizations and CV mortality
10
Q
Acceptable increase in Cr after initiating an ACEi
A
- Up to 30% if no oliguria
- May stabilise at 30%
11
Q
Additional treatments for HFrEF
A
Additional interventions:
- HR >70bpm despite BB and sinus, consider ivabradine (sinus node inhibitor)
- Recent HF hospitalization and worsening HF, consider vericiguat (guanylate cyclase inhibitor - lowers BP, avoid if SBP < 100 or on nitrates)
- Black patients on optimal GDMT or unable to tolerate ARNI/ACEi/ARB, consider hydralazine-nitrates
- Suboptimal rate control for AF or symptoms despite optimised GDMT, consider Dig (avoid in renal impairment, sinus node dysfunction)
12
Q
Treatment of Dyspnea in CHF
A
- Opioids
- Small RCTs for opioids for dyspnea in heart failure (more evidence for COPD)
- May also be useful for refractory angina
- Preference for longer acting opioids (rather than PRN) for better compliance and fewer adverse events - Oxygen
- Very poor evidence, use only if the patient is on opioids, hypoxic, and feels relief with oxygen - Benzos
- May be used for dyspnea, but evidence is lacking and are risky in frail older aldults - Antipsychotics for dyspnea
- More evidence than benzos - Thoracentesis
- Likely to reaccumulate rapidly - SL Nitro
- If dyspnea is an anginal symptom - Diuresis
13
Q
Treatment of Depression in CHF
A
- Occurs in 20% of patients with CHF and increases mortality rate
- TCAs
- Avoid, due to QT prolongation/arrhythmias and anticholinergic effects - SSRIs
- Generally well tolerated - SNRIs
- Useful if the patient also has neuropathic pain - Psychosocial care
- Honest communication, adequate plan of care following hospital discharge, and communication with family
- Reduction of emotional/physical burden on family
- Exercise
- Behavioural Activation
14
Q
Treatment of Refractory angina or pain in CHF
A
Opioids
- Small RCTs for opioids for dyspnea in heart failure (more evidence for COPD)
- May also be useful for refractory angina
- Preference for longer acting opioids for better compliance and fewer adverse events
- Preferred to PRN dosing
NSAIDs
- Avoid in CHF due to sodium retention/HF exacerbation
Caution with QT prolonging meds
- Methadone
- Venlafaxine
- TCAs
Spinal cord stimulators, stellate ganglion blocks, spinal opioids
- Can be used for refractory angina (opioids generally preferred)
15
Q
Indications for CRT
A
- Pacing system used to resynchronise ventricles
- May improve QOL and prolong life in patients with LV systolic dysfunction and dyssynchrony
- Can improve EF and symptoms
Candidates
- Ensure tx is optimised first (eg. ivabradine, ARNI)
- Patients in sinus rhythm with EF < 35% and QRS >130msec with LBBB with ambulatory symptomatic HF despite optimal medical therapy
Consider CRT:
- As above, but with QRS >150msec with NON-LBBB
- Permanent AF expected to have close to 100% pacing
