congestive heart failure

Question 1

What are the ACC/AHA Heart Failure Stages?

Answer 1

Stage A: At risk for HF with no symptoms or structural disease, but risk factors present
Stage B: Pre-HF with no symptoms but structural heart disease or elevated filling pressures
Stage C: Structural heart disease with current or past HF symptoms
Stage D: Refractory symptoms despite therapy, interfering with daily life or causing recurrent hospitalizations

Question 2

Describe the NYHA Class I classification.

Answer 2

Symptom onset occurs with more than ordinary level of activity.

Question 3

Describe the NYHA Class II classification.

Answer 3

Symptom onset occurs with an ordinary level of activity.

Question 4

Describe the NYHA Class III classification, including Class IIIa and IIIb.

Answer 4

Class III: Symptom onset with minimal activity
Class IIIa: No dyspnea at rest
Class IIIb: Recent onset of dyspnea at rest

Question 5

Describe the NYHA Class IV classification.

Answer 5

Symptoms are present at rest.

Question 6

How is heart failure classified based on left ventricular ejection fraction (LV EF)?

Answer 6

HFrEF: LV EF ≤ 40%
HF with mildly reduced EF: LV EF 41-49% with evidence of HF
HFpEF: LV EF ≥ 50% with evidence of HF
HF with improved EF: LV EF > 40%, previously ≤ 40%

Question 6

What initial lab assessments are recommended for evaluating a patient with heart failure (HF)?

Answer 6

Complete blood picture, iron profile, renal profile, and liver profile.

Question 7

Why is a renal profile important in heart failure patients?

Answer 7

It assesses renal injury, guides medication choice, and helps establish baseline renal function before starting RAAS inhibitors, SGLT-2 inhibitors, or diuretics.

Question 8

What is the prognostic value of serum sodium in heart failure?

Answer 8

Hyponatremia predicts higher in-hospital and 30-day mortality in chronic heart failure.

Question 9

Why might a liver profile be performed in HF patients?

Answer 9

To check for hepatic congestion, which may elevate gamma-glutamyl transferase, AST, and ALT levels.

Question 10

When should urine studies be used in HF assessment?

Answer 10

To diagnose amyloidosis, using urine and serum electrophoresis and monoclonal light chain assays.

Question 11

What role does BNP or NT-ProBNP play in HF diagnosis?

Answer 11

Differentiates cardiac from noncardiac dyspnea and assesses mortality risk in HF patients, correlating with NYHA classification.

Question 12

How can troponin-I or T levels inform HF prognosis?

Answer 12

Persistent elevation indicates ongoing myocardial injury and predicts adverse outcomes.

Question 13

What are typical ECG findings in HF?

Answer 13

Signs of prior infarction, chamber enlargement, conduction delay, arrhythmia, or specific etiologies like low voltage in cardiac amyloidosis.

Question 14

What CHF indicators might a chest radiograph reveal?

Answer 14

Enlarged cardiac silhouette, lung base edema, vascular congestion, and Kerley B lines.

Question 15

Why is echocardiography often the first choice for HF imaging?

Answer 15

It quantifies ventricular function, structural abnormalities, and wall motion abnormalities and is readily available.

Question 16

What is NT-pro-BNP, and how is it used in heart failure diagnosis?

Answer 16

NT-pro-BNP is an inactive moiety created when pro-BNP is cleaved, and it can be used similarly to BNP to assess heart failure.

Question 17

Why might a normal BNP level not exclude heart failure diagnosis?

Answer 17

In HFpEF and/or obesity, BNP levels may be lower; up to 30% of acute HFpEF patients may have BNP below 100 pg/mL, and obesity reduces BNP production and increases clearance.

Question 18

How do BNP levels in HFpEF compare to those in HFrEF?

Answer 18

Back: BNP levels in HFpEF tend to be about 50% of those seen in HFrEF at a similar symptom level.

Question 19

What drugs are used for symptom relief in heart failure?

Answer 19

Back: Diuretics, nitrates, and digoxin.

Question 20

Which drugs are used for long-term management and improved survival in heart failure?

Answer 20

Back: ACE inhibitors, beta-blockers, aldosterone antagonists, ARBs, ARNIs, SGLT2 inhibitors, and sinus node inhibitors.

Question 21

What is the role of angiotensin converting enzyme (ACE) inhibitors in heart failure?

Answer 21

Back: They help improve survival and manage symptoms over the long term.

Question 22

How do beta-blockers benefit heart failure patients?

Answer 22

Back: They are used for long-term management to improve survival and control symptoms.

Question 23

Drug treatment for long-term management and improved survival is with

Answer 23

Angiotensin converting enzyme (ACE) inhibitors

Beta-blockers

Aldosterone antagonists

Angiotensin II receptor blockers (ARBs)

Angiotensin receptor/neprilysin inhibitors (ARNIs)

Sodium-glucose cotransporter-2 inhibitors (SGLT2i)

Sinus node inhibitors

Question 24

For which heart failure patients are aldosterone antagonists especially beneficial?

Answer 24

Back: Patients with moderate to severe heart failure symptoms or left ventricular ejection fraction (LVEF) < 30%.

Question 25

Name two common aldosterone antagonists used in heart failure treatment.

Answer 25

Back: Spironolactone (25-50 mg orally once a day) and eplerenone (25-100 mg orally once a day).

Question 26

Which aldosterone antagonist does not cause gynecomastia in males?

Answer 26

Back: Eplerenone.

Question 27

What should be monitored when a patient starts aldosterone antagonists?

Answer 27

Back: Serum potassium and creatinine levels every 1-2 weeks for the first 4-6 weeks, and after dose changes.

Question 28

When should the dose of aldosterone antagonists be lowered or stopped?

Answer 28

Back: Lowered if potassium is 5.0-5.5 mEq/L, stopped if potassium is > 5.5 mEq/L, creatinine > 2.5 mg/dL, or if ECG changes indicate hyperkalemia.

Question 29

Why should aldosterone antagonists not be combined with both an ACE inhibitor and an ARB?

Answer 29

Back: Due to the high risk of hyperkalemia and renal dysfunction.

Question 30

What is the preferred combination of drugs for patients with HFrEF?

Answer 30

Back: An aldosterone antagonist plus either an ACE inhibitor or an ARB.

Question 31

Which heart failure patients should be prescribed ACE inhibitors?

Answer 31

Back: All patients with HFrEF unless contraindicated (e.g., high creatinine, renal artery stenosis, or history of ACE inhibitor–induced angioedema).

Question 32

What is the mechanism of action of ACE inhibitors in heart failure?

Answer 32

Back: ACE inhibitors reduce angiotensin II production and bradykinin breakdown, affecting sympathetic nervous system activity, vascular tone, and myocardial performance.

Question 33

List the hemodynamic effects of ACE inhibitors.

Answer 33

Back: Arterial and venous vasodilation, decreased LV filling pressure, decreased systemic vascular resistance, and improved ventricular remodeling.

Question 34

What is a typical approach to dosing ACE inhibitors in heart failure?

Answer 34

Back: Start with a low dose and gradually increase over 8 weeks as tolerated, with target doses of drugs like enalapril (10-20 mg twice daily) and lisinopril (20-30 mg once daily).

Question 35

What monitoring is required for patients on ACE inhibitors?

Answer 35

Back: Check serum electrolytes and renal function before starting, at 1 month, and after significant dose increases or clinical changes.

Question 36

What are common adverse effects of ACE inhibitors?

Answer 36

Back: Reversible creatinine elevation, hyperkalemia, cough (5-15% of patients), rash, dysgeusia, and rarely, life-threatening angioedema.

Question 37

When are ARBs preferred over ACE inhibitors in heart failure?

Answer 37

Back: In patients who cannot tolerate ACE inhibitors due to cough or angioedema.

Question 38

What are usual target doses for common ARBs in heart failure?

Answer 38

Back: Valsartan 160 mg twice daily, candesartan 32 mg once daily, losartan 50-100 mg once daily.

Question 39

For what conditions are ARBs recommended in patients with HFpEF?

Answer 39

Back: If they are already being used to treat hypertension, diabetic kidney disease, or microalbuminuria.

Question 40

What are ARNIs, and how do they work?

Answer 40

Back: ARNIs combine an ARB and a neprilysin inhibitor (e.g., sacubitril) to lower BP, decrease afterload, and enhance natriuresis by inhibiting the breakdown of beneficial peptides.

Question 41

What is the role of ARNIs in HFrEF?

Answer 41

Back: ARNIs like sacubitril/valsartan reduce cardiovascular mortality and HF hospitalizations, especially in NYHA class II or III HFrEF patients.

Question 42

What are the dosing options for sacubitril/valsartan?

Answer 42

Back: Available in 24/26 mg, 49/51 mg, and 97/103 mg, taken twice daily. Dose varies based on previous ACE/ARB use and patient condition.

Question 43

Why is a washout period needed when switching from an ACE inhibitor to an ARNI?

Answer 43

Back: To reduce the risk of angioedema; ACE inhibitors must be stopped 36 hours before starting an ARNI.