Congestive Heart Failure Flashcards

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1
Q

Definition Congestive Heart Failure

A

Is defined as a clinical syndrome that results in cardiac dysfunction from myocardial loss or dysfunction and is characterized by left ventricular hypertrophy, dysfunction, or both.

HF stimulates a cascade of neurohormonal and circulatory responses that are reflected in the signs and symptoms commonly associated with HF: shortness of breath, fatigue, reduced exercise tolerance, and fluid retention

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2
Q

The mortality rate for Medicare

A

The mortality rate for Medicare patients with HF remains at 50% after an HF hospitalization The cost burden associated with this prevalence is estimated to increase from $21 billion to $53 billion in direct costs during this period

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3
Q

Key of reducing hospitalization and improving QOL

A

Managing HF symptom exacerbation in the primary care setting is paramount to improving quality of life and reducing hospitalizations for this population.

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4
Q
  1. List the signs and symptoms commonly associated with CHF. (Article)
A

• shortness of breath. • Fatigue. • Reduced exercise tolerance. • Fluid retention.

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5
Q
  1. What are the two elements that lead to HF
A

Disminución en el cardiac output o fallo de bomba

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6
Q
  1. In CHF Describe the pathophysiology of HF
A

a. Primary factors in pump dysfunction leading to ventricular dilation cause by endothelial dysfunction in the cardiac, coronary vascular, and peripheral vascular systems,

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7
Q

b. In CHF What is the consequence of pump dysfunction

A

•leading to ventricular dilation.

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8
Q

c. In CHF What happens after ventricular dilation?

A

The remodeling (which occurs as a consequence of neurohormonal stress, cytokine activation, and hemodynamic compromise) may be halted or reversed through medications and therapeutic interventions such as cardiac resynchronization therapy and left ventricular assist devices.

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9
Q

d. In CHF What can stop remodeling?

A

El remodeling puede interrumpirse (halted) o revertirse mediante medicamentos e intervenciones terapéuticas, como: • Terapia de resincronización cardíaca. • Dispositivos de asistencia ventricular izquierda. (Left ventricular assist devises.)

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10
Q
  1. What are the comorbid conditions that affect how a patient responds to treatment for CHF?
A

a. Hypertension (HTN) b. Diabetes. c. Sleep apnea: El pte de fallo no responde bien al to casi siempre porque no corrige, sino que usa el C-pap. d. Atrial fibrillation. e. Coronary heart disease (CHD). f. Gout. g. Dyslipidemia. h. Reactive airway disease.

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11
Q
  1. List the common triggers of HF
A

Common triggers include: • Consumption of foods with high sodium content. • Excessive fluid intake. • Non-adherence to medical therapy. • Recurrent ischemia. • worsening valvular heart disease.

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12
Q
  1. Classification of HF according to 2013 ACCF/AHA guidelines
A

HF and EF Reducido el EF <40 % HF pEF >50% p=preservada Borderline 41-49% Improved> 40%

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13
Q

Classification of HF: HF and EF Reducido

A

el EF <40 % También se conoce como HF sistólica. Los ensayos clínicos aleatorios han incluido principalmente pacientes con HFrEF y sólo en estos pacientes se han demostrado terapias eficaces hasta la fecha.

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14
Q

Classification of HF Heart Failure with Preserved Ejection Fraction (HFpEF)

A

EF ≥50% También se conoce como HF diastólica. Se han utilizado varios criterios diferentes para definir mejor el HFpEF. El diagnóstico de HFpEF es un reto porque es en gran medida una de excluir otras posibles causas no cardiacas de síntomas sugestivos de IC. Hasta la fecha, no se han identificado terapias eficaces.

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15
Q

Classification of HF . HFpEF, Borderline

A

EF : 41% to 49% Estos pacientes caen en un grupo límite o intermedio. Sus características, patrones de tratamiento y resultados parecen similares a los del paciente con HFpEF.

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16
Q

Classification of HF : HFpEF, Improved

A

EF: >40% Se ha reconocido que un subconjunto de pacientes con HFpEF previamente había HFrEF. Estos pacientes con mejoría o recuperación en EF pueden ser clínicamente distintos de aquellos con EF persistentemente conservado o EF reducido. Se necesitan más investigaciones para caracterizar mejor a estos pacientes.

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17
Q

ACCF/AHA stages of HF vs NYHA funcional cathegory A vs None

A

ACCF /AHA: A- At High risk for HF but without structural heart disease or symtoms of HR NYHA : None

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18
Q

ACCF/AHA stages of HF vs NYHA funcional cathegory B vs I

A

ACCF /AHA: B = Structural heart disease but without sign s or symtoms of HF NYHA : I = no limitation of physical activity. ordinary physical activity does not cause symptoms of HF

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19
Q

ACCF/AHA stages of HF vs NYHA funcional cathegory C vs 1-IV

A

ACCF/AHA C= Structural heart disease with prior or current symptoms of HF NYHA : I= no limitation of physical activity. ordinary physical activity does not cause symptoms of HF II= Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity result in symptoms of HF III= Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. IV= Unable to carry on any physical act. without symptoms of HF, or symptoms of HR at rest.

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20
Q

ACCF/AHA stages of HF vs NYHA funcional cathegory D vs IV

A

ACCF /AHA D= refractory HF requiring specialized interventions NYHA IV= Unable to carry on any physical act. without symptoms of HF, or symptoms of HR at rest.

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21
Q
  1. What should be included in the H&P of a patient with HF?

Recomendation level B

A
  1. A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF (Identificar trastornos o comportamientos de condiciones cardiacas y no cardiacas que pueden causar o acelerar el desarrollo de la HF. )
  2. In patient with idopatic DCM a 3-generational family history should be obtained to aid in establishing the diagnosis of familial DCM. Hx familiar de condiciones cardiacas. En paciente con DCM (disease congestion miocardic). Se debe obtener el family history de hasta 3 generaciones para ayudar en el establecimiento del diagnostico de DCM.
  3. Volume status and vital signs should be assessed at
    each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venouspressure and the presence of peripheral edema or orthopnea.
    1. (En cada encuentro con el paciente se tiene que medir el estatus de volumen y los vital sings: • Se pesa en cada visita • Se mide presión venosa yugular • Se evalúa por ortopnea • Edema periferal • Signos vitales.)
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22
Q

What is the initial lab evaluation of patients with HF? (Slide presentation)

A
  1. CBC, U/A.
  2. Serum electrolito: Magnesio y calcio.
  3. Urea Nitrógeno
  4. Creatinina serum
  5. Glucosa.
  6. Fasting lipid profile (FLP)
  7. Pruebas de función hepática
  8. TSH.
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23
Q

List the other diagnostic tests for HF and the areas that are evaluated with each

A

De acuerdo con la guía de 2013, la ecocardiografía bidimensional con doppler sigue siendo el método preferido para la evaluación diagnóstica de la fracción de eyección del ventrículo izquierdo (FEVI), el tamaño del VI, el espesor de la pared y la función de la válvula.

Como alternativa, la ventriculografía con radionucleidos es también un instrumento diagnóstico Es útil para medir volúmenes de LVEF y LV.

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24
Q

Efectos 2rios de de medicamentos

A

Los ARB te ocasionan hypercalemia , no tanta tos

Los antagonistas de aldosterana hypercalemia

Beta blocker –enmascara los signos de hypoglisemia, vigilar los ptees diabético

Los diuréticos de tipo Loop son tóxicos en oído.

Los thiazidas se administran 30 minutos antes de los loop y se potencia el efecto diurético de la droga. (en pacientes con overload)

Los nitratos no los puedo usar junto con los resucitadores del miembro (cialis, levita)

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25
Q

CHF Tx : Angiotensin converting enzyme inhibitors (ACE-I)

Names:

A

Enalapril (Vasotec)

Ramipril (Altace)

Captopril (Capoten)

Lisinopril (Zestril/Prinivil)

Trandolopril (Mavik)

Quinapril (Accupril)

Benazepril (Lotensin)

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26
Q

Mecanismo accion:

Angiotensin converting enzyme inhibitors (ACE-I)

A

Blocks the conversion of angiotensin I to angiotensin II (potent vasoconstrictor) enhancing vasodilation, reducing fluid volume, and reducingperipheral vascular resistance After myocardial infarction,reduces ventricular remodeling

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27
Q

ACE - I adverse effects and key points in monitoring

A

Volume depletion Worsened kidney function Cough Hypotension *Angioedema (mouth or lip edema) with or without anaphylaxis (a rarebut serious side effect).

Blood pressure (BP)— evaluate for orthostasis if patient is symptomatic. Serum electrolytes to evaluate kidney function (potassium, BUN, and creatinine)

28
Q

Angiotensin II Receptor Blockers names

A
  1. Candesartan (Atacand)
  2. Irbesartan (Avapro)
  3. Losartan (Cozaar)
  4. Valsartan (Diovan

Similar act

29
Q

ARB Mechanims of action

A

Similar action to ACE-I, resulting in vasodilation, reduced blood
volume, and prevention of ventricular remodeling

30
Q

ARB Adverse effects and key points to monitor

A
  1. Worsened kidney function
  2. Hyperkalemia
  3. Not likely to cause a cough
  4. Less likely to cause angioedema

Monitor :

Blood pressure (BP)— evaluate for orthostasis if patient is symptomatic

Serum electrolytes to evaluate
kidney function (potassium, BUN,
and creatinine)

31
Q
Aldosterone antagonists (also known as potassium
sparing diuretic) names
A

Spironolactone (Aldactone)
Eplerenone (Inspra)

32
Q

Aldosterone antagonist : mechanims of action , advers effects and key points to monitor

A

MA : Inhibits aldosterone, resulting in retention of ion potassium and
excretion of Naþ/Cl-/water.

AE: Hyperkalemia, Gynecomastia, (10% incidence)

Monitor :

  1. Monitor serum potassium 1 day, 1
  2. week, and 1 month after starting
  3. Avoid foods or medications high in potassium
  4. Avoid salt substitutes containing potassium
33
Q

Beta Blockers* (only use betablockers that
are FDA approved for use in HF)

A

Bisoprolol (Zebeta)
Carvedilol (Coreg)
Metoprolol (Lopressor or Toprol)

MA:

  1. Blocks sympathetic nervous system resulting in decreased BP, heart rate (HR), and myocardial oxygen demand
  2. Blocks renin release from nephrons
  3. Helps decrease angina in patients with HF from ischemic etiology

Adverse effects

  1. Bradycardia,
  2. Heart block,
  3. Hypotension,
  4. Severe bronchospasm in patient with reactive airway disease (RAD)
  5. Temporary fluid retention in patients with HF
  6. Fatigue
  7. Depression
  8. May mask signs of hypoglycemia
34
Q

BB what to monitor

A
  1. HR, BP, and heart rhythm
  2. Orthostasis, if dizzy
  3. Wheezing in patients with RAD
  4. Peripheral edema and weight gain
  5. in patients with HF
  6. Educate patients with diabetes to monitor for hypoglycemia
35
Q

Digoxin

A

names: Digoxin (Lanoxin) Digoxin dosing and therapeutic
levels are lower than previously recommended—digoxin level
0.8-2.0 ng/ml

Starting dose: 0.125 mg daily if
older than 70 and 0.25 mg daily if
less than 70 and normal renal function

MA: Weak inotrope, slows atrioventricular conduction

Adverse Effects:

  1. Cardiac dysrhythmias, especially in
  2. patients with hypokalemia or hyperkalemia
  3. Bradycardia
  4. Heart block
  5. Digoxin toxicity
36
Q

Digoxin key points to monitor

A
  1. Heart rate and rhythm
  2. Adjust dose for age, lean body
  3. mass, and renal function
  4. Observe for signs of digoxin
  5. toxicity: nausea, vomiting, diarrhea,
  6. fatigue, yellow or blurred vision, flulike
  7. symptoms
37
Q

Diuretic Loop

A

Names :

  1. Furosemide (Lasix)
  2. Torsemide (Demadex)
  3. Bumetanide (Bumex)

MA

  1. Blocks reabsorption of Na+/Cl- and water at Loop of Henle

Adverse effects:

  1. Hypotension
  2. Volume depletion
  3. Dehydration
  4. Electrolyte abnormalities: hypokalemia, hypomagnesemia, hyponatremia, or hyperglycemia
  5. May worsen kidney function
  6. Hyperuricemia
  7. Ototoxicity, more common in high doses or if given with other ototoxic medications
38
Q

Diuretics loop key points to monitor

A

Monitor :

  1. BP for hypotension and orthostasis
  2. HR if BP decreases (reflex tachycardia)
  3. Overdiuresis: dizziness, oliguria,
  4. thirst, excessive weight loss
  5. Serum electrolytes
  6. Ototoxicity
39
Q

Thiazide

A

names :

  1. Hydrochlorothiazide (HCTZ)
  2. Chlorthalidone
  3. Metolazone, a thiazide-like diuretic

MA

  1. Blocks reabsorption of Na+ / Ca- and water
  2. Same as above, administered 30 minutes before loop diuretic to enhance effect of loop for patients with HF

Adverse effects

  1. Same as loop
  2. No ototoxicity
40
Q

Thiazide key point to monitor

A

Point to monitor

  1. Same as loop diuretics
  2. BP for hypotension and orthostasis
  3. HR if BP decreases (reflex
  4. tachycardia)
  5. Overdiuresis: dizziness, oliguria, thirst, excessive weight loss
  6. Serum electrolytes
  7. Ototoxicity
41
Q

Nitrates

A

names:

  1. Nitroglycerin various routes:
  2. Sublingual—spray or tablet
  3. Oral—short and long acting forms
  4. Transdermal
  5. Intravenous

MA

  1. Vascular smooth muscle dilation in periphery and
  2. coronary arteries

AE

  1. Headache
  2. Dizziness
  3. Reflex tachycardia
  4. Flushing
  5. Syncope
42
Q
  1. Nitratos key points to monitor
A
  1. BP
  2. Do not administer within 24 hours of sildenafil (viagra) or 48 hours of tadalafil (cialis)
  3. Vardenafil is contraindicated with nitrates
  4. Ensure a nitrate-free interval of 10-12 hours
43
Q

Hydralazine

A

Name :

  1. Hydralazine (Apresoline)

MA

  1. Direct vasodilator through
  2. arteriolar smooth muscle
  3. relaxation

AE

  1. Reflex tachycardia
  2. Fluid retention

Points to monitor

  1. BP
  2. HR, especially if BP drops
44
Q

CHF JPN common medications:

A
  1. Angiotensin converting enzyme inhibitors (ACE-I): Enalapril (Vasotec), Ramipril (Altace), Captopril (Capoten)
  2. Angiotensin II receptor blockers: Candesartan (Atacand)
  3. Irbesartan (Avapro), Losartan (Cozaar), Valsartan (Diovan)
  4. Aldosterone antagonists (also known as potassium
    sparing diuretic) - Spironolactone (Aldactone)
    Eplerenone (Inspra)
  5. Beta Blockers* (only use betablockers that
    are FDA approved for use in HF) : Bisopropolol (zebeta) Carvedilol (coreg), metoprolor (lobresor or toprol)
  6. Digoxin- lanoxin
  7. Diurtics-loop- Furosemide (Lasix), Torsemide (Demadex)
    Bumetanide (Bumex
  8. Thiazide - Hydrocholrothiazide (HCTZ) , metolazone, thiazised like diruetic, Chlorthalidone
  9. Nitrates- nitroglycerin varous routes
  10. Hydralazine- Hydralazine - Apresoline
45
Q

Approaches to reduce hospitalization in the management of CHF patient

A

When integrated into a comprehensive system, this
option promotes self-care and provides substantive
patient surveillance in an effort to reduce HF hospitalizations.

Son los frecuent fliers que vuelan mucho y van mucho al hospital

  1. include telemonitoring, : Telemonitoring
    consists of a digital transmission of physiologic data
    and symptom reporting to remote providers
  2. Structured telephone supports through automated
    phone calls provide a second alternative to
    providing patient follow-up communication and
    support for patients with chronic HF
    support, and
  3. disease management -> engage in self-care, -> provide focused interventions over a defined period with a multidisciplinary approach.
46
Q

Stages, phenotypes and treatment of HF STAGE A

A
  1. Stage A - At high risk for HF but without structural heart disease or symptoms of HF.
  2. patient with
    • HTN
    • Arterosclerotid disease
    • DM
    • obesity
    • metabolic sindrome
    • uso de tabaco y otros agentes cardiotoxicos
  3. patient
    • using cardiotoxins
    • with family hx of cardiomypathy
  4. Therapy goal: heart healthy lifestyle
    • prevent vacular coronary disease
    • prevent LV structural abnormalities
  5. drugs:
    • ACEI or ARB in approprieate pts. for Vscular diseas or DM
    • statins as appropriate
    • (comienzas controlando HTN, y lipidos para reducir risk de HF. no tx se trata de prevenir fallo de bomba.
47
Q

Stages, phenotypes and treatment Stage B

A

Stage B - Structural heart disease but without signs or symptoms of HF.

  1. patient with:
  • Previous MI
  • LV remodeling including LVH and Low EF
  • Asyntomatic valcular disease
  1. Therapy goal:
  • Prevent HF symtoms
  • prevent futrher cardiac remodeling

3.drugs:

  • ACEI or ARB in approprieate pts. for Vscular diseas or DM
  • Beta blockers as appropriate
  1. in selected patients
  • ICD
  • revascularization or valvular surgery as appropriate
48
Q

Stages, phenothypes and Treatment of HF Stage C HF pEF

A

Structural heart disease with prior or current symptoms of HF

Patient with known structural Heart diseas and HF symptoms ans signs

HF pEF:

  1. goals : control symtoms, improved HRQOL, prevent hospitalization, prevent mortality
  2. strategies: identification of comorbidities
  3. treatment : diuresis to relieve symptoms of congestions, follow guideliesn driven indication for comorbilidities eg. HTN, AF, CAD, DM
  4. Revascularizacion or vasvular surgery as appropiate
49
Q

Stages, phenothypes and Treatment of HF Stage C - HF r EF

A

Structural heart disease with prior or current symptoms of HF

Patient with known structural Heart diseas and HF symptoms ans signs

HF rEF:

  1. goals : control symtoms, pt education, prevent hospitalization, prevent mortality
  2. Drug for rutine use : diuretics for fluid retention, ACEI, or ARB, Beta blockers, Aldostreone antagonist
  3. Drugs for use in selected patients:
    1. hydralazine / isosorbide dinitrate
    2. ACEI and ARB
    3. Digoxin
  4. In selected patient
    1. CRT
    2. ICD
    3. Revascularizacion or vasvular surgery as appropiate
50
Q

Stages, phenothypes and Treatment of HF Stage D -Refractory HF

A

Structural heart disease with prior or current symptoms of HF

Patient with : marked HF symptoms at rest despite GDMT recurrent hospitalizations

  1. goals : control symtoms, improved HR QOL, reduce hospital readmisions, establish patients end of life goals
  2. options:
    1. Advance care measures
    2. heart transplant
    3. chronic inotrpes
    4. temporary or permament MCS
    5. experimental surgery or drugs
    6. paliative care and hospice
    7. ICD deactivation
51
Q

The brain natriuretic peptide (BNP)

A
  1. El péptido natiuretico tipo B (BNP) es una hormona producida por el corazón.
  2. Se libera en respuesta a cambios en la presión dentro del corazón. Estos cambios pueden estar relacionados con la insuficiencia cardíaca.
  3. En general, el nivel de BNP aumenta cuando la insuficiencia cardíaca se desarrolla o empeora, y disminuye cuando la condición es estable.
  4. En la mayoría de los casos, los niveles de BNP son más altos en pacientes con insuficiencia cardíaca que las personas que tienen una función cardíaca normal.
  5. Es posible que su equipo de atención médica se refiera al BNP como NT-proBNP. Los niveles de BNP y NT-proBNP pueden medirse para ayudar a diagnosticar y monitorear pacientes con insuficiencia cardíaca. Es importante no comparar BNP con NT-proBNP, ya que puede haber una diferencia de 5 a 10 veces entre los resultados de la prueba.
  6. A normal level of NT-proBNP, based on Cleveland Clinic’s Reference Range is:
    • Less than 125 pg/mL for patients aged 0-74 years
    • Less than 450 pg/mL for patients aged 75-99 years
  7. If you have heart failure, the following NT-proBNP levels could mean your heart function is unstable:
  • Higher than 450 pg/mL for patients under age 50
  • Higher than 900 pg.mL for patients age 50 and older
52
Q

CXR & echocardiogram slide 37

A
  1. Patients with suspected or new-onset HF, or those presenting with acute decompensated HF, should undergo a chest x-ray to assess heart size and pulmonary congestion, and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patients’ symptoms.
  2. A 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function.
  3. Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy.
53
Q

Recommendations for Noninvasive Imaging: COR Strengh of recommendation and LOE quality of evidence or level.

A
  1. Patients with suspected, acute, or new-onset HF should undergo a chest x-ray : COR I LOE=C
  2. A 2-dimensional echocardiogram with Doppler should be performed for initial evaluation of HF ; I vs C
  3. Repeat measurement of EF is useful in patients with HF who have had a significant change in clinical status or received treatment that might affect cardiac function, or for consideration of device therapy. I vs C
  4. Noninvasive imaging to detect myocardial ischemia and viability is reasonable in HF and CAD IIa vs
  5. Viability assessment is reasonable before revascularization in HF patients with CAD IIa vs B
  6. Radionuclide ventriculography or MRI can be useful to assess LVEF and volume IIa vs C
  7. MRI is reasonable when assessing myocardial infiltration or scars IIa vs B
  8. Routine repeat measurement of LV function assessment should not be performed III: No Benefit vs B
54
Q

BNP in ambulatory setting #29 y # 30

A
  1. In ambulatory patients with dyspnea, measurement of BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP) is useful to support clinical decision making regarding the diagnosis of HF, especially in the setting of clinical uncertainty.
  2. Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF.
  3. * guided HF therapy can be useful to achieve optimal dosing of GDMT in select clinically euvolemic patients followed in a well-structured HF disease management program.
  4. Usefulness to reduce hospitalization or mortality in HF pts. not well established.
  5. Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with chronic HF.
55
Q

Recommendations for Biomarkers in HF slide 34

A

A. Natriuretic peptides:

  1. Diagnosis or exclusion of HF in Ambulatory, Acute (I and A)
  2. Prognosis of HF in ambulatory, acute (I and A)
  3. Achieve GDMT ambulatory - in acute - IIb and A
  4. Guidance of acutely decompensated HF therapy in
    Acute - IIb and C

B. Biomarkers of myocardial injury

  1. Additive risk stratification in Acute, Ambulatory, I and A

C. Biomarkers of myocardial fibrosis

  1. Additive risk stratification
    1. in Ambulatory IIb and B
    2. in Acute IIb and A
56
Q

CHF Treatment by stages (slide 48, 53)

Stage A

A
  1. Hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of HF.
  2. Other conditions that may lead to or contribute to HF should be controlled or avoided.
  • such as obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents,
57
Q

CHF Treatment by stages (slide 48, 53)

Stage B

A
  1. In all patients with a recent or remote history of MI or ACS and reduced EF,
    • ACE inhibitors should be used to prevent s-HF and reduce mortality.
    • In patients intolerant of ACE inhibitors,
      • ARBs are appropriate unless contraindicated.
  2. In all patients with a recent or remote history of MI or ACS and reduced EF, ​evidence-based beta blockers should be used to reduce mortality
  3. In all patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic HF and cardiovascular events.
  4. BP should be controlled to prevent s- HF
  5. ACE inhibitors should be used in all patients with a reduced EF to prevent HF
  6. Beta blockers should be used in all patients with a reduced EF to prevent HF
  7. An ICD is reasonable in patients with asymptomatic ischemic cardiomyopathy who are at least 40 d post-MI, have an LVEF ≤30%, and on GDMT
  8. Nondihydropyridine calcium channel blockers may be harmful in patients with low LVEF

Guideline Determined Medical Therapy

Iimplantable cardioverter-defibrillator

58
Q

Farmacology Tx of Stage C HFrEF = NYHA I-IV

A

HFr EF Stage C HFrEF = NYHA I-IV

  1. ACE or ARB & Beta blockers
    • for all volume overload, NYHA class II-IV patients
      • add lop diuretics
    • for persitently simptomtic African americans, class III -IV
      • add Hydral -nitrates
    • for class II-IV patients provided estimate creatinine > 30 ml/min and K+< 5.0 meq/dl
      • add Aldosterne antagonist : spronolactone=12.5 to 25 mg, eplerenone: 25mg once

note:

  • Diuretics are recommended in patients with HFrEF who have evidence of fluid retention, unless contraindicated, to improve symptoms.
  • ACE inhibitors are recommended in patients with HFrEF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality.
  • ARBs are recommended in patients with HFrEF with current or prior symptoms who are ACE inhibitor-intolerant, unless contraindicated, to reduce morbidity and mortality.
59
Q

CHF non pharmacological interventions:

A
  • Continuous positive airway pressure (CPAP) can be beneficial to increase LVEF and improve functional status in patients with HF and sleep apnea.
  • Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL, and mortality.
  • Patients with HF should receive specific education to facilitate HF self-care.
  • Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status.
  • Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms.
60
Q

CHF med that are potentially harmful in stage C

A
  1. Nutritional supplements as treatment for HF
  2. Hormonal therapies other than to correct deficiencies
  3. Drugs know to adversely affect clinical status of ptes with HF with HFrEF
    1. (e.g., most antiarrhythmic drugs,
    2. most calcium channel blocking drugs (except amlodipine)
    3. NSAIDs, or TZDs)
61
Q

Management of stage C HFrEF part 1

A
  1. Diuretics are recommended in patients with HFrEF with fluid retention
  2. ACE inhibitors are recommended for all patients with HFrEF
  3. ARBs are recommended in patients with HFrEF who are ACE inhibitor intolerant
  4. ARB are seasonable alternatives to ACE inhibitor as first line therapy in HFrEF
  5. The addition of an ARB may be considered in persistently symptomatic patients with HFrEF on GDMT
  6. Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful
62
Q
  1. Part 2 Management of Stage C CHF HFrEF
A
  1. Beta Blockers: Use of 1 of the 3 beta blockers proven to reduce mortality is recommended for all stable patients
  2. Aldosterone Antagonists: Aldosterone receptor antagonists are recommended in patients with NYHA class II-IV HF who have LVEF ≤35%
    • Aldosterone receptor antagonists are recommended in patients following an acute MI who have LVEF ≤40% with symptoms of HF or DM
    • Inappropriate use of aldosterone receptor antagonists may be harmful
  3. Hydralazine and Isosorbide Dinitrate:
    • The combination of hydralazine and isosorbide dinitrate is recommended for African-Americans, with NYHA class III–IV HFrEF on GDMT
    • A combination of hydralazine and isosorbide dinitrate can be useful in patients with HFrEF who cannot be given ACE inhibitors or ARBs
  4. Digoxin can be beneficial in patients with HFrEF
  5. Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardioembolic stroke should receive chronic anticoagulant therapy
  6. Statins are not beneficial as adjunctive therapy when prescribed solely for HF
    7.
63
Q

CHF common triggers

A
  • Consumption of foods with high sodium content.
  • Excessive fluid intake.
  • Nonadherence to medical therapy.
  • Recurrent ischemia.
  • worsening valvular heart disease
64
Q

Preferable method for dx evaluation

A
  1. De acuerdo con la guía de 2013, la ecocardiografía bidimensional con doppler sigue siendo el método preferido para la evaluación diagnóstica de la fracción de eyección del ventrículo izquierdo (FEVI), el tamaño del VI, el espesor de la pared y la función de la válvula.
  2. Un diagnóstico de HF. Un CXR (chest x ray) debe ser evaluado para las siguientes anomalías:
  • Cardiomegalia.
  • Infiltrados pulmonares, pleurales y derrames pericárdico
  1. Un ECG de 12 derivaciones en un paciente con HF puede revelar cambios isquémicos:
  • hipertrofia ventricular izquierda.
  • Bloqueo de rama izquierda (LBBB).
  • Bloqueo de rama derecha (RBBB).
  • Trastorno del ritmo, como: fibrilación auricular o taquicardia.
  1. En los pacientes con angina o sospecha de isquemia que son candidatos potenciales para la revascularización, se recomienda la angiografía coronaria
65
Q

Precausiones con medicamentos HF

A
  • Los ARB te ocasionan hypercalemia , no tanta tos
  • Los antagonistas de aldosterana hypercalemia
  • Beta blocker –enmascara los signos de hypoglisemia, vigilar los ptees diabético
  • Los diuréticos de tipo Loop son tóxicos en oído.
  • Los thiazidas se administran 30 minutos antes de los loop y se potencia el efecto diurético de la droga. (en pacientes con overload)
  • Los nitratos no los puedo usar junto con los resucitadores del miembro (cialis, levita)