Heart Failure

Question 1

What are the typical signs and symptoms of Heart Failure? (as per CPS)

Answer 1

Dyspnea, fatigue and fluid retention

Question 2

What ejection fraction indicates HFrEF

Answer 2

<40%

Question 3

EF that indicates HFpEF?

Answer 3

> 50%

Question 4

conditions known to exacerbate HF?

Answer 4

Anemia, arrhythmias, myocardial ischemia (so 3 issues with heart function no duh it increases heart dysfunction), infections, renal dysfunction, thyroid dysfunction, uncontrolled dysfunction, uncontrolled HTN, valvular heart disease

Question 5

Drugs of note that can contribute to HF exacerbation

Answer 5

Any drug that causes fluid or sodium retention (of note: androgens, corticosteroids, minoxidil)

Negative iontropes (B-blockers, antiarrhythmics except amiodarone or dofetilide, CC blockers (not amlodipine or felodipine), propefol.

Cardiotoxics (of note clozapine, cocaine, trastuzumab)

Question 6

Recommended Na intake in HF

Answer 6

<2-3g/day and 1-2g/day for those with severe HF

Question 7

What weight gain amount might indicate water retention and indicate necessity to go to hospital

Answer 7

0.5kg/day for several consecutive days or 2kg in 3 days

Question 8

What causes BNP to be elevated?

Answer 8

Stress in heart (atria and ventricles)

Question 9

Would you expect BNP and ANP to be high or low in HF?

Answer 9

ELEVATED!

Question 10

Describe the staging of NYHA functional classification

Answer 10

I = no symptoms w/ ordinary activity
II = symptoms with ordinary activity
III = symptoms occur with less that ordinary activity
IV = Symptoms occur at rest or with minimal activity

Question 11

What is an ARNI?

Answer 11

combined angiotension receptor blocker and nepilysin inhibitor (commercially avaliable version = valsartan/sacubitril)

Question 12

Why are ACE inhibitors used in HFrEF?

Answer 12

Proven to show benefits in improvement of symptoms, reduce hospitilizations, MI, and death

Question 13

ACE inhibitor dose titratration schedule?

Answer 13

increase in 7 to 14 day intervals to target dose

Question 14

How much can SrCr increase after initation of ACE?

Answer 14

30% risk expected

Question 15

Washout time between switching to an ACE from ARNI or from ACE to ARNI?

Answer 15

36Hrs or irsk of angioedmea

Question 16

ARNI titration schedule?

Answer 16

Q2-4W increases

Question 17

which BB are approved for HF due to mortality benefits?

Answer 17

Bisoprolol, carvedilol, metoprolol

Question 18

Why would you use ethacrynic acid?

Answer 18

Furosemide is CI (sulfa allergy etc)

Question 19

What do thiazide and loop diuretics deplete?

Answer 19

Potassium and magnesium

Question 20

when to add mineralocorticoid recepotr antagonist?

Answer 20

when HFrEF uncontrolled despite ACE and BB optimization

Question 21

Canadian guideline HF class that indicates MRA use?

Answer 21

NYHA II

> 55 YO w/ LVEF <30% (or <35% if QRS > 130msec) and recent hoptiziliation for CV or elevated BNP or NT-proBNP

Question 22

What makes eplerenone a more inticing option for some patients?

Answer 22

Doesnt produce gynecomastia so patient who experience this on spirono should try eplere

Question 23

When to consider ivabradine?

Answer 23

LVEF <35% w/ NYHA II-III symptoms who are in sinus rythm with resting heart rate >77bpm

Question 24

Why consider digoxin?

Answer 24

improves symptoms and reduces the risk of hospitlization for exacerbations of HFrEF

DOES NOT DECREASE MORTALITY in patients with persistent moderate to severe symptoms

Question 25

ISDM + hydralazine use?

Answer 25

Replacement for ACE/ARB/ARNI in patients non tolerant

Can be used in combo with ACE/ARB/ARNI when other treatment modalities exausted

Reduces mortality and morbidity in black patients (CPS says this I assume its just the population studied) with NYHA III-IV

Question 26

omega-3 poly UNSATURATED fatty acid supplementation

Answer 26

some evidence that 1g/day may be beneficial for reducing CV events