Heart Failure Flashcards
What is NYHA Classes?
I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
ACC staging?
A At high risk for heart failure but without structural heart disease or symptoms of heart failure.
B Structural heart disease but without signs or symptoms of heart failure.
C Structural heart disease with prior or current symptoms of heart failure.
D Refractory heart failure requiring specialized interventions.
At ACC stage B Heart failure what should be initiated?
Should initiate GDMT
BB
ACE/ARB/ARNI
When patients go from ACC stage B to Stage C (implying they have also hit NYHA II or greater) initiate what?
Add on Aldactone or Hydralazine/Imdur for black patients
When to consider an ICD for HF patients? if they have LBBB think about doing?
ACC stage C patients, NHYA > II, and a reduced EF (<35%)
NOTE patients with LBBB are candidate’s for CRT (cardiac resynchronization therapy) which is a pacemaker lead in the LV.
What are Heart failure approved Beta Blockers?
heart-failure approved beta blocker [HFBB]
carvedilol, metoprolol, or bisoprolol
What did the PARADIGM-HF trial show?
The PARADIGM-HF trial showed a 16% all-cause death reduction and 21% hazard reduction for HF first hospitalization in the ARNI group compared to the ACEi group
What did the PIONEER-HF trial show?
PIONEER-HF trial suggested benefits of ARNI initiation during hospitalization greater than that achieved with ACEi
GDMT dosing of ACEi?
RAAS-I show modest dose responsiveness. High-dose RAAS-I (equivalent to lisinopril 20–40 mg daily) results in a 6% decrease in all-cause mortality compared to low-dose RAAS-I (equivalent to lisinopril 5–10 mg daily)
GDMT dose of Aldactone?
There is no clear dose response relationship with MRA, although the target dose in major trials was the equivalent of 25–50 mg/day of spironolactone
Blood pressure relationship with Toprol and Coreg in HFrEF?
Carvedilol may have a more potent blood pressure lowering effect versus metoprolol succinate in those with more elevated blood pressure. Although, for patients with lower blood pressure at baseline, β-blockers are hemodynamically well tolerated. In COPERNICUS, patients with a systolic blood pressure (SBP) of 85–95 mmHg at baseline had an increase in SBP with carvedilol greater than placebo.
Should BB be continued during admission for Acute heart failure?
β-blockers should not routinely be discontinued on admission for AHF. Multiple studies have shown that discontinuation of β-blockers in AHF is associated with worsening short- and long-term mortality, although hypotension/shock or severe pulmonary edema may represent indications for temporary discontinuation. Otherwise, as long as the patient confirms adherence prior to admission, β-blockers can be safely continued during hospitalization.
How to up titrate BB in HF patients? Special considerations?
β-blockers should be initiated or up-titrated so long as the patient is hemodynamically stable without marked volume overload, typically after the initiation of a RAAS-I/ARNI. Younger patients with higher BMI and without chronic obstructive pulmonary disease tend to tolerate higher doses and may be appropriate for a higher starting dose or more aggressive up-titration. Up-titration in patients may occur as tolerated toward target dose prior to discharge
When to add Hydralazine/Imdur?
Although the hydralazine/nitrate combination was the first treatment to show mortality benefit in HFrEF, its usage varies widely.Current guidelines recommend a hydralazine/nitrate combination for New York Heart Association (NYHA) class III/IV self-described African-American patients who are optimized on RAAS-I and β-blockers.
Because of modest mortality benefits and relatively larger blood pressure effects, the hydralazine/nitrate combination does not need to be prioritized for in-hospital initiation and is not one of the critical four pillars of therapy.
In patients who cannot take RAAS-I/ARNI due to renal dysfunction, hyperkalemia, or drug intolerance, the hydralazine/nitrate combination can be considered as alternate therapy, regardless of race
Metoprolol CR/XL Randomised Intervention Trial in Heart Failure (MERIT-HF) showed?
sustained-release metoprolol (i.e., metoprolol succinate), also a beta1-selective blocker, reduced mortality by 34 percent in patients with predominantly mild or moderate chronic heart failure.
Metoprolol, 159 mg per day was mean in the study
