Heart failure

Question 1

Causes of high output heart failure

Answer 1

Obesity
Advanced liver cirrhosis
Anaemia
AV fistulas
Thyroid storm
B1 deficiency- wet beriberi
Sepsis
Multiple myeloma
Glomerulonephritis
Polycythemia vera
Carcinoid heart disease

Question 2

Causes of raised BNP/ NT-proBNP outside HF

Answer 2

Advanced age
Renal failure
AF/ arrhythmias

low levels- obesity, flash pulmonary oedema, pericardial constriction

Question 2

Framingham HF score

Answer 2

H2FPEF score- assesses likelihood of HF in preserved EF
<1- excludes HFpeF
>5- HFpEF ruled in

Variables
- BMI >30 (2)
- HTN with at least 2 meds (1)
- AF (3)
- PA systolic pressure >35
- Age >60
- Elevated filling pressure >9

Question 3

Pharmacotherapy for HFrEF

Answer 3

ACC/AHA stage B
- Beta blocker
PLUS either an ACEI or ARB

ACC/AHA stages C and D:
- Diuretics
- RAAS inhibitors
- Beta blockers
- SGLT2 inhibitors
- Mineralocorticoid receptor antagonists

Question 4

Additional pharmacotherapy for HFrEF

Answer 4

Isosorbide dinitrate with hydralazine
- black people with NYHA III-IV HFrEF
- People who cannot tolerare RAAS inhibitors (i.e. renal function)

Ivabradine
- NYHA II-IIII HFrEF
- Stable LVEF <35%
- Maximum medical therapy w/ beta-blocker
- SR >70 at rest

Digoxin
- refractory to initial medications

Vericiguat (Soluble guanylate cyclase stimulator)
- LVEF <45%
- Maximum medical therapy
- worsening HF symptoms

Omega-3 fatty acid
- NYHA II-IV HFrEF

Question 5

Pharmacotherapy for HFpEF

Answer 5

First-line:
- SGLT2i
- Loop diuretic for patients with congestion

Consider
- MRA
- ARNI/ ARB

Question 6

Loop diuretic for patients with congestion

Answer 6

Non DHP CCB
- Verapamil, diltiazem

NSAIDs

Thiazolidinediones- pioglitazone

Antidepressants

Inhaled anaesthetics- myocardia depression, decreases sympathetic activity

Class IC and III antiarrhythmics
- Felcainide, propafeonone
- Amiodarone, sotalol, ibutilide, dofetilide

DPP4 inihibitors- alogliptin, saxagliptin, sitagliptin

Question 7

Indications of CRT in heart failure

Answer 7

Stage C HFrEF on optimised medical therapy with expected survival >1 year
- LVEF ≤ 35% with NYHA class II–IV symptoms and sinus rhythm OR select patients with AFib PLUS:
QRS duration of > 150 ms with or without LBBB pattern
OR QRS duration of 120–149 ms with LBBB pattern
- LVEF ≤ 35% requiring pacing for other purposes, e.g., replacement of existing PPM
- LVEF 36–50% with high-risk AV block

Question 7

Indications of AICDs in heart failure

Answer 7

HFeEF with expected survival >1 year on GDMT with:
- Nonischemic dilated cardiomyopathy (DCM) or ischemic heart disease at least 40 days post-MI with LVEF ≤ 35% and NYHA class II–III
- Ischemic heart disease at least 40 days post-MI with LVEF ≤ 30% and NYHA class I

Question 8

Management options for advanced heart failure

Answer 8

Mechanical circulatory support (MCS)
- intra-aortic balloon pump
- venoarterial extracorporeal membrane oxygenation
- LVAD

IV ionotropes
- adrenergic agonist, PDE3 inhibitos, vasopressors
- palliative/ awaiting device or transplany

Heart transplant

Question 9

Factors associated with worse prognosis for HF

Answer 9

Signs of congestion
- oedema, S3 heart sound, lung rales

Persistently elevated BNP and/or NT-pro BNP

Hyponatremia

Systolic BP < 120 mm Hg
Chronic comorbidities, e.g., diabetes mellitus, anemia, obesity

Unintentional weight loss or underweight

Implantable cardioverter-defibrillator use