Heart failure

Question 1

What’s first line for all heart failure?

Answer 1

Lifestyle changes – cessation or restriction ETOH, tobacco cessation, limit sodium to 2.5g/day, fluid restriction only if class IV, weight loss

Question 2

What are the four pillars of meds for heart failure?

Answer 2

PRIMARY: 4 pillars of meds
Renin-angiotensin system inhibitors:
Preferred: sacubitril/valsartan

Beta blockers:
Preferred: carvedilol, metoprolol, succinate, bisoprolol

Mineralocorticoid receptor antagonists:
Preferred: spironolactone, eplerenone

SGLT2 inhibitors:
Preferred: dapagliflozin, empagliflozin

Question 3

What are additional treatments measures for heart failure?

Answer 3

Diuretics (loop) + low sodium diet
Cardiac rehab

Question 4

How do you treat heart failure with life-threatening arrhythmias?

Answer 4

Life-threatening arrhythmias = implantable ICD, pacemaker for bradycardia or prolonged QRS (most get both)

Question 5

How do you treat reduced HF EF?

Answer 5

all 4 pillars - starting dose + work up to goal dose

Question 6

How do you treat preserved HF EF?

Answer 6

Cardiac rehab + diet = small improvements in exercise tolerance

Diuretics for volume overload – loop + low salt diet

Class II or III + elevated BNP = SGLT2 inhibitor + mineralocorticoid receptor antagonist

Secondary medications:
Sacubitril-valsartan
ACEI/ARB
Beta blocker

Question 7

How do you treat advanced HF?

Answer 7

IV loop diuretics, fluid + sodium restriction
All conventional therapies employed
Referral to advance HF program
Palliative care

Question 8

What are short term devices for advanced HF?

Answer 8

Short term devices - intra-aortic balloon pump, percutaneous circulatory assist devices, extracorporeal membrane oxygenation (ECMO)

Question 9

What are long term devices for advanced HF?

Answer 9

Long term devices - left ventricular assist devices (LVAD) - bridging time for transplant

Question 10

What are severe treatments for advanced HF?

Answer 10

Cardiac transplant – Class IV, cardiogenic shock, not amenable to percutaneous or surgical revascularization, life-threatening arrhythmias unresponsible to therapy

CIs: life expectancy <2 years, irreversible pulmonary HTN, severe cerebrovascular disease, substance use, inability to comply

Question 11

How do you treat acute decompensated HF?

Answer 11

Start with IV loop diuretic (refractory, add thiazide)

Oxygen

Vasodilators (IV nitroglycerin, sodium nitroprusside)

Inotropic therapy (dopamine, dobutamine)