Heart Failure

Question 1

Sequence of therapy

Answer 1

Loop diuretic for symptom relief
ACEi uptitrating weekly to a moderate dose (reduces mortality)
B blocker (not acutely) start low, slowly titrate
Aldosterone antagonist (spirinolactone or eplerenone)l: care in pts eGFR120ms

Question 2

Pt education

Answer 2

Compliance with meds
Daily weights
Avoid dietary Na
Fluid restriction
Reg exercise

Question 3

Assessing prognosis

Answer 3

NYHA class 4
Rpt hospitalisations
Hyponatraemia Na 34

Question 4

Inpt mx

Answer 4

Diuresis
Evaluate reason for decompensation
Continue usual ACEi and Bblocker unless hypotensive or demonstrate poor Perfusion or signs of low output heart failure (hypotension, worsening liver and renal fcn, cool extremities)
Cease ACEi, ARB, diuretics, aldosterone antag with worsening renal fcn
Vasopressin antagonist for hypervolemic or euvolemic hyponatraemia (no mortality benefit)

Question 5

Cardiogenic shock evaluation

Answer 5

Bedside TTE to look fr structural causes ie AMI, free wall rupture, papillary muscle rupture, infection

Right heart catheter placement: ax filling pressures, cardiac output, systemic vasc resistance

Question 6

Cardiogenic shock mx

Answer 6

Vasoactive meds to increase CO and raise BP

Dobutamine
Milrinone

Mechanical therapy

Intraaortic balloon pump
Percut or surgically implanted short term mechanical ventricular assist devices (VAD)
Common cx: vascular compromise at pt of insertion

Question 7

Advanced refractory heart failure

Answer 7

Inotropic therapy: can increase mortality; survival

Question 8

Heart transplant drugs

Answer 8

Calcineurin inhibitor (cyclosporin or tacrolimus)
Antiproliferative agent (mycophenalate mofetil, sirolimus, everolimus)
Prednisolone ( aim to wean by 1 yr)

Question 9

Heart transplant risks

Answer 9

First yr:

Increased risk infection while immunosuppressive drugs high
Rejection (20%): signs incl heart failure, atrial arrhythmias typically flutter. Typically asymptomatic necessitating routine endomyocardial bx

Long term risk:

Cardiac allograft vasculopathy: >50% pts after 5 yrs

• diffuse intimal thickening of coronary arteries
• PCI and CABG not beneficial
• atypical chest painbecoz heart is denervated
• w/o vagal innervation HR 90-110: marked response to adenosine

Lymphoproliferative disorders
Skin cancers