Heart Failure Flashcards
BNP levels & NT Pro BNP levels in normal subjects
10 pmol/L ( Not pg/ml)- Normal levels same for both. All below values are I pg/ ml.
HF- BNP- <100pg/ml very high negative predictive value
100-400–not sensitive or specific
>400– heart failure
NT Pro BNP- <300 —means no heart failure
<50 yrs- 450 pg/ ml
50-75 yrs- 900 pg/ml
>75 yrs- 1800 pg/ ml
UPTODATE 2018
NT pro BNP of —– is roughly equivalent to BNP of >100pg/ml for diagnosis of HF
> 900 pg/ml
—% of RV pressure rise is accounted by LV
63% ie almost 2/3 rd
Pulmonary vascular congestion in CXR means
ill defined plump vessels
Also increased interstitial markings
Peri bronchial cuffing etc
Entresto should be given only after ……..hours of an ACE inhibitor
36 hrs
Heart failure with reduced ejection fraction is EF less than
40%
Sacubitril is given if EF less than
40%
Minimum BP to start Sacubitril
100 mm Hg
Gold standard for salt intake estimation at individual level
24 hr urine sodium extraction
Sub categorization of Class B and Class C level of evidence started from
ACC/AHA
2015
B R& B NR
C LD & C EO
Class 2b ACCAHA recommendation means
Benefit EQUAL to or MORE THAN risk ( WEAK Recommendation)
2a is MODERATE recommendation
Class1 is STRONG recommendation
Benefit = Risk means COR will be
Class 3 (Moderate) ie No benefit
Class 3 ( Harm) is Risk > Benefit
Stage C Heart Failure is
Once symptoms develop
Can never go back to stage B
The rationale for developing ARB
Angiotensin 2 production continue s through alternate enzyme pathways with ACEI
NEPRILYSIN inhibitors inhibit
Neprilysin 😜( enzyme that degrades natriuretic peptides, bradykinin, adrenomedullin and other vasoactive peptides)
ARNI vs ARB reduces
Death or hospitalization by 20%- similar extent of benefit in both
Best ACEI for heart failure
All are same
2017 ACC/ AHA
ACEI to be cautious if K
More than 5
ACEI can cause cough in up to
20%
2017 ACC/AHA
Abrupt withdrawal of ACEI should be avoided -which guideline
ACC/AHA 2017 Heart Failure
Patient on ARB for HTN can continue same if Heart Failure develops - which guidelines
2017 ACC/AHA
ARNI is superior than ACEI which Guidelines
2017 ACC/AHA
Guidelines on ARNI as per ACC/AHA 2017
- Chronic 2. symptomatic HFrEF
- Class 2/3
REPLACE with ARNI to further reduce morbidity and mortality
COR for LVAD in refractory HF
2a
The BNP/ NT Pro BNP cut off used in the PARADIGM-HF study for giving ARNI
BNP> 150: NTPro BNP> 600
or 100 & 400 If history of hospitalization within 12 months
Target dose of ARNI
200 BD
slowly uptitrate
Time gap between ARNI and ACEI should be at least
36 hours
Neprilysin PLUS ACEI was
Omapatrilat- High Angioedema-3 fold increase compared to Enalapril.
Single molecule with ACE , Neprilysin inhibition unlike ARNI
HFrEF means EF of
40% or less
More than 40% is preserved EF
Role of Ivabradine in HF-ACC AHA 2017
- Stable chronic HF (EF-35 or less)- For 4 weeks stable on GDEM
- Symptomatic Gd2/3
- On GDEM ( on max tolerated beta blockers )
- Sinus rhythm
- Rate> 70
Pts enrolled in study included a small no of Paroxsmal AF and PPI But predominantly in Sinus rhythm
MI within 2 months were excluded
Only 25% were on optimal BB. In view of MORTALITY benefits of BB first uptitrate them then only add Ivabradine
The benefit of Ivabradine in HF is mainly driven by reduced
Hospitalization
Not much by mortality
Level C evidence categories
C- LD- Limited data
C -EO- Expert Opinion
Obesity and BNP
Associated with lower BNP values in HF
BNP level assay in ARNI therapy
Unreliable for HF as BNP levels will be high due to ARNI
NT- Pro BNP can be used
BNP is a substrate for Neprilysin but not NT-pro BNP. So BNP will increase
Markers which provide additional prognostic value over BNP in HF
Galectin 3, Soluble ST 2, hscrp etc-(considered as markers of myocardial fibrosis or injury)
A non cardiac cause of high BNP
Bacterial sepsis
Class of recommendation For checking BNP in Stage A HF
2a
50 pg/ml or more benefits from more aggressive therapy-reduces incidence of HF( Asymptomatic)
ACC 2017
BNP recommendations in HF
Admission BNP-1a
Predischarge BNP-2a
ACCHA2017
How ACEI increase bradykinin
They inhibit Kininase enz
Angio edema with ACE is more in
Blacks and Women
<1% incidence
ACEI to be used Cautiously if K is
5 or more
Aldactone also same 5
Therapies for Class 4 HF patients
Spiranolactone
Hydralazine-Nitrate in Blacks
CRT
And ACEI/ARB/BB/Diuretics
All others are in Class 2-3
ICD in HF
- EF-35 or less
- > 40 days post MI
- Class 2-3
Therapies in 2-3 HF only
ARNI, ICD,Ivabradine ,IV Iron
EF in CRT and ICD in HF
EF- 35 or less in both
CRT-QRS 150 or more with LBBB pattern —COR 1
COR of Aldosterone antagonist in HFpEF
IIb.
- EF45 or more
- BNP-increased or
- HF admission in a year
These drugs will reduce hospitalization
From TOPCAT study
ACC/AHA 2017
Role of coronary revasc in HFpEF
COR II a
ACCHA2017
IV Iron in HF
- Ferritin <100
- Or 100-300 If Transferrin saturation less than 20%
- Class 2-3
Role of Nitrate therapy in HFrEF
Reduce Pulmonary congestion and Improve exercise tolerance
PDE 5 inhibitors augment nitric oxide by
Increasing cGMP
Role of correction of Anemia with Erythropoietin stimulating agents in HF
COR Class 3- No benefit
Found also to have a significant increase in thromboembolic events and NS increase in strokes
ACCHA 2017 stand on ARNI in hfPef for control of HTN
RAAS inhibition with ACEI/ARB/MRA and possibly ARNI
Sleep Apnea treatment with ———— is harmful in HF
Adaptive Servo Ventilation in Central sleep Apnea. -Higher mortality rate
Incidence of sleep Apnea in HF
60%
ACCHA 2017
Use of. CPAP in HF plus OSA
Improves sleep quality
No benefit on CVS events
(A.F. progressing to permanent AF less likely- in a trial with A.F. and OSA)
ARB and Angioedema
Some patients have developed. So caution advised when giving ARB in a patient who had angioedema with ACEI
After starting ARB check RFT after
1-2 weeks of starting
ACCHA 2013
Why only Metoprolol succinate, bisoprolol and Carvedilol only should be used in HF
ACCHA 2017
All B.B. are not equal in HF
Eg. Studies with Bucindolol and Metoprolol tartarate was not as effective as others in studies . Nebivolol didn’t affect mortality
When can you start beta blockers in hospitalized
Once they are out of intravenous INOTROPIC therapy
ACCHA 2013
How to reduce hypotension risk with ACE plus B.B. in HF
Give at different times of the day
ACCHA 2013
Causes of fatigue in heart failure
Sleep Apnea
Overdiuresis
Depression
Also Beta blocker
When to use MRA Post MI
- LVEF-40% or less
- Symptoms of HF
- Or Diabetes Mellitus
MRA in HF to be used if
- EF-35% or less
- NYHA 3/4
- If NYHA 2- should have high BNP or history of prior hospitalization
ACCHA 2013
Few Non HF causes of high BNP
LVH
Anemia
Obstructive Sleep Apnea
Valvular diseases
The new ACCHA COR/LOE is from the year
2015
Creatinine cut off for MRA
2.5 creatinine-STOP ( But 2 in women)
Or GFR-30 -STOP
Role of MRA in HFpEF is
to reduce hospitalization
Hepcidin is
Protein which shifts Iron to the intravascular compartment
Levels are low in HF. This is the rationale for IV Iron therapy in HF- 2b
ACCHA 2017
GFR calculation inSPRINT trial was with
MDRD equation
In HF pEF HTN is preferably treated with (ACCHA2017)
RAAS inhibitors- ACE/ARB/MRA and possibly ARNI- ACCHA 2017
And target SBP<130
SPRINT said target BP of 120/80 or less which was modified to an office setting value of ——by ACCHA 2017
130/80- they say office BP is 5-10 mmHg high than research setting
2015 SPRINT trial was basically
Targeting a new BP target for pts at high cardiovascular risk
This reduced HF and cardiac death
The upper limit of normal in non acute settings for BNP and NT-pro BNP is
ESC 2016 guidelines
35 pg/ ml and 125 pg / ml respectively
2016 ESC HF guidelines
In Acute settings <100 and 300pg/ml
