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Cardio > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

BNP levels & NT Pro BNP levels in normal subjects

A

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

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2
Q

NT pro BNP of —– is roughly equivalent to BNP of >100pg/ml for diagnosis of HF

A

> 900 pg/ml

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3
Q

—% of RV pressure rise is accounted by LV

A

63% ie almost 2/3 rd

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4
Q

Pulmonary vascular congestion in CXR means

A

ill defined plump vessels

Also increased interstitial markings
Peri bronchial cuffing etc

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5
Q

Entresto should be given only after ……..hours of an ACE inhibitor

A

36 hrs

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6
Q

Heart failure with reduced ejection fraction is EF less than

A

40%

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7
Q

Sacubitril is given if EF less than

A

40%

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8
Q

Minimum BP to start Sacubitril

A

100 mm Hg

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9
Q

Gold standard for salt intake estimation at individual level

A

24 hr urine sodium extraction

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10
Q

Sub categorization of Class B and Class C level of evidence started from

ACC/AHA

A

2015

B R& B NR

C LD & C EO

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11
Q

Class 2b ACCAHA recommendation means

A

Benefit EQUAL to or MORE THAN risk ( WEAK Recommendation)

2a is MODERATE recommendation

Class1 is STRONG recommendation

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12
Q

Benefit = Risk means COR will be

A

Class 3 (Moderate) ie No benefit

Class 3 ( Harm) is Risk > Benefit

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13
Q

Stage C Heart Failure is

A

Once symptoms develop

Can never go back to stage B

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14
Q

The rationale for developing ARB

A

Angiotensin 2 production continue s through alternate enzyme pathways with ACEI

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15
Q

NEPRILYSIN inhibitors inhibit

A

Neprilysin 😜( enzyme that degrades natriuretic peptides, bradykinin, adrenomedullin and other vasoactive peptides)

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16
Q

ARNI vs ARB reduces

A

Death or hospitalization by 20%- similar extent of benefit in both

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17
Q

Best ACEI for heart failure

A

All are same

2017 ACC/ AHA

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18
Q

ACEI to be cautious if K

A

More than 5

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19
Q

ACEI can cause cough in up to

A

20%

2017 ACC/AHA

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20
Q

Abrupt withdrawal of ACEI should be avoided -which guideline

A

ACC/AHA 2017 Heart Failure

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21
Q

Patient on ARB for HTN can continue same if Heart Failure develops - which guidelines

A

2017 ACC/AHA

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22
Q

ARNI is superior than ACEI which Guidelines

A

2017 ACC/AHA

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23
Q

Guidelines on ARNI as per ACC/AHA 2017

A
  1. Chronic 2. symptomatic HFrEF
  2. Class 2/3

REPLACE with ARNI to further reduce morbidity and mortality

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24
Q

COR for LVAD in refractory HF

A

2a

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25
Q

The BNP/ NT Pro BNP cut off used in the PARADIGM-HF study for giving ARNI

A

BNP> 150: NTPro BNP> 600

or 100 & 400 If history of hospitalization within 12 months

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26
Q

Target dose of ARNI

A

200 BD

slowly uptitrate

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27
Q

Time gap between ARNI and ACEI should be at least

A

36 hours

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28
Q

Neprilysin PLUS ACEI was

A

Omapatrilat- High Angioedema-3 fold increase compared to Enalapril.

Single molecule with ACE , Neprilysin inhibition unlike ARNI

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29
Q

HFrEF means EF of

A

40% or less

More than 40% is preserved EF

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30
Q

Role of Ivabradine in HF-ACC AHA 2017

A
  1. Stable chronic HF (EF-35 or less)- For 4 weeks stable on GDEM
  2. Symptomatic Gd2/3
  3. On GDEM ( on max tolerated beta blockers )
  4. Sinus rhythm
  5. 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

31
Q

The benefit of Ivabradine in HF is mainly driven by reduced

A

Hospitalization

Not much by mortality

32
Q

Level C evidence categories

A

C- LD- Limited data

C -EO- Expert Opinion

33
Q

Obesity and BNP

A

Associated with lower BNP values in HF

34
Q

BNP level assay in ARNI therapy

A

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

35
Q

Markers which provide additional prognostic value over BNP in HF

A

Galectin 3, Soluble ST 2, hscrp etc-(considered as markers of myocardial fibrosis or injury)

36
Q

A non cardiac cause of high BNP

A

Bacterial sepsis

37
Q

Class of recommendation For checking BNP in Stage A HF

A

2a

50 pg/ml or more benefits from more aggressive therapy-reduces incidence of HF( Asymptomatic)

ACC 2017

38
Q

BNP recommendations in HF

A

Admission BNP-1a

Predischarge BNP-2a

ACCHA2017

39
Q

How ACEI increase bradykinin

A

They inhibit Kininase enz

40
Q

Angio edema with ACE is more in

A

Blacks and Women

<1% incidence

41
Q

ACEI to be used Cautiously if K is

A

5 or more

Aldactone also same 5

42
Q

Therapies for Class 4 HF patients

A

Spiranolactone
Hydralazine-Nitrate in Blacks
CRT

And ACEI/ARB/BB/Diuretics

All others are in Class 2-3

43
Q

ICD in HF

A
  1. EF-35 or less
  2. > 40 days post MI
  3. Class 2-3
44
Q

Therapies in 2-3 HF only

A

ARNI, ICD,Ivabradine ,IV Iron

45
Q

EF in CRT and ICD in HF

A

EF- 35 or less in both

CRT-QRS 150 or more with LBBB pattern —COR 1

46
Q

COR of Aldosterone antagonist in HFpEF

A

IIb.

  1. EF45 or more
  2. BNP-increased or
  3. HF admission in a year

These drugs will reduce hospitalization

From TOPCAT study

ACC/AHA 2017

47
Q

Role of coronary revasc in HFpEF

A

COR II a

ACCHA2017

48
Q

IV Iron in HF

A
  1. Ferritin <100
  2. Or 100-300 If Transferrin saturation less than 20%
  3. Class 2-3
49
Q

Role of Nitrate therapy in HFrEF

A

Reduce Pulmonary congestion and Improve exercise tolerance

50
Q

PDE 5 inhibitors augment nitric oxide by

A

Increasing cGMP

51
Q

Role of correction of Anemia with Erythropoietin stimulating agents in HF

A

COR Class 3- No benefit

Found also to have a significant increase in thromboembolic events and NS increase in strokes

52
Q

ACCHA 2017 stand on ARNI in hfPef for control of HTN

A

RAAS inhibition with ACEI/ARB/MRA and possibly ARNI

53
Q

Sleep Apnea treatment with ———— is harmful in HF

A

Adaptive Servo Ventilation in Central sleep Apnea. -Higher mortality rate

54
Q

Incidence of sleep Apnea in HF

A

60%

ACCHA 2017

55
Q

Use of. CPAP in HF plus OSA

A

Improves sleep quality
No benefit on CVS events

(A.F. progressing to permanent AF less likely- in a trial with A.F. and OSA)

56
Q

ARB and Angioedema

A

Some patients have developed. So caution advised when giving ARB in a patient who had angioedema with ACEI

57
Q

After starting ARB check RFT after

A

1-2 weeks of starting

ACCHA 2013

58
Q

Why only Metoprolol succinate, bisoprolol and Carvedilol only should be used in HF

A

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

59
Q

When can you start beta blockers in hospitalized

A

Once they are out of intravenous INOTROPIC therapy

ACCHA 2013

60
Q

How to reduce hypotension risk with ACE plus B.B. in HF

A

Give at different times of the day

ACCHA 2013

61
Q

Causes of fatigue in heart failure

A

Sleep Apnea
Overdiuresis
Depression
Also Beta blocker

62
Q

When to use MRA Post MI

A
  1. LVEF-40% or less
  2. Symptoms of HF
  3. Or Diabetes Mellitus
63
Q

MRA in HF to be used if

A
  1. EF-35% or less
  2. NYHA 3/4
  3. If NYHA 2- should have high BNP or history of prior hospitalization

ACCHA 2013

64
Q

Few Non HF causes of high BNP

A

LVH
Anemia
Obstructive Sleep Apnea
Valvular diseases

65
Q

The new ACCHA COR/LOE is from the year

A

2015

66
Q

Creatinine cut off for MRA

A

2.5 creatinine-STOP ( But 2 in women)

Or GFR-30 -STOP

67
Q

Role of MRA in HFpEF is

A

to reduce hospitalization

68
Q

Hepcidin is

A

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

69
Q

GFR calculation inSPRINT trial was with

A

MDRD equation

70
Q

In HF pEF HTN is preferably treated with (ACCHA2017)

A

RAAS inhibitors- ACE/ARB/MRA and possibly ARNI- ACCHA 2017

And target SBP<130

71
Q

SPRINT said target BP of 120/80 or less which was modified to an office setting value of ——by ACCHA 2017

A

130/80- they say office BP is 5-10 mmHg high than research setting

72
Q

2015 SPRINT trial was basically

A

Targeting a new BP target for pts at high cardiovascular risk

This reduced HF and cardiac death

73
Q

The upper limit of normal in non acute settings for BNP and NT-pro BNP is

ESC 2016 guidelines

A

35 pg/ ml and 125 pg / ml respectively

2016 ESC HF guidelines

In Acute settings <100 and 300pg/ml

Cardio (36 decks)

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