Heart Failure

Question 1

Prognosis in Heart Failure

Answer 1

worst when hypotension* or renal failure* non-toleration of ACEi
low cholesterol
resting sinus tach
hyperurecemia
higher loop diuretic requirements
hyponatremia
elev BNP
renal insuff

Question 2

Mortality with newly dx HF

Answer 2

50%

Question 3

HFPEF dx

Answer 3

RHC with exercise - exaggerated systemic BP response, cardiac filling pressures and pulmonary artery pressures to exercise (PAP >45mm Hg) - augmentation of CO blunted and insufficient to support excercise - lack of systolic and diastolic reserve, lack of chronotropic response

Equal prevalence, mortality as HFrEF
more female, older, HTN
No drugs that decrease mortality

Question 4

African american HF patients

Answer 4

AA pt on OMT with NYHA III-IV

add hydralazine and nitrates (isordil)

Question 5

Takutsubo

Answer 5

Treat with BB/ACEi

complete normalization of LVEF expected

Question 6

BNP

Answer 6

falsely low in obese patients

Question 7

Viral Myocarditis

Answer 7

MCC - Parvovirus B19, HHV-6

Adenovirus RARE

Question 8

Dilated CM

Answer 8

increased EDV, dec’d EF, inc’d eccentric mass

Question 9

Worst risk factors for HF

Answer 9

HTN, CAD

Question 10

Tx HFpEF

Answer 10

No good guideline tx
Vol control with diuresis
BP Control (class I)
Control of ventricular rate (or SR) with Afib
Eval for ischemia

Question 11

Refractory NYHA III

Answer 11

If on ACEi, BB and has good K+/Cr can add aldosterone antagonist

Question 12

HFpEF

Answer 12

2/2 infiltrative CM
biatrial enlargment
No AWM abn
low voltage

Question 13

Diuresis

Answer 13

Torsemide and bumetanide better bioavailablity than lasix

Question 14

Iontropes

Answer 14

syptomatic improvement

increased moratlity from inc’d arrhythmias

Question 15

Milronone

Answer 15

bypass B-adrenergic rcts (useful in patients on chronic B agonist meds) -> higher doses of dobutamine needed to ellicit same response
less tachyphalixis with milronone

Question 16

Mortality reduction HFpEF

Answer 16

No therapy reduces mortality

Question 17

NYHA III

Answer 17

on pt with Cr<2.5, normal K
already on max BB, ACEi, lasix
Add spironolactone

Question 18

Endomyocardial bx

Answer 18

acute HF
AV block
Young
dx giant cell or eos myocarditis
r/o infiltrative CM

Question 19

Giant cell myocarditis

Answer 19

suspect in acute HF in patients with other autoimmune dz ie hashimotos thyroiditis
Dx Biopsy endomyocardial

Question 20

NYHA Classes

Answer 20

I: No symptoms or limitation of physical activity
II: Mild symtoms, limitiations with of physical activity with ordinary activities
III: Limitation of physical activity with LESS than normal activity
IV: Symptoms at rest

Question 21

ACC/AHA HF Stages

Answer 21

A: At risk for HF (ie on doxarubicin) but no structural changes or si/sx HF
B: Structural disease but no signs/sx HF
C: Structural heart disease with prior or current Sx of HF
D: Refractory HF requiring specialized intervention

Question 22

Lymphocytic Myocarditis

Answer 22

only chronic cases responsive to steroids

No role in acute viral mediated CM

Question 23

ARVC

Answer 23

excercise induced VT
RV enlargement
RBBB
epsilon wave (blip at end of QRS)
T-wave inversions V1-4
plakoglobin, desmoplakin (desmosomes) defect - alters fxn of gap junctions

Dx: Cardiac MR
once dx established -> genetic testing

BB
catheter ablation
Discourage competitive sports - exacerbates phenotype of ARVC - progression of disease (converts more myocardium to fat)