Heart Failure

Question 1

Definitions of heart failure diagnostic categories

Answer 1

HFrEF - EF < 40%
HFpEF - EF > 50% (delayed HR recovery and less increase in CO with exercise)

Subcategories
HFpEF, borderline - EF 41-49%
HFpEF, improved - pts with HFpEF who previously had HFrEF

Question 2

What are the New York Heart Association (NYHA) Classifications

Answer 2

I - no limitation
II - comfortable at rest, but ordinary physical activity results in symptoms
III - comfortable at rest, but less than ordinary activity causes symptoms
IV - unable to carry out any physical activity, or sxs at rest

Question 3

How is BNP related to CrCl?

Answer 3

BNP is renally excreted, so it is inversely proportional to Cr Clearance

Question 4

How do you interpret BNP levels?

What is the exception?

Answer 4

BNP < 100 excludes HF as cause of dyspnea
BNP > 400 confers 95% likelihood

*exception if BMI > 35 - upper normal is 50 as BNP is possibly cleared by adipocytes

Question 5

Physio bases for HF treatment: Which meds do you use for the following?

Preload reduction

Answer 5

Diuretics, nitrates

Question 6

Physio bases for HF treatment: Which meds do you use for the following?

Afterload reduction

Answer 6

ACE/ARB, hydralazine, nitrates

Question 7

Physio bases for HF treatment: Which meds do you use for the following?

Sympathetic blockade

Answer 7

Beta blockers

Question 8

Physio bases for HF treatment: Which meds do you use for the following?

Aldosterone antagonist therapy

Answer 8

spironolactone, eplerenone

Question 9

State whether this medication has morbidity and mortality benefit, symptom improvement, decreased hospitalizations in treatment of HF:

ACE/ARB

Answer 9

Reduces morbidity and mortality

LOE A

Question 10

State whether this medication has morbidity and mortality benefit, symptom improvement, decreased hospitalizations in treatment of HF:

Beta blocker

Answer 10

Mortality rates improve with BB in addition to ACEi and diuretics

Decrease mortality in pts with prior MI regardless of NYHA

Start when pt is stable and euvolemic

Question 11

Which beta blockers are “the proven 3” in HF

Answer 11

Metoprolol succinate, carvedilol, bisoprolol

Question 12

State whether this medication has morbidity and mortality benefit, symptom improvement, decreased hospitalizations in treatment of HF:

Aldosterone antagonists

Answer 12

reduce mortality and improve EF

• GFR must be > 30 and K < 5
• choices are spironolactone and eplerenone
• eplerenon is better for breast tenderness

Question 13

State whether this medication has morbidity and mortality benefit, symptom improvement, decreased hospitalizations in treatment of HF:

Furosemide

Answer 13

Improves symptoms and reduces hospitalizations

Class I recommendation, LOE C

Question 14

State whether this medication has morbidity and mortality benefit, symptom improvement, decreased hospitalizations in treatment of HF:

BIDIL

Answer 14

Hydralazine + Isosorbide Dinitrate
Reduces mortality rates and improves quality of life measures
- particularly effective in african americans with NYHA III or IV HF
- used when diuretics, BB and ACE do not control sx or are not tolerated

Question 15

State whether this medication has morbidity and mortality benefit, symptom improvement, decreased hospitalizations in treatment of HF:

ARNI = ARB + Neprilysin Inhibitor

Answer 15

Compared to enalapril - reduced death and hospitalization
Class I recommendation: use in pts with chronic SYMPTOMATIC HFrEF NYHA II or III

• wait 36 hours after stopping ACEi to start entresto

Question 16

Which medications should you avoid in HFrEF?

Answer 16

• CCB (may continue amlodipine)
• Most antiarrhythmics
• NSAIDs
• Thiazolidinediones (- glitazones)

Question 17

Who should get an AICD?

Answer 17

Criteria to meet:

• EF < 35%
• NYHA II or III sx on medications
• life expectancy > 1 year

Question 18

Who should get cardiac resynchronization therapy (CRT) (biventricular pacing)?

Answer 18

Criteria to meet:

• EF < 35%
• NYHA II, III, or IV sx on meds
• QRS > 150 ms
• life expectancy > 1 year

Question 19

What have studies shown about guidelines for BMI in HF

Answer 19

• weight loss should only be encouraged in pts with BMI > 40

- survival is highest in pts with BMI 30-32

Question 20

What are the sodium and fluid restriction guidelines in HF

Answer 20

• Sodium < 2400 mg daily

- fluid < 2L/day may be appropriate in pts with hyponatremia or persistent retention