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Cardiology (Long) > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

HF: PRICMCP

A

P: SOB, orthopnoea, PND, weight gain, ascites, leg swelling, current and baseline NYHA - what is the dry weight?***

R: Precipitants: Compliance, AMI, arrythmia, infection, hyperthyroid, PE, NSAIDs, anaemia (and pregnancy).

Risk factors - medications (anthracyclins, Trastuzmab), alcohol

I: recent TTE, EST, angiogram, endomyocardial bipsy (?myocarditis), cardiac MRI (acute myocarditis)

C: compliance to fluid, salt restrictions, medications

M: pharm & non-pharm & CRT/devices, if so why was it inserted? Do they know how to adjust lasix dose?

C: complications - VT/VF, hospital admissions, ICU

Current status: recent change in symptoms, recent changes in therapy, hospitalisations, weight changes & any planned IVx

Prognosis & insight

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2
Q

HF - examination

A

General: SOB at rest/exertion

Weight & dry weight

BMI + Signs of malnutrition (cardiac cachexia)

Cardio exam - L vs R sided signs

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3
Q

Classify NYHA

A
  • I Asymptomatic
  • II Symptoms with ordinary activity (slight limitation of physical activity)
  • III Symptoms with less than ordinary activity (marked limitation of physical activity)
  • IV Symptoms at rest
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4
Q

What are the most important precipitants of acute heart failure? (9)

A
  • Non-compliance (with medications or salt/H2O restriction)
  • Arrhythmia
  • Ischaemia
  • Infection (esp. pneumonia)
  • Anaemia
  • Medications that worsen fluid retention (NSAIDs, COX2 and CCBs)
  • Thyrotoxicosis
  • Pulmonary embolism
  • Pregnancy / Surgery
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5
Q

Symptoms/signs of right heart failure? (4)

A
  • Oedema
  • Ascites
  • Raised JVP
  • Anorexia/nausea (cardiac cachexia due to oedema in the bowel)
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6
Q

What is your approach to investigating HF?

A

Investigatin for precipitants & underlyging causes

Collateral Hx from family & GP - adherance, recent medication changes

ECG - ischaemia, arrythmia, conduction abnormaliies, LVH, speckled patern suggestive of infiltration

Bloods: FBC (anaemia), EUC (renal failure), TFT, troponin, BNP, inflammatory markers and cultures (consider D.dimer)

24h-Holter / loop recorder

TTE (RWMA, valve disease, chamber size, RVSP, infiltrative changes)

Stress ECG or TTE or MIBI (inducible ischaemia)

Angiogram

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7
Q

What is your approach in managing this patient with HF?

A

Goals:

Identify & treat underlying causes, maximise function, prevent progression & complications - APO, SCD

Confirm Dx:

  • Review previous ECG, TTE, angiogram (and other test as appropriate) to confirm aetiology of underlying condiins and severity of HF

A: investigate for secondary causes & associations

  • Anaemia, thyrotoxicosis, PE, infection, arrythmia, ischaemia, avoid NSAIDs. Screen for depression, OSA and treat.
  • See if underlying cause needs to be further optimised: stress test - ?inducible ischaemia, ?worsening valvular disease (intervention)?, cardioversion for AF?

T: Non-pharm

  • Education: importance of adherence in prevening complications, measuring weights, prognosis of disease. Use written summary.
  • Salt & fluid restriction (<1.5L)
  • Life-style: exercise, smoking cessation, minimise alcohol
  • Infection prevention: CCF patients → higher risk of LRTI. Vaccinate
  • Nutrition: high-fibre diet, limit saturated fats, dietician involvement
  • Formulate documented action plan: if weight gain >2kg/2days → seek medical advice / increase diuretics. If weight loss - contact medical advice.
  • Cardiac rehab - improves funcional capacity and symptoms, reduces hospitalisations, increases survival and QOL. NOT swimming.
  • LTO2

T: Pharm

  • ACEi, BB, MRA, Entresto, Ivabradine, Digoxin, Diuretics…etc.
  • Devices: biventricular pacing, AICD, LVAD (as a bridge to transplant)

Involve family, GP for ongoing encouragment for adherence and support

Ensure F/U, monitor progress and screen for complications

  • Regular follow-up for monitoring symptoms, new ECG changes suggestive of ischaemia or LBBB (CRT), bloods monitor for renal failure or hyperkalaemia (with HF meds), TTE to assess LVEF and continue to titrate HF pharmacological therapy
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8
Q

HF: Salt restriction regime?

A

NYHA I-II: aim <3g / day

NYHA III-IV: aim <2g/day

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9
Q

Describe, briefly, the pathway to optimal heart failure medical management

A

Assess fluid status

  • If dry, start an ACEI and a beta blocker
  • If wet, start an ACEI and diuresis until dry

Add an MRA

Titrate BB, ACEI and MRA (in that order) until target dose or intolerance is reached

  • This can take up to 5-6 months, depending on agents

Repeat ECHO once maximal tolerated doses of the three core medications has been achieved

  • If LVEF remains < 40%, swap in sacubitril-valsartan
  • If LVEF remains < 35%, Pt is in sinus rhythm and HR is > 70, consider ivabradine
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10
Q

What is your approach to deteriorating renal function when you start ARNI/ACEi?

A
  • Exclude other cause for volume depletion – bleeding, infection…etc
  • Correct hypovolaemia
  • Reduce diuretics / ARNI / ACEi DOSE
  • Recommence with close monitoring
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11
Q

Mx options for ongoing symptoms despite ARNI, BB and MRA? (4)

A
  • Diuretics – lasix, bumetanide, thiazides
  • Digoxin – AF RVR + HF
  • Nitrates – temporary vasodilators
  • Inotropes – short term only for symptoms (e.g. dobutamine or Levosimendan - Calcium sensitiser) – e.g. “dobutamine holiday” – where patient is admitted for 5 days and have improved symptoms for some months
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12
Q

Option in place of ACEi/ARNI/ARB if patient is not tolerant?

A

•Hydralazine + Nitrate (grade 2B) as long as BP >90

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13
Q

Spiel evidence for ACE-I, BB, MRA, Ivabradine, ARNI

A
  • ACE-i: ↑ survival in NYHA (I-IV)
  • BB: ↑ survival in NYHA (II-stable IV), ↓ SCD
  • MRA: ↑ survival in NYHA (III-IV), ↓ hospitalisations
  • Ivabradine: ↓ hospitalisations only
  • ARNI (Angiotensin Receptor Neprilysin Inhibitor): ↓ all cause mortality, CV mortality, hospitalisation – c/w enalapril (PARADIGM-HF trial)
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14
Q

Side effects of ACEi/ARB/ARNI (6)

A

Think hypotension + allergic picture.

Hypotension, AKI, Hyperkalaemia

Cough, rash, angioedema

ARNI can also cause anaemia

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15
Q

Side effects of beta-blockers (5)

A
  • Bradycardia
  • Hypotension
  • Transient worsening of HF
  • Nightmares
  • GI side effects
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16
Q

Side effects of MRAs (7)

A

Mineralocorticoid - so think sex hormone related stuff. Remember

  • Hypo-Na
  • Hyper-K
  • Gyneocomastia + Mastalgia (breast pain)
  • Agranulocytosis
  • Drug-induced Lupus
  • Hepatotoxicity
17
Q

Risk factors for dilated cardiomyopathy (3)

A
  • Family Hx
  • Alcohol excess
  • Haemochromatosis
18
Q

ECG findings to look for in acute heart failure (4)

A
  • Arrhythmia
  • Ischaemia – new or old
  • LVH
  • LBBB (degree of prolongation correlates with severity)
19
Q

Less common causes of dilated cardiomyopathy (7) - i.e. other than alcohol induced or ischaemic CM

A
  • Tachycardia-induced (usually AF)
  • Medication: Anthracyclines/trastuzumab
  • Radiation
  • Sarcoidosis (infiltrative)
  • Genetic syndromes (e.g. myotonic dystrophy)
  • Myocarditis
  • Pregnancy
20
Q

How should heart failure medications be titrated?

A

•Doses should be doubled, one at a time, every fortnight until intolerance emerges or the maximum dose is reached

21
Q

Managing HF in CKD patient - why is it important?

A

•About 50% of HF patients will have or develop CKD

22
Q

Would you use ACEi in HF patients who also has eGFR <45?

A
  • SAVE trial (Survival And Ventricular Enlargement) study of captopril vs. placebo post MI
  • >2,200 patients with HFrEF
  • 1/3rd eGFR <60
  • 10% eGFR <45
  • CKD patients did worse, but superiority of Captopril was maintained in patients irrespective of CKD
23
Q

Does increase in Creatinine or decrease in GFR when ACEi/ARB is used represent renal damage?

A

No - rather, it is an expected side effect: acute increase up to 30% usually stabilises over time and is strongly associated with renal protection

•This does not equate to renal damage – as it is reversible upon reduction or withdrawal

24
Q

Is beta-blockade recommended for HF for patients with CKD?

A

•MERIT-HF trial (4,000 patients, Metoprolol XL)

  • ~500 had GFR <45
  • HR for metoprolol group = 0.41

•CIBIS II trial (2,500 patients, Bisoprolol)

  • Included patients with Cr up to 300
  • HR = 0.66 for bisoprolol group

•Overall, benefit of BBs were maintained in patients with CKD

25
Q

Would you use MRA for HF patients with significant CKD? (spiel - include a quick pathophysiology)

A

There is theoratical advantage of using MRA, as Aldosterone promotes glomerulosclerosis + tubulo-interstitial fibrosis.

Korean HF registry study witn 1000 HF patients with eGFR <45

Use of spironolactone - decreased mortaliy in univariate but not mulivariate.

So based on this evidence, I won’t but it would also be reasonable as long as patient does not have signficant hyperkalaemia or hypotension

26
Q

Would you consider ARNI as a 1st line therapy for HF instead of ACEi? (name of the trial)

A

Yes.

PARADIGM-HF trial

  • ~8,400 patients with HFrEF
  • stopped early due to an overwhelming benefit in overall mortality, CV mortality, hospitalizations, and HF symptoms in favour of ARNI
  • Fewer ARNI patients experienced worsening kidney function or serious hyperkalemia
  • Important exclusions:
  • baseline eGFR < 30
  • During run-in eGFR falling to 35% decrease in eGFR
  • During run-in K ≥ 5.5 mEq/L K
27
Q

What to do for the truly ACEi/ARB intolerant patient with HF and CKD?

A
  • Hydralazine-isosorbide dinitrate (H-ISDN)
  • Opinion-based (mine) versus evidence-based
  • Fixed dose combination H-ISDN was used in African American Heart Failure Trial (A-HeFT) added to standard therapy
  • ~40% reduction in mortality and hospitalization
  • •Included 17% of patients with CKD
28
Q

Acutely – how would you mange concurrent HF vs AKI?

A
  • Judicious use of diuretics – often effective in treatment of volume overload among patients with low eGFR
  • Diuretics should not be withheld to prevent ↑ in urea/Cr – instead patient should be diuresed to euvolaemia or to the level that is well tolerated by patient → and recheck urea/Cr

So the most important = regular reassessment of volume status – give diuretics if overloaded, and WH if volume deplete/dry

•If refractory – should consider dialysis

Cardiology (Long) (13 decks)

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