Heart Failure - Management

Question 1

Multimodal treatment of HF generally includes:

Answer 1

○ Dietary and lifestyle changes
○ Treatment of cause (such as ischemic heart disease)
○ Medications (several classes)
○ Device therapy in some Pts (such as CRTs, LVADs, etc.)
○ Heart transplantation in some patients
○ Cardiopulmonary rehabilitation

Question 2

Short-term goals for Heart Failure treatment:

Answer 2

Relieving symptoms; improving hemodynamics; avoiding
hypokalemia, renal dysfunction, and symptomatic hypotension; and
correcting neurohormonal activation

Question 3

Long-term goals for Heart Failure treatment:

Answer 3

Correcting hypertension, preventing myocardial infarction
and atherosclerosis, improving cardiac function, reducing hospitalizations,
improving survival, and improving quality of life.

Question 4

Immediate treatment for Heart failure

Answer 4

may require inpatient hospitalization for acute or worsening heart failure due to certain disorders (acute MI, A-Fib with
rapid ventricular rate, severe HTN, acute valvular regurgitation), as well
as for patients with pulmonary edema, severe symptoms, new-onset HF,
or HF that is unresponsive to outpatient treatment.

Question 5

Long term Pharmacologic Treatments for Heart failure include:

Answer 5

■ ACE inhibitors / ARBs
■ ARNIs
■ Beta-blockers
■ Aldosterone antagonists

Question 6

Symptomatic relief Pharmacologic Treatments for Heart failure include:

Answer 6

■ Diuretics (commonly)
■ Vasodilators
■ Digoxin

Question 7

For medical management, we generally classify HF patients as either

Answer 7

○ Heart Failure with Reduced Ejection Fraction (HFrEF) - 40% or below
○ Heart Failure with Mildly Reduced Ejection Fraction (HFmEF) – 41-49%
○ Heart Failure with Preserved Ejection Fraction (HFpEF) – 50% or higher
○ Heart Failure with improved EF (HFimpEF) – got better, was 40% or below

Question 8

STAGE A Heart failure treatment:

Answer 8

at-risk for HF
● SGLT-2 inhibitors should be started in pts with DM with or at elevated risk of CV disease
to reduce hospitalization.
● Control co-morbidities

Question 9

STAGE B heart failure treatment:

Answer 9

pre-HF à focus on GDMT
● CLASS I: (≦ 40%) ACEi or ARB, control co-morbidities, cardio-selective BB (e.g.
carvedilol)
● >40% control so-morbidities

Question 10

STAGE C & D Heart failure treatment

Answer 10

Symptoms present (see slides)

Question 11

The most effective class of medication for significantly decreasing
volume status in a HF patient with volume overload

Answer 11

Diuretics

Question 12

these meds Should be added early to offset the potassium-losing effects of higher-
dose Loop Diuretics

Answer 12

Aldosterone Antagonises (Potassiom-sparing diuretics)

Question 13

_____ can cause hypovolemia with hypotension, hyponatremia, hypomagnesemia, and severe hypokalemia

Answer 13

Loop diuretics

Question 14

Examples of aldosterone antagonists

Answer 14

Spironolactone or Eplerenone.

Question 15

Examples of loop diuretics

Answer 15

Furosemide, Bumetanide, and Torsemide

Question 16

Examples of thiazide diuretics

Answer 16

Hydrochlorothiazide and Chlorthalidone

Question 17

T/F All patients with HFrEF should be given oral ACE Inhibitors unless
contraindicated

Answer 17

T

Question 18

Beneficial effects of ACE inhibitors in regards to HF

Answer 18

■ Reduces production of Angiotensin II and breakdown of bradykinin
■ Slight arterial and venous vasodilation (decreased TPR)
■ Sustained decreases in LV filling pressure during rest and exercise
■ Favorable effects on ventricular remodeling

Question 19

These have been proven to prolong survival and reduce the number of
hospitalizations for patients with HF

Answer 19

Ace Inhibitors

Question 20

In ______, ACE inhibitors and ARBs are likely equally as effective

Answer 20

chronic HFrEF,

Question 21

In _____, ARBs should be used only if they are already being used to
treat HTN, diabetic kidney disease, or microalbuminuria

Answer 21

HFpEF,

Question 22

Complications of Angiotensin Receptor (Blockers) / Neprilysin Inhibitor (ARNI)

Answer 22

hypotension, hyperkalemia, renal dysfunction, and
angioedema

Question 23

Angiotensin Receptor (Blockers) / Neprilysin Inhibitor (ARNI) example

Answer 23

Valsartan/Sacubitril (Entresto)

Question 24

_____ may be very helpful in patients truly
intolerant of ACE inhibitors or ARBs (usually because of significant renal
dysfunction)

Answer 24

Hydralazine plus Isosorbide Dinitrate

Question 25

______ significantly reduced
the risk of death and hospitalization for HF in those with HF with reduced EF

Answer 25

SGLT2 Inhibitors

Question 26

Ivabradine (Corlanor)

Answer 26

○ Ivabradine works on a channel in the sinus node and slows the sinus rate.
○ The SHIFT trial revealed that Ivabradine may reduce hospitalization for HF by 18% in
some select patients.
○ Indicated for stable patients with HF and HR of at least 70 bpm who are taking the
maximally tolerated dose of beta-blockers (or can’t take beta-blockers)

Question 27

Vericiguat (Verquvo)

Answer 27

○ The new medication reduces the risk of
cardiovascular death and HF hospitalization
following HF hospitalization in those with LV EF less than 45%.

Question 28

Digoxin

Answer 28

○ Digitalis inhibits the sodium-potassium pump, which causes weak positive
inotropy (increases the strength of myocardial contraction)

Question 29

EKG findings that are characteristic of digitalis toxicity

Answer 29

downsloping “scooped”
ST segments in I and aVL as well as biphasic T waves V5-V6

Question 30

Dietary Sodium Restriction in HF management

Answer 30

■ Limiting intake of sodium helps limit fluid retention. All patients should
eliminate salt in cooking and at the table, and avoid salty foods. The most
severely ill should limit intake to < 2 g per day

Question 31

Monitoring Daily Morning Weight in HF management

Answer 31

Monitoring body weight daily helps detect sodium and water retention
early, before it becomes severe. If weight increases > 5 pounds over a few
days, may consider increasing diuretic dose

Question 32

Regular Light Activity in HF management

Answer 32

■ Activities such as walking is generally encouraged. Formal cardiac
rehabilitation programs are useful for HFrEF especially

Question 33

Stage A and B are _____ while C and D _____

Answer 33

“at risk of HF,” have HF

Question 34

When HF patients experience acute
decompensation, signs and symptoms
of left and right heart failure arise, such as:

Answer 34

Dyspnea, orthopnea, PND, fatigue,
peripheral edema, etc

Question 35

Treatment of acute exacerbations of HF generally revolves around _____

Answer 35

correcting the volume overload by diuresis

Question 36

Implantable Cardioverter-Defibrillator (ICD)

Answer 36

○ Recommended for patients with otherwise good life expectancy who
experience occasional symptomatic runs of VT or VF.
○ Defibrillates the heart back into normal rhythm

Question 37

Cardiac Resynchronization Therapy Device (CRT)

Answer 37

○ Essentially a pacemaker which kicks in and initiates depolarization of the
ventricles when the heart is not beating normally.
○ Most helpful for patients with significant conduction defects, such as AV
blocks or Bundle Branch Blocks

Question 38

Heart transplantation is the treatment of choice for patients ______

Answer 38

under the age of 60 years who have
severe, refractory HF and no other life-
threatening conditions, and who are highly
adherent to management recommendations

Question 39

Patients who are waiting for a donor heart to
become available have a _____% mortality rate.

Answer 39

12-15

Question 40

If a donor heart does become available, survival is _____% at 1 year after surgery, with annual mortality of about _____% per year

Answer 40

85-90; 4

Question 41

Prognosis of heart failure

Answer 41

Generally, patients with heart failure have a poor prognosis unless the cause
is correctable (which is not common)

Question 42

5-year survival rates after a first-time hospitalization for heart failure is
about ____%, regardless of the patient’s ejection fraction

Answer 42

35

Question 43

Predictors of poor prognosis in HF

Answer 43

include hypotension, low EF, presence of CAD,
elevated troponins, elevated BUN, reduced GFR, chronic hyponatremia, and poor functional capacity (such as difficulty walking due to symptoms).
● Heart failure usually involves gradual deterioration, interrupted by bouts of
severe decompensation

Question 44

Patient family education about heart failure

Answer 44

● All patients and families should be taught about the expected and natural
disease progression and the risk of sudden cardiac death.
● For some patients, quality of life is
more important than quantity of life.
○ For this reason, it’s important to
determine the patient’s wishes
about resuscitation if their
condition deteriorates suddenly