Heart Failure: prioritizing drugs

Question 1

What is class I heart failure?

Answer 1

Reduced EF (<40%), aka systolic HF (treatable!!)

Question 2

What levels can put you at increased risk of death from HF?

Answer 2

1. Increased age
2. Decreased LVEF
3. Being black

Question 3

Risk factors for HF?

Answer 3

1. HTN
2. Diseased valves
3. Heart attacks
4. Diabetes mellitus

Question 4

What model do we focus on now for HF? What are consequences?

Answer 4

Neurohormonal model: myocyte injury, oxidative stress, inflammation and ECM remodeling;

1. With index event we have
2. ANS and RAS and cytokine systems to compensate
3. LV remodeling and cardiac decompensation

Question 5

Which drugs for HF can decrease mortality and morbidity? What does not decrease both of these but decreases hospitalization?

Answer 5

ACEi/ARBs, beta-blockers, aldosterone antagonists, hydralazine nitrates, diuretics;
cardiac glycosides

Question 6

Stage A HF defined as

Answer 6

1. high risk for HF but no risk of structural heart disease or symptoms of HF
2. Think HTN, atherosclerotic diseases, diabetes, obesity, metabolic syndrome should be controlled
3. Think cardio toxins and history of cardiomyopathy
4. Aim: reduce factors; use ACEi/ARB and thiazides!!!

Question 7

Stage B HF defined as

Answer 7

1. structural heart disease WITHOUT symptoms or signs of HF
2. Previous MI, LV remodeling including LVH and low EF
3. Asymp valvular diseases
4. Aim: same as stage A; drugs are beta blockers in ACEi

Question 8

Difference between A/B/C/D HF staging and I/II/III/IV staging?

Answer 8

Roman numerals: more dynamic changes as opposed to going from A to C which can take time!!

Question 9

Someone with NSTEMI, HTN, hyperlipidemia; low EF and EKG shows LVH; what drugs indicated?

Answer 9

1. Give ACEi
2. beta blocker
3. aspirin (for life; dual antiplatelet with clopidigrel would have been good if conditions arose less than a year ago)
4. Statin for hyperlipidemia

Question 10

Stage C HF:

Answer 10

1. structural heart disease with PRIOR or CURRENT symptoms of HF
2. known structural heart disease and symptoms of HF
3. same measures as A and B
4. Diuretics, ACEi, beta-blockers, aldosterone antagonist, hydralazine/nitrates!!

Question 11

In stage C or class I-IV, what is indicated treatment (algorithm)?

Answer 11

1. ACEi/ARB AND beta-blocker
2. for VOLUME OVERLOAD, think loop diuretics
3. For persistently symp AA’s, also hydral-nitrates!!
4. For creatinine high and K low, give aldosterone antagonist

Question 12

In stage D, there is

Answer 12

1. REFRACTORY HF requiring specialized intervention plus usual therapy
2. Marked symptoms at rest despite max therapy!! Recurrent hospitalization and unsafe discharge
3. appropriate measures under the previous stages
4. Options: compassionate end of life care, heart transplant, ventricular assist device, chronic inotropic and diuretic therapy!!!