HF

Question 1

☆In what conditions is ACE-I contraindicated when treating patient with heart failure ? ( Answer 6 conditions )

Answer 1

1. Angioedema: A history of angioedema related to previous ACE inhibitor therapy is a strong contraindication due to the risk of recurrence
2. Bilateral Renal Artery Stenosis
3. Pregnancy
4. Hyperkalemia: (potassium levels >5.5 mmol/L) is a contraindication because ACE inhibitors can increase potassium levels further leading to arrhythmias.
5. Severe Hypotension
6. Severe Renal Dysfunction: it can be used cautiously in patients with mild to moderate renal impairment.

Question 2

☆What is the workup that needs to be done for a patient with heart failure exacerbation?

Answer 2

1. History and Physical Examination
   
   • Detailed history
   • assess vital signs, signs of fluid overload (e.g., jugular venous distention, peripheral edema), and other relevant findings (e.g., rales, hepatomegaly).
2. Laboratory Tests:
   
   • (CBC): To check for anemia or infection.
   • Electrolytes, (BUN), and Creatinine
   • Liver Function Tests: To evaluate hepatic congestion or dysfunction.
   • Brain Natriuretic Peptide (BNP) or N-terminal pro-BNP (NT-proBNP): Elevated levels help confirm the diagnosis of heart failure and assess severity.
     - Cardiac Biomarkers (e.g., Troponins)**: To rule out myocardial infarction as a precipitating factor.
   • Thyroid Function Tests: To check for thyroid dysfunction as a contributing factor.
3. Imaging Studies:
   
   • Chest X-ray**: To evaluate for pulmonary congestion, cardiomegaly, or other pulmonary pathology.
   • Echocardiogram: To assess left and right ventricular function, valvular function, and other structural abnormalities.
   • Electrocardiogram (ECG): To identify arrhythmias, ischemic changes, or other cardiac abnormalities.
4. Additional Tests:
   
   • Arterial Blood Gas (ABG): In cases of severe respiratory distress or to assess oxygenation and acid-base status.
   • Urinalysis: To check for proteinuria, infection, or other renal issues.
   • Pulmonary Function Tests: If there is a suspicion of concomitant pulmonary disease.
5. Hemodynamic Monitoring (if indicated):
   
   • Swan-Ganz Catheterization: In cases where precise measurement of cardiac output and pressures is needed, especially in critically ill patients.
6. Review of Current Medications:
   
   • Assess adherence and potential drug interactions or side effects that could contribute to heart failure exacerbation.
7. Lifestyle and Social Factors:
   
   • Evaluate dietary habits, fluid intake, alcohol use, and social support systems.

Question 3

☆What are the drugs that lower mortality in patients with systolic dysfunction? ( Answer includes 7 classes of meds )

Answer 3

1. ACE Inhibitors: enalapril, lisinopril, and ramipril.
2. ARBs
3. Beta-blockers: carvedilol, metoprolol succinate, and bisoprolol.
4. Aldosterone Antagonists: as spironolactone and eplerenone
5. Neprilysin Inhibitor and ARB Combination (ARNI): Sacubitril/valsartan (Entresto) has been shown to reduce mortality and hospitalization rates compared to ACE inhibitors alone.
6. SGLT2 Inhibitors: Recently, medications such as dapagliflozin and empagliflozin have shown to improve outcomes in heart failure with reduced ejection fraction, reducing both cardiovascular death and hospitalizations.
7. Hydralazine and Isosorbide Dinitrate: This combination is particularly effective in African American patients

These medications are often used in combination to optimize treatment and improve patient outcomes.

Question 4

☆What are the drugs that decrease symptoms but NOT mortality in patients with HF?

Answer 4

1. Diuretics:
   
   • Loop Diuretics (e.g.,furosemide, bumetanide, torsemide)
   • Thiazide Diuretics (e.g., hydrochlorothiazide, chlorthalidone): Often used in combination with loop diuretics for additive diuretic effect.
2. Digoxin
3. Vasodilators
   
   • Hydralazine (when not combined with isosorbide dinitrate): Used primarily to reduce afterload.
   • Isosorbide Dinitrate (when not combined with hydralazine): Used primarily to reduce preload by venodilation.
4. Ivabradine: This drug reduces heart rate in patients with heart failure and reduced ejection fraction (HFrEF)