Laflamme- Chapter 3 (Heart Failure) Flashcards
What dose of Bumetanide is equivalent to 40mg Lasix?
Bumetanide 1mg daily
What is Spironolactone dosing if CrCl 30-49?
25mg daily
What are three contraindications to ACEi/ARB use?
- Angioedema
- RAS
- Pregnancy
What are contraindications for beta blockers?
- Active HF
- Shock
- Hypoperfusion
- Asthma
- PR > 240 msec
- 2nd or 3rd deg heart block
- Severe PAD
What are 2 contraindications for MRA use?
- Hyper K > 5.0
- GFR < 30
What part of the nephron does MRA work on?
-Collecting tubule
Name 5 mechanisms for Diuretic resistance
- Post sodium excretion stimulation of the RAAS
- Decreased absorption due to edema of the intestinal wall
- Decreased CO and getting diuretic to kidney
- Hypertrophy of distal tubule
- Cardiorenal syndrome
How does Digoxin work?
Inhibits the Na-K-ATPase pump which increased intramyocyte Ca (increases inotropy) and increases vagal tone
What is serum target level for digoxin?
-0.5-0.9 ng/ml
Name 12 medications that increase Digoxin levels
- Amiodarone
- Verapamil
- Nifedipine
- Carvedilol
- Captopril
- Propafenone
- Quinidine
- Spironolactone
- Cyclosporine
- Macrolides
What % of HF patients have Central Sleep Apnea?
40%
What is Cheyne-Stokes breathing?
- Hyperventilation followed by apnea (>10 seconds) with no ventilatory effort
- This is associated with pulmonary congestion and is an independent RF for mortality.
-What is the treatment for Cheyne Stokes breathing?
- Optimize HF therapy
- There is no benefit for CPAP (CANPAP) or Servo-Ventilation (SERVE HF, increased mortality)
What % of HF patients have OSA?
-10 %
What are the 6 echo features of diastolic dysfunction?
- E/e prime > 15
- E/A inversion during valsalva
- Diastolic dominance of PV inflow
- Prolonged reversal of flow in PV during atrial kick
- LA dilatation
- Pulmonary hypertension
What is the MOA of Nitroglycerin?
- NO intracellular -> cGMP in smooth muscle cells -> leads to Vasodilation
- Venous vasodilator > Arterial/Coronary
What is the MOA of Nitroprusside?
-Balanced vasodilator with a shorter have life than nitroglycerin
What is the unique risk of Nitroprusside?
-Cyanide toxicity
How does Nesiritide work?
- Recombinant BNP
- No benefit in ASCEND HF, ROSE AHF
What is the MOA of Dobutamine?
-Beta 1 and Beta 2 agonist
What is the MOA of Dopamine?
- Positive inotrope and vasopressor
- Vasodilator at low doses
- It is a NE precursor
What is the MOA of Milrinone?
-PDE3 Inhibitor -> increased intracellular CAMP -> Increased intracellular Ca2+
What are hemodynamic targets for the following during HF management for the following: LCWP, CVP, BP, SVO2, SVR, CI
- Wedge < 18
- CVP < 8
- MAP > 60
- SVO2 > 70%
- SVR 1000-1200
- CI 2.2
How much do the following increase CO? IABP, Impella, ECMO
- IABP: 10-15%
- Impella: 2.5-5L/min
- ECMO: 5 L/min
When to list for transplant on basis of CPX?
-14 (12 if on BB)
What cold ischemia time is required for a Heart donor?
-Cold ischemia time < 4h
What two cardiac investigations do donors need?
- TTE
- Cath (depending on risk)
What PRA level indicates that patient is sensitized?
10%
What is management for patients who are PRA sensitized?
-IVIG, Rituximab, Plasmapheresis
Name 4 hemodynamic contraindications to transplant?
- PVR > 3 WU
- TPG (mPAP - Wedge) > 15
- PVR > 2.5 WU in response to pharmacologic challenge while maintaining SBP > 85mmHg
- PVR Index (TPG/CI) > 6
Name 12 non-hemodynamic contraindications to transplant?
- Irreversible renal function GFR < 30
- Irreversible liver dsiease
- Pre-existing cancer
- Active infection
- Clinically severe CVD
- PAD which limit rehab
- DM with target organ damage or poor control Hba1c > 7.5%
- Non compliance
- Active substance use
- Obesity > 35 BMI
- Age > 70 y.o
- Frailty
What are the stages of the Priority Allocation system?
1) other
2) Inpatient or outpatient on inotropes
3) Incomplicated VAD, inhospital on inotropes, arrhytmhmia
4) Dependent on MCS
What two medications can be given for transplant induction therapy?
- Anti IL2 receptor antibodies (Basiliximab)
- rATG (antithymocyte immunoglobulins)
How long to continue corticosteroids?
6 months then tapering
How do CNI’s work?
-decrease T cell activation
How do purine synthesis inhibitors work? (AZA, MMF)
-Inhibit Tcell and Bcell proliferation
When would you use an MTOR inhibitor? (Sirolimus)
- Alternative to CNI in presence of renal toxicity
- Decreases the risk of CAV, treatment of CAV
What is the main risk of MTOR inhibitor?
Impaired wound healing
What is the mechanism for cellular rejection?
-Lymphocyte infiltrates weeks to years post transplant
What % of Cellular rejection occurs in the first year post transplant?
40%
How to monitor for Cellular rejection?
-Weekly biopsy for 6 weeks, then monthly for 6 months, then every 3 months for 2 years
What are 4 risk factors for cellular rejection?
- Young
- Female
- CMV+
- HLA incompatibility
How to treat cellular rejection?
-Corticosteroids, intensify immunosuppression
How do you stage Cellular rejection?
OR: Absence of rejection
1R: < 1 zon of myocyte injury from lymphocytic infiltration
2R: 2 or more zones
3R: Multiple zones
What is Humoral rejection?
-Anti donor HLA antibodies form, absence of lymphocytic infiltrate
What does Humoral rejection look like on echo? Biopsy?
- Echo: Graft dysfunction, wall thickening (edema)
- Biospy: Capillary endothelial congestion, macrophages in capillaries, no lymphocytes
What is the prevalence of CAV at 10 years?
50%
What is the hallmark of CAV on cath/imaging/biopsy?
Diffuse concentric neointimal proliferation
Why do patients with CAV have less angina than those with native CAD
No angina due to denervation
What are 6 RFs for CAV?
- All traditional CAD RFs
- Rejection history
- HLA incomptability
- Graft ischemia time
- Donor age
- CMV+
How to treat CAV?
- Statins
- ASA
- Control RFs
- MTor inhibitor
- PCI (possible)
- Re transplant
What three microbes need prophylaxis? For how long?
-6-12 months post transplant
CMV: Acyclovir/Valganciclovir
PJP: TMP/SMX
Toxoplasmosis: Voriconazole
What is risk of malignancy at 10 years? What are 3 most common?
- 30%
- Lymphoma, Skin cancer, Solid organs
What is mean survival post transplant?
-10 years
Describe the Intermacs Profile?
Used to describe time to mechanical support
1) Crashing and burning (hours)
2) Progressive Decline on Inotropes (days)
3) Stable but Inotrope dependent (weeks)
4) Recurrent HF (week to months)
5) Exertion Intolerant (variable)
6) Exertion limited (variable)
7) NYHA III (not candidate)
Name 9 factors that predict post LVAD in hospital survival?
- Plt < 148
- Albumin < 33
- INR > 1.1
- Vasodilator therapy
- AST > 45
- mPAP < 25
- AST > 45
- Hct < .34
- BUN < 51
- Absence of IV inotrope
How should you titrate speed according to echo? (3)
- Aortic valve opening every 3 cycles
- Position of IV septum
- LV and RV chambers
What is anticoagulation for LVAD?
-INR 2-3, ASA 81mg daily
What should BP target be in LVAD?
MAP 60-80mmhg
Name 10 complications of LVADs?
- RV failure
- Fusion of Aortic valve leaflets
- Bleeding (vWF deficiency)
- Hemolysis
- HIT
- Stroke
- Infection
- Break down
- Device thrombosis
- Allosensitization
What are 3 indications for Heart Transplant?
- Advanced/Late stage heart failure with unacceptable QoL and high anticipated mortality despite optimal medical therapy
- Peak VO2 < 14 (< 12 if beta blocker)
- High anticipated 1 year transplant free mortality by accepted scores ( < 80% 1y survival based on Seattle HF score)
What are 4 mechanisms of Cardiorenal syndrome?
- Venous congestion
- Hypovolemia
- Ascites
- Hypoperfusion
- Medications
What are 5 causes of Cardiomyopathy that also cause heart block?
- Myocarditis
- Amyloidosis
- Familial CMO (LMNA, SCN5a)
- Lyme Disease
- Myotonic Dystrophy
