T8 - Insuficiência Cardíaca

Question 1

What is heart failure? What do the accompaning molecular abnormalities cause?

Answer 1

The inability of the heart to pump blood in an amount sufficient to meet the metabolic needs of the organs.
Progressive deterioration of the failing heart and premature myocardial cell death.

Question 2

HF may be accompanied by what physical signs?

Answer 2

• Pulmonary crackles
• Elevated jugular venous
• Peripheral oedema
• Other

Question 3

HF Three subtypes according to LV ejection fraction (EF)?

Answer 3

• HF with preserved EF (HFpEF): LVEF ≥50%
• HF with mid-range EF (HFmrEF): LVEF 40–49%
• HF with reduced EF (HFrEF): LVEF <40%

Question 4

HF-PEF vs HF-REF?

Answer 4

Patients with HF-PEF are older and more often female and obese than those with HF-REF.

They are less likely to have CHD and more likely to have hypertension and atrial fibrillation.

Question 5

Hospitalizations?

Answer 5

Hospitalizations are common after HF diagnosis, with 83% patients hospitalized at least once and 43% hospitalized at least 4 times.

Question 6

HF prognosis?

Answer 6

Worse than that of many common forms of cancer

Question 7

The two main causes of HF?

Answer 7

Coronary Heart Disease (HF-REF) and Hypertension (HF-PEF)

Question 8

Risk factors to heart failure?

Answer 8

Hypertension
Obesity
DM2
DPOC
Dyslipidemia

Question 9

Etiology - HFrEF?

Answer 9

Coronary Heart Disease

Question 10

Etiology - HFpEF?

Answer 10

Patients with HFpEF are less likely to have CHD and more likely to have hypertension , atrial fibrillation and other comorbidities

Question 11

Pathophysiology and prognosis of HF?

Answer 11

LVD - Hemodynamic Changes - Neurohormones, Cytokines, Cytoskeleton - Molecular Changes (LVH, necrosis, apoptosis, fibrosis) - Remodelling - LVD

Question 12

Sintomas HF?

Answer 12

Alterações da periferia

• Alterações hemodinâmicas (vasoconstrição, ret Na e H2O)
• Miopatia (esquelética – astenia, respiratória – dispneia)

Question 13

Prognóstico (alterações do coração) in HF?

Answer 13

• • NH, citoquinas e sobrecarga
• → Alt. moleculares cardíacas (proliferação, apoptose, necrose e fibrose)
• → “cardiomiopatia de sobrecarga” (DVE e remodelagem progressiva)

Question 14

What is the bad prognosis of HF linked with?

Answer 14

Cardiac molecular changes (induced by neurohormonal activation, and causing premature cell death and remodeling)

Question 15

Insuficiência Cardíaca FE reduzida - Consequências da remodelagem?

Answer 15

Dilatação e Disfunção sistólica e diastólica de um ou ambos os ventrículos.
•↓ do inotropismo e do débito cardíaco (DV sistólica)
•↑da pressão telediastólica VE (DV diastólica)
•Regurgitações valvulares
•↑ da FC

Question 16

Anatomopatologia de HFrEF? HFpEF?

Answer 16

Left ventricular dilatation (Hipertrofia excêntrica)
Interstitial fibrosis

Hipertrofia ventricular concêntrica

Ambos podem causar fibrilhação auricular.

Question 17

Heart Failure - Cardinal symptoms and signs?

Answer 17

. Fatigue
. Dyspnea
. Edema

Question 18

Insuficiência cardíaca - Sinais físicos?

Answer 18

. BD (baixo débito) - Hipotensão, Taquicardia, Cianose
. ICE - Crepitações
. ICD - TVJ, Refluxo Hepato-Jugular, Hepatomegalia, Ascite, Edemas pré-tibiais
Cardiomegalia, sopros (IM e IT)
Caquexia (citocinas)

Question 19

Heart Failure - ECG?

Answer 19

• AFib , VT
• LBBB
• LVH
• Myocardial infarction

A normal ECG virtually excludes HF

Question 20

HF - RX de tórax?

Answer 20

• I C/T
• Contorno cardíaco (Cardiomegalia)
• Congestão pulmonar

Question 21

Natriuretic Peptides?

Answer 21

NPs levels are intimately correlated with left ventricular end-diastolic pressure.
Normal NPs in a non-treated patient BNP virtually exclude HF.

Question 22

HF Diagnosis?

Answer 22

1. Clinical History
   - HF Symptoms
   - Hx of CAD, HTA, other HF risk factors
   - Use of Diuretics
2. Physical examination
   - Rales
   - JV dilation, JG reflux, Hepatomegalia, Ascite, Ankle edema
3. Any ECG Abnormality

Natriuretic Peptides (NT-proBNP >125 pg/ml e BNP >35 pg/ml)
Echocardiography

If HF confirmed:

• Determine aetiology
• Start appropriate treatment

Question 23

HF Diagnosis - Essential initial investigations?

Answer 23

• Electrocardiogram
• Natriuretic peptides
• Echocardiography

Question 24

HF Diagnosis - Symptoms and signs?

Answer 24

Typical Symptoms:
- Orthopnea
- DPN
- Fatigue
- Ankle swelling
Specific Sings:
- Elevated juguar venous pressure
- Hepatojugular reflex
- S3 (gallop)
- Laterally displaced apical impulse

Question 25

Insuficiência cardíaca - Classificação da NYHA?

Answer 25

. Classe I – Actividade usual não causa fadiga, dispneia ou palpitações importantes

. Classe II – confortável em repouso; actividade usual causa fadiga, dispneia ou palpitações (no dia a dia)

. Classe III – confortável em repouso; actividade ligeira causa fadiga, dispneia ou palpitações (ex: vestir, lavar, pequenos esforços)

. Classe IV - sintomas em repouso

Question 26

Insuficiência cardíaca - Diagnóstico diferencial?

Answer 26

. IR
. Anemia
. DPOC
. Obesidade
. Destreino
. Varizes
. Hipotiroidismo

Question 27

Insuficiência cardíaca - Complicações principais?

Answer 27

. IC Aguda
. Arritmias: FA, TV, FV
. Alterações da condução
. Embolias

Question 28

Hospitalizations in HF patients?

Answer 28

• • Are frequent and are not decreasing
• • The main cause of hospitalization above 65y
• • 45% of patients with AHF will be rehospitalized at least once within 12 months
• • A marker of bad prognosis

Question 29

Prognosis of HF?

Answer 29

50% of pts will die within 5 years of HF diagnosis.

HF prognosis is worse than that of many common forms of cancer.

Question 30

Heart Failure therapy - Goals?

Answer 30

 Relieve symptoms
 Prevent hospital admissions
 Improve survival

Question 31

Heart Failure Treatment - Never forget?

Answer 31

1 – Diagnose and treat the etiology
2 – Patient education
3 – Nonpharmacological treatment

Question 32

HFrEF Treatment?

Answer 32

SNS e RAAS targets
NH blockade and Congestion Management

iCEA and B-blocker (titulandoo até doses mais altas) –> Add a MRA (ant. rect.mineralocoirticoides)

• Tolerates iECA/ARB - ARNi
• SR,QRSd >130ms - Evaluate for CRT
• SR, HR > 70bpm - Ivabradina

FA ou LVEF<35% refratária - cardiodesfribilador

Question 33

HFpEF and HFmrEF Treatment?

Answer 33

 Symptoms Relief
o Diuretics
 HF Hospitalizations prevention
o Candesartan, nevibolol, spironolactone, digoxin
 Survival improvement
o None

Question 34

Treatment strategies in HFpEF and HFmrEF?

Answer 34

• Address co-morbidities
- Cardiovascular (HTA, CAD, AFib, PH) 
- Non-cardiovascular (Obesity, DM, CKD, COPD, Iron deficiency, anemia)
• Address congestion (Diuretics)
• Control HR, BP and myocardial ischemia
• Hypoglycemic drugs: 
- iSGLT2: 1rst-line agent, reduced weight, BP, HF hospitalizations and CV mortality
- Metformin

Question 35

HF organization of care?

Answer 35

However it is not possible for all HF patients to receive specialist care from cardiologists due to the size of this population.
Close co-operation between cardiologists, internists and primary care physicians is necessary.

Question 36

Primary care specialists: Role?

Answer 36

HF Diagnosis
- Symptoms and signs
- ECG
- NPs
- 2D-Echo
Non-Pharmacological therapy • Diet and exercise
Pharmacological therapy 
- NH-Blockers
- ARNIs and Ivabradine
- Diuretics
Follow-up
Patients referral

Question 37

Primary care specialists: When to refer patients?

Answer 37

Etiological Diagnosis
Non-Pharmacological therapy
- Devices
- Intervention
- Surgery
HF Decompensation
- Hospital Admission
- IV therapy
- Mechanical support (hemodynamic, respiratory, renal)

Question 38

Principles of drug therapy HF-REF?

Answer 38

NH blockers: highest tolerated doses
ARNI: highest tolerated doses
Ivabradine: highest tolerated doses
Diuretics: lowest dose for effect
Digoxin: low dose (0.125 mg/day)