Trials Flashcards
What is the Save trial Intervention In who Outcomes
Treat MI with ACE inhibitor. Mostly asymptomatic Reduced mi.
What is stitch hypothesis 1 Who Intervention Outcomr
Omt vs Cabg in Ef <35. No stastical difference but in pt without angina. Lots of crossover. No survival difference with viability.
Survival differences in heart mate 2 trial
60% in hm2 vs 24% with xve at 2 yrs
Cumulative effect of ace inhibitors? + beta blockers + aldo blockers
28% 34% 15%
Solvd trial When Who Outcomes
1991 Ef < 35. Two trials one with sx/one no sx Enalapril 10 bid Lowered all cause mortality and death/HF hospitalizations
Save trial Who What happened
Post mi Ef <40, no overt HF Placebo vs captopril Reduced cv death 21%
What are the 4 bb trials RRR, inlusion
Us carvedilol 65 rrr, mild/mod HF Ef <3 cibis 35 mod/severe merit 35 mild/mod hf improve Ef by 30% Copernicus 35 severe Capricorn post mi
Comet trial
Carvedilol va metop Much less dm
Who should get beta blockers when to start When to titrate dose?
Symptomatic and asymptomatic Ef <40 Initiate once euvolemic/Discontinue inotropes prior to sc Change dose every 2 week
Elite 2 trial outcomes
Losartan had no benefit over captopril
Val heft Intervention Outcomes
Valsartan added to ace. Reduced HF hospitalizations.
Charm alt/added
Charm alt had benefit Added did not
Optimaal Intervention Outcome
Losartan vs captopril post mi. No difference
Valiant Intervention Outcome
Post mi Valsartan v captopril No differences
Who should get arb
Class 1: ace intolerant, those on Arbs already, Don’t use post mi, don’t use if on spirinolactone.
Consensus trial Intervention Outcome
Enalapril in stage d. Nnt 7
Optime CHF
No benefit of milrinone .5 But seemed to work better in non ischemic
Corona-Gissi HF
No benefit of statins
Rales Population Outcome Weaknesses
Class iv. Nnt 9 Weakness low use bb
Emphasis Population Intervention Nnt/rrr
Class ii/3 Ef<30 spirinolactone Nnt 19 rrr 15%
Ephasus Population Nnt
MI, Ef<35, sx of HF Nnt 44
How often should you measure k in pt on aldostorone
At week one and four and every 3 mos Don’t give k unless less than 4
Enrollment in emphasis Primary outcome Findings rrr nnt
Nyha 2, ef<30 or 35 with wide qrs Cv death or hf hospitalization, Rrr 30, nnt 19
Aheft What is endpoint?
Composite death, HF, qol 4 % arr Recommended for aa, with moderate to severe symptoms reasonable in ace intolerant
Goal digoxin level
Less than 1.
Should patients with non ischemic cm get aspirin
No
HEAAL
NYHA 2-4, Ef< 40 Ace intolerant, randomized to 150 vs 50 of losartan. Higher doses reduced hospitalizations.
Shift trial
Class. 2-4 Decreased HF death, hospitalizations if hr > 77
Why use swan
Low bp Fluid status Renal failure Vasoactive agents Advanced therapies
What’s a cross sectional study
Data collected at a single point in time.
Why is randomization important
Eliminates bias from treatment assignment Tries to remove type 1 error.
What is most important thing about clinical trial endpoints
If doesn’t hit primary end point must ignore secondary endpoint.
Utility of secondary endpoints
Only useful if statistically significant primary endpoint.
Best primary outcomes
Clinical outcomes Symptoms Surrogates (may not always work).
How to do multiple primary endpoints
Account for alpha (type 1 error). Must decide this at the beginning.
Point of subgroups
Look at them but don’t make any conclusions
Phlebostatic axis
4th intercostal space Midpoint between anterior and posterior chat.
What lung zone do you want to be in when wedge
Zone 3 Zone 1/2 collapse of alveolar
When do you want to measure chambers
End expiration. Subtract half peep if on ventilator.
When does wedge pressure occur
Look at pr V wave occurs in t p (closer to p) can look for double bump in pa to predict presence of v wave V wave a combination of volume already in la and regurgitate volume.
Fick
Cardiac out= oxygen consumption/oxygen extracted Oxygen capactity = 13*hgb* av o2 difference. Guess consumption 3-4 l kilo
Constriction versus restriction
Look in diastole! Constriction dip and plateu. Rvedp> 1/3 RSVP. Restriction pas > 50. Lvedp-rvedp>5
Differentiate between restriction/constriction and tamponade
Tamponade loose y descent.
Pathoneumonic finding in hcm hemodynamics
Spike and dome
Class I indication for pa catheter
To guide therapy in patients who are in respiratory distress Or impaired perfusion but you can’t determine fluid status, Bp remains low, renal fxn worse, need vasoactive agents, support for device.
Catheter whip
Tall and skinny artifact
Best surrogate for outcomes in heart failure
Lv size.
Ace inhibitors integrated recs
All patients ef <40 Doses should be titrated to doses used in clinical trials
How long does it take to improve ef in beta blockers
3 months.
Differences between bisoprolol, metoprolol and carvedilol
Bisoprolol and metoprolol much more beta one selective.
Carvedilol vs metoprolol
Carvdedilol better at lower doses better in diabetics Metoprolol better in hypotensive, copd etc
Beta blockers integrated recs
Beta blockers are reccomended for symptomatic and asymptomatic ef <40 Decomp: Initiate after optimizing volume status and prior to discharge.
Elite 2 trial
Losartan not better than captopril
Optimaal/Valiant
Post mi. No better than ace.
Charm added
Only trial to show benefit of ace + arb (combine m and m).
Who should be on arb
Reccommended for intolerant of ace Technically ok as alternative for ace if post mi (valiant) Do not use routinely in addition to ace post mi (valiant)
Inclusion criteria for ephesus
Post mi, ef< 40, Chf or dm
Emphasis trial
Nyha class ii, ef < 35%
Arb recs
Class ii-iv, Ef < 35% Post mi ef 2.5, potassium >5 Avoid cyp3a4 and eplerenone.
Hydralazine/nitrates
AA: moderate to severe sx (lvef <35or 45 with 6.5 cm ventricle). Reasonable for patients on ace/arb who are symptomatic
Polypharm
Addition of arb (a) Addition of Aldo (a) Hydralazine/nitrates (c)
Digoxin
Consider if lvef <1.0 start and .125 Ok to use in Afib, if beta blocker not working.
Aspirin for heart failure
No benefit in non ischemics.
Watch trial
Excluding Afib, warfarin aspirin and clopidigrel class 2-4 Ef <35 No benefit Warcef also showed no benefit.
Drugs to avoid In HF
NSAIDs Ccb stage b, (negative inotropy). Only use vasoselective - amlodopine. Only can use amiodarone/dofetilide
Warfarin
Amio, Bactrim, may increase Rifampin may decrease.
What drugs are metabolized by cyp4503a4 What downregulate cyp
Tarolimus, statins. Dig, sirolimus, cyclosporine, eplerenone Diltiazem, amio, Bactrim, flucinazole, flagyl.
Elderly and HF
Ace and bb Watch out for volume status, postural hypotension, cva
Beta blocker guideline Contraindication
Contraindication if have active bronchospasm. Use with caution if hypoglycemic, asthma, resting limb ischemia
Anemia and heart failure
Can cause high output HF. But takes a lot of anemia. Independentally associated with worse HF mortality. 12 better than 10.
Epo in heart failure
Black box warning. Can increase stroke.
Fair HF
Improved self reported symptoms with iron. No guidelines yet
Define apnea
No air flow for 10 seconds despite effort 5 episodes per hour. A/h index >3 worse
Why cheyenne stokes
Low co2 because breathe too fast .. Lead to vicious cycle of hypo ventilation.
Canpap trial
No differences in qol, exercise intolerance etc.
Who is bipap good for ? Nocturnal o2?
Bipap Good for hypoventillation not hyperventilation O2 good for hyperventilation Exercise training. Bb and CRT work
Sad hart
Zoloft or placebo No benefit
Effexor
May increase Bp Wellbutrin can also increase Bp Celexa bad qt
Discharge instructions?
Meds Diet Activity Weight What to do if Follow up appointment call within 3 days and clinic within 7 days.
Number one reason for readmission in optimize HF
Arrhythmia.
What predicts outcomes in HF
Readmission, renal disease (creat Clarence >60).
Rules for starting Aldosterone Antogonists
Modererate to Severe Sx
Creatinine <2 in women, 2.5 in men
K <5
DO NOT START IF PATIENT IS NOT COMPLIANT.
Cardiac amyloid
Sardcoid
Myocarditis
Episioon wave
