Heart Failure
What does GDMT stand for & name the different classes?
Guideline-Directed Medical Therapy
Beta-Blocker
ACE/ARB/ARNi
SGLT-2i
MRA
You turn the corner, see your patient enter into new spontaneous asymptomatic afib w/ rvr rates 150s on the monitor. What's your initial medical therapy and what is the goal heart rate?
*Bonus 100 Points if you can name the trial supporting heart rate goal.
IV metoprolol 5mg x 3
IV Diltiazem
Goal heart rate <110
*Bonus Points! Race 2 Trial
EKG reveals ST elevations in 2, 3, AVF with slightly elevated troponins and hemodynamically stable. Is it ok to give this person nitrates? how long do you have to get the patient to the cath lab?
Yes, nitrates are ok as long as you don't cause hypotension and they didn't take a phosphodiesterase inhibitor.
90 minutes door-to-balloon time
What is the murmur and location of the murmur associated with mitral valve regurgitation?
Holosystolic Murmur located along the cardiac apex.
What is the recommended device for a patient following admission for palpitations without documented arrhythmia over their hospital course and normal ECHO?
Cardiac Monitor
Multiple types of monitors: 24 hour, 2 week, 1 month, to permenant. Patient-triggered vs Continuous.
- Holter monitor: 24 - 2 weeks
- Event Monitor: triggered
- Ziopatch (if you are at the VA)
- Loop recorder, pacemaker, ICDs
What is the most common cause of heart failure with reduced ejection fraction in the USA?
Ischemic heart disease
VA Nights! Rapid! Patient is cold & wet & unresponsive without a pulse or respiration. EKG shows....VFIB
What is your next step?
CPR & ACLS
Cardiac Defibrillation!
A troponin rise without EKG changes indicates what type of MI?
NSTEMI
Could be Type 1 or Type 2 NSTEMI
Which valvular lesion is most often associated with atrial fibrillation?
Mitral stenosis
This is known as valvular afib :)
You have a 71-year-old-male, PMHx of nonvalvular Afib, HFpEF, CKD, T2DM, BMI 40, and depression with a recent hospitalization for a massive GI bleed while on apixaban due to a Dieulafoy's lesion. What do you think we should do for stroke prevention?
Maybe a Watchman!?
contraindications for a watchman include (LAA thrombus, active bacteremia, inadequate anatomy)
A 61yoM, 10lbs overweight, dyspneic, orthopneic, JVD to mandible, is admitted to the hospital. He takes PO Lasix 20mg morning and afternoon and states he has been compliant. You and your team discuss his inpatient diuretic plan. Which is better, IV infusion or bolus, and what trial discussed this?
*100 Point Bonus: what would you discharge him on?
2024 Cochrane review and the pivotal DOSE trial (2011) demonstrated that neither intravenous diuretic infusion nor intravenous diuretic bolus is superior in terms of key clinical outcomes such as symptom relief, renal function, mortality, or length of hospital stay in patients with acute heart failure.
*Torsemide (better oral bioavailability, longer duration of action, even an anti-aldosterone effects so less hypokalemia with a makeshift MRA!).
*Bumex (same as above, minus the anti-aldosterone effects?)
Your 71-year-old otherwise healthy patient admitted for constipation is complaining of brain fog & chest pain. Heart rate 29 bpm. RR 35. Skin is cool. Lactate 5. What'd you do?
Check EMR - on anything that could cause bradycardia (BB? CCB?)?
Give atropine 0.5mg-1mg q 3-5min for up to 3mg. If unsuccessful, consider epinephrine, isoprotenerol, transcutaneous pacing while arranging for transvenous pacing. Call cards!
EKG ST elevations in the lateral precordial leads, very high troponin, chest pain, diaphoresis, pain radiating to arm and jaw...what's the management for this patient?
Aspirin 325mg: chewable tablets
Plavix or another antiplatelet (ticagrelor or prasugrel)
Heparin gtt (although, evidence goes back and forth on true mortality benefit if not going to cath lab)
Call cards and panic!!!!
You have a patient that just underwent a CABG and AV replacement with a prosthetic heart valve. Which anticoagulant do you think they should receive?
Warfarin. The only anticoagulant that is approved now for prosthetic heart valves.
You have a patient with unfortunately terrible TTE windows and refuses TEE. You are concerned about severe mitral stenosis secondary to rheumatic heart disease. What's another modality you can use to evaluate his valves?
Cardiac CTA or MRI are acceptable answers
70yoF, metastatic breast cancer, admitted with presumed malignant right pleural effusion and failure to thrive. The next morning, blood pressure rapidly drops from 130/80 to 90/60. HR is NSR and 110bpm. Cardiac exam reveals distant heart sounds. Bedside ECHO reveals a rapidly enlarging pericardial effusion with leftward deviation of the interventricular septum. What is the next step?
There is some data that it is safer to drain the pleural effusion first, which can relieve the pericardial pressures too
How long does someone need to be anti-coagulated if >48 hours of atrial fibrillation before cardioverting?
At least 3 weeks uninterrupted or can do TEE and try to visualize Left atrial thrombus and DCCV.
58yo obese male with a 100 pack-year smoking history presents to the ED with complaints at least 2 hours of weakness, sub-sternal chest pressure, and shortness of breath that has been going on since he was woken up by his chest pressure. Initial EKG reveals normal sinus rhythm and minimal ST depressions. Initial troponin is normal. Troponin in 4 hours has risen by 60% without EKG changes and the patient noting worsening chest pressure. What is the diagnosis & how long do you have for a PCI if an obstruction is present?
NSTEMI
Up to 48 hours for NSTEMI.
"In high-risk patients with NSTE-ACS and no contraindications, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death from 6.5% to 4.9%."
https://www.ncbi.nlm.nih.gov/books/NBK513228/
A 65 year old male presents to the clinic with complaints of dyspnea, syncope, and angina. What is the most likely diagnosis and what do you expect to see on the ECHO?
*Bonus 100 Points: what are the indications for AV surgery?
Severe aortic stenosis (the triad)
Criteria
1.Aortic jet velocity >/= 4m/sec
2. Mean transvalvular pressure gradient >/= 40mmHg
3. Valve area usually </=1.0cm^2 but not required
**Bonus = indications for AV surgery is the above criteria plus symptoms, LVEF <50%, and/or undergoing other cardiac surgery (CABG).
What is the recommended device as primary prevention for a patient with a
- prior MI & LVEF <30%
- NYHA 2 or greater & LVEF <35% despite optimal GDMT
Implantable Cardioverter Defibrillator
What is the newly emerging pathophysiology of HFpEF?
Vascular endothelial cell dysfunction in the setting of pro-inflammatory conditions leading to systemic microvascular inflammation, oxidative stress, and impaired nitric-oxide signaling, leading to myocardial fibrosis/hypertrophy. Such as in metabolic syndrome, diabetes, obesity, lung disease...etc.
https://www.nejm.org/doi/full/10.1056/NEJMcp1511175
Hamo CE, DeJong C, Hartshorne-Evans N, Lund LH, Shah SJ, Solomon S, Lam CSP. Heart failure with preserved ejection fraction. Nat Rev Dis Primers. 2024 Aug 14;10(1):55. doi: 10.1038/s41572-024-00540-y. PMID: 39143132.
Nagueh SF. Heart failure with preserved ejection fraction: insights into diagnosis and pathophysiology. Cardiovasc Res. 2021 Mar 21;117(4):999-1014. doi: 10.1093/cvr/cvaa228. PMID: 32717061.
63yoM, obese, normal EF without wall motion abnormalities, normal global longitudinal strain, with a CAC score of 200 and CTA showing CAD in LAD, has developed persistent rate-controlled atrial fibrillation on metoprolol succinate 50mg over the past 3 months while on apixaban. How long do you have to get him into sinus rhythm and what intervention are you thinking?
Direct current cardioversion vs chemical cardioversion. You have one year to get the patient into NSR.
EAST-AFNET 4 trial
55 year old female, metastatic pancreatic cancer, admitted to medicine team 1 for malnutrition, hypernatremia, and intractable abdominal pain with severe nausea. The next day, her telemetry shows a sharp rise in HR up to 120, BP is 96/69, T 99.5, O2 down to 88% while on 6LNC and RR 25. You get rainbow labs, CXR, and EKG. CBC and BMP are similar to previous. VBG reveals lactate 3 and CO2 32. HS Troponin is elevated. BNP is elevated. Baseline is normal on admission. AP CXR shows clear lungs and mets on left ribs. EKG reveals sinus tachycardia. What will help you clutch the diagnosis?
Bedside ECHO or if miraculously stable enough -- CTPE
This patient is having massive PE. Consider thrombolytics. No absolute contraindications but mets may have invaded into a vessel somewhere.
Which patients require antibiotic prophylaxis for a dental surgery?
1. prosthetic heart valves
2. prior infective endocarditis
3. cardiac transplant recipients with valvulopathy
[The American College of Cardiology and American Heart Association]
What is the mechanism by which an ICDs treat tachyarrhythmias?
First, the device may try Anti-Tachycardia pacing and then if that is unsuccessful, it may defibrillate.