Definitions
Define heart failure with preserved ejection fraction
HF with LVEF ≥50 percent and evidence of diastolic dysfunction.
Cardiac
•Coronary artery disease
•Hypertension
•Cardiomyopathy
•Valvular heart disease
•Arrhythmia
How do the stages proposed by American College of Cardiology Foundation and American Heart Association relate to the 4 classes of NYHA?
Guidelines are for diagnosis and treatment of heart failure, and are based on 4 progressive stages of heart failure. Progression from one stage to the next is associated with reduced 5 year survival and increased plasma BNP.
How does BNP or NT-proBNP measurement aide in management of CHF?
Useful in predicting response and progression of disease and survival
You have a 60 y old patient who smokes, with diabetes, hypertension, obesity, hyperlipidemia, and a normal physical exam. Loves to have whiskey shots each night as well.
What class of heart failure is this and how do you manage it?
Class A: Stress a heart-healthy lifestyle by Quit smoking, Quit alcohol, Exercise regularly
Prevent vascular and coronary artery disease with ACE-I or ARB in patients with hypertension or diabetes mellitus, and Statins in those with comorbid conditions or appropriate ASCVD
What class of medication is used with reduced ejection fraction CHF? What are some examples? What is benefit?
•Loop diuretics (furosemide, bumetanide, torsemide) are most commonly used.
•Diuretics do not provide mortality benefit; they provide symptomatic relief from congestion.
Define heart failure with reduced ejection fraction
HF with reduced EF (HFrEF) is defined as LVEF ≤40 percent with abnormalities in systolic function
Name 1 of the 2 infectious causes of heart failure
•Myocarditis
•Pericarditis
Who is included in stage A as proposed by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA)?
patients at risk of heart failure who are asymptomatic with no structural heart disease
Most dyspneic patients with HF have values above 400 pg/mL, while values below 100 pg/mL have a very high negative predictive value for HF as a cause of dyspnea
In the range between 100 and 400 pg/mL, plasma BNP concentrations are not very sensitive or specific for detecting or excluding HF.
Other diagnoses, such as pulmonary embolism, LV dysfunction without exacerbation, and cor pulmonale should also be considered in patients with plasma BNP concentrations in this range.
You have a 55 year old patient with hx of MI, coronary atherosclerosis, and an echo with LVH, EF of 47%, and mitral valve regurgitation. No complaints. Physical exam normal except murmur.
What class of CHF and what is management?
•Prevent heart failure symptoms, Prevent further cardiac remodeling
•ACE-I or ARB in patients with hypertension or diabetes mellitus and/or LV systolic dysfunction
•Beta Blocker therapy to patients with LV systolic dysfunction without contraindication
What medication reduces all cause mortality in CHF?
ACE-I and ARBS!
•No demonstrated difference amongst class or specific ACE-I/ARB if dosing is appropriate.
•Increase dose every 2 weeks until target or maximally tolerated dose is achieved.
DEFINE NYHA CLASS I and II
I.No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
II.Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.
Name the two endocrine causes of heart failure
Diabetes mellitus
Thyroid disease
Who is in Stage B as proposed by ACCF and AHA?
Those with structural heart disease who are symptomatic or have a history of heart failure symptoms.
includes NYHA Class I , in which there are no limitations on physical activity.
How does the body compensate for LV dysfunction initially?
What happens when this fails?
•Activation of the renin-angiotensin-aldosterone system (RAAS) and the adrenergic nervous system, which maintain cardiac output through increased retention of salt and water
•Increased myocardial contractility
•When these compensatory mechanism fail after repeat insults, LV remodeling occurs including myocyte hypertrophy which causes alterations in the contractile properties of the myocyte as well as reorganization of the extracellular matrix with dissolution of the organized structural collagen weave surrounding myocytes.
66 year old male with shortness of breath, and edema. On workup there is LVH on echo.
What class of CHF And What is Management?
•Control symptoms and prevent hospitalization with lifestyle modifications such as restricting fluid intake, restricting dietary sodium, monitoring daily weights.
•Diuresis to relive symptoms of congestion.
•Guideline driven management for comorbidities of coronary artery disease, hypertension, diabetes mellitus and other vascular or cardiac conditions.
What medication reduces all cause mortality in atrial fibrillation and reduced EF CHF?
•β-blockers reduce all-cause mortality by 30% and cardiovascular mortality by 34% among patients with atrial fibrillation and HFrEF-->carvedilol, sustained-release Metoprolol (succinate), Bisoprolol
•Cardioselective β-blockers (Metoprolol succinate and bisoprolol) are recommended in patients with reactive airway disease such as asthma.
DEFINE NYHA CLASS III
III. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.
Name the 2 collagen vascular diseases that can cause heart failure
SLE
Scleroderma
Who is included in Stage C of the ACCF and AHA guidelines?
Patients with structural heart disease who are symptomatic currently or have history of heart failure symptoms, and includes NYHA I, II, III, and IV
Patient with hx, PE, labs consistent with chf, what imaging would you obtain?
XRAY=new onset and acutely decompensated- heart size and pulmonary congestion,and look for cause
echo- look at LV size, function, wall thickness and motion, and valve function--> repeat if change in clinical status, recent clinical event, treatment that may affect EF, or if candidate for device
In Class C CHF patient , what would be medical therapy?
•Treat using NYHA Class and Guideline Directed Medical Therapy recommendations.
•Beta Blockers
•Aldosterone Antagonist
•ACE-I or ARB or ARNI
•Diuretics for fluid retention
•Digoxin
•Hydralazine and Isosorbide dinitrate
•Consider ICD
What newer class of drug reduces mortality and hospital readmissions? How do you initiate this drug in patient on ACE-I or ARB?
Angiotensin Receptor-Neprilysin Inhibitor (ARNI)
Hold the ACEI/ARB for 48 hours to avoid angioedema
•Caution in patients with: Low blood pressure (systolic blood pressure <80 mm Hg), Chronic Kidney Disease (creatinine >3.0 mg/dL), Hyperkalemia (potassium >5.5 mEq/L), Women of child-bearing age without contraception
DEFINE NYHA CLASS IV
IV. Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.
Give 5 causes of acute heart failure exacerbation
•Anemia,Myocardial infarction,Uncontrolled arrhythmias such as Atrial fibrillation,Fluid overload due to salt intake water intake or medication noncompliance, Hypo and hyper thyroid, Chronic kidney disease, renal failure, nephrotic syndrome, Sleep Apnea, Systemic infection
Who is included in Stage D of the ACCF and AHA GROUPING?
Patients with refractory heart failure, who required specialized interventions, includes NYHA IV
A patient presents with shortness of breath and edema, what is your diagnostic workup?
history and physical
cbc, ua, fasting lipids, liver function, lytes with ca and mag, bun, cr, glucose , tsh, eKG
Consider other testing for cause- rheum dz, amyloidosis, pheo, hiv, hemochromatosis
What is management of patient in class D CHF?
•Control symptoms and prevent hospitalization with lifestyle modifications: restricting fluid intake, restricting dietary sodium, monitoring daily weights, Establish end-of-life goals, Implantable cardiac devices,Revascularization or valvular surgery, May need to consider investigational studies, Start to consider transplant
What is the role of Mineralocorticoid Receptor Antagonists in Reduced EF CHF?
•Spironolactone and eplerenone contribute to renin angiotensin-aldosterone system blockade and have been shown to reduce mortality by up to 30%.
•They have also been shown to reduce heart failure hospitalizations by up to 40%.
•An MRA should be added to therapy after initiation of ACE inhibitor/ARB/ARNI and β-blocker in patients with LVEF of 35% or less and continued symptoms .
Watch Cr and K levels (avoid in Cr >2.5, K > 5)