ReAdY 4 bOaRD?
A 73-year-old female presents with complaints of dyspnea and decreasing exercise tolerance over the past few months. She says she has to prop herself up on two pillows in order to breathe better. She also complains of palpitations, even at rest. She has long-standing hypertension, but has not taken any antihypertensive medications for several years. She has no history of ischemic heart disease. On examination her blood pressure is 155/92 mm Hg, her pulse rate is 108 beats/min and irregular, and her lungs have bibasilar crackles. An EKG reveals atrial fibrillation, but no changes of acute ischemia.
Which one of the following would be most useful for determining her initial treatment? (check one)
A. A chest radiograph
B. Cardiac catheterization
C. Echocardiography
D. A TSH level
E. A D-dimer level
Answer: C (echo)
4 pillars of GDMT?
ARNI/ACEi, beta blocker, MRA, SGLT2i
A patient presents with new dyspnea, edema, and suspected heart failure. No prior workup. What diagnostic would you get?
What is transthoracic echocardiogram (TTE)?
These anti-inflammatory drugs worsen HF by reducing renal perfusion and promoting sodium retention.
What are NSAIDs?
Which one of the following classes of anti-diabetic medications also improves outcomes in patients with heart failure?
a.SGLT2 inhibitors
b.Biguanides (metformin)
c.Insulin
d.DPP4 inhibitors
A. SGLT2 inhibitors
Which one of the following is most likely to be seen with diastolic dysfunction? (check one)
A. A dialated left ventricle
B. A preserved ejection fraction
C. Aortic insufficiency
D. Pericardial effusion
answer: B. A preserved ejection fraction
Heart failure due to diastolic dysfunction occurs in the older population. The criteria for diastolic heart
failure include symptoms and signs consistent with heart failure (including dyspnea), a nondilated left
ventricle with a preserved ejection fraction (³50%), and evidence of structural heart disease such as
diastolic dysfunction on echocardiography (SOR C).
3 Beta blockers proven to reduce mortality and hospitalization
bisoprolol, carvedilol BID or sustained released metoprolol succinate
A patient with HF has history of MI and regional wall motion abnormalities on echo. Cause of HF?
What is ischemic cardiomyopathy?
sodium restriction cut off?
2300mg /day
You recently added spironolactone to your patient’s drug regimen for heart failure. Which of the following lab values should be carefully monitored?
a.Calcium
b.Magnesium
c.Chloride
d.Potassium
D.Potassium
A 55-year-old male has New York Heart Association Class II heart failure. He becomes dyspneic with significant exertion. His only medication is an ACE inhibitor. Which one of the following additional medications has been shown to improve longevity in this situation? (check one)
A. Digitalis
B. Warfarin (Coumadin)
C. β-Blockers
D. Amiodarone (Cordarone)
E. Non-dihydropyridine calcium channel blockers
Answer: C. β-Blockers
- reduce mortality in symptomatic patients with heart failure (SOR A).
Not digoxin
- trend toward increased mortality among women with heart failure who were taking digoxin
- but digoxin levels were higher among women than men.
Not warfarin
- no evidence
Not amiodarone
- no evidence in pt without A-fib
Not Calcium channel blockers
- cause peripheral vasodilation, decreased heart rate, decreased cardiac contractility, and decreased cardiac conduction.
Before starting sacubitril/valsartan, this washout period is required after stopping an ACE inhibitor. How long is the wash out period?
What is 36 hours?
This condition should be suspected in HF patients with thickened myocardium and low-voltage ECG.
What is cardiac amyloidosis?
This electrolyte abnormality is a major reason to discontinue MRAs due to risk of fatal arrhythmia.
BONUS if you get the exact cut off
What is hyperkalemia (K⁺ >5.5)?
A 61-year-old woman has been admitted to your inpatient service with a new diagnosis of heart failure. Which one of her medications increases risk of fluid overload and should be discontinued?
a.Pioglitazone
b.Gabapentin
c.Diltiazem
d.Desipramine
A.Pioglitazone
A 68-year-old African-American male with a history of hypertension and heart failure continues to have shortness of breath and fatigue after walking only one block. He has normal breath sounds, no murmur, and no edema on examination. His current medications include furosemide (Lasix), 20 mg/day, and metoprolol extended-release (Toprol-XL), 50 mg/day. He previously took lisinopril (Prinivil, Zestril), but it was discontinued because of angioedema. A recent echocardiogram showed an ejection fraction of 35%.
Which one of the following would be most likely to improve both symptoms and survival in this patient?
(check one)
A. Valsartan (Diovan)
B. Metolazone (Zaroxolyn)
C. Digoxin
D. Verapamil (Calan, Isoptin)
E. Isosorbide/hydralazine (BiDil)
Answer: E. Isosorbide/hydralazine
- systolic heart failure, the usual management
1: ACE inhibitor and a ß-blocker
- Since this patient had angioedema with an ACE inhibitor, an angiotensin receptor blocker may cause this side effect
2. combination of direct-acting vasodilators such as isorbide and hydralazine
- For patients who cannot tolerate an ACE inhibitor, especially African-Americans,
Metolazone (thiazide-like diuretic)
- not necessary unless the patient has volume overload that does not respond to increased doses of furosemide.
Digoxin (inhibiting the Na+/K+-ATPase, cardiac glycosides)
- may improve symptoms, but has not been shown to increase survival
Verapamil (CCB)
- negatively ionotropic; bad
A patient with HFrEF on max beta blocker has HR 78 in sinus rhythm, already on GMDT. What additional med can they get?
What is ivabradine?
This imaging modality is most useful when HF etiology is unclear and infiltrative disease is suspected.
What is cardiac MRI?
EF cut off to consider ICD or CRT?
LVEF ≤35%
Which one of the following is the most common cause of heart failure with preserved ejection fraction (HFpEF)?
a.Amyloidosis
b.Aortic valvular disease
c.Dilated cardiomyopathy
d.Hypertensive left ventricular hypertrophy
D. Hypertensive Left Ventricular Hypertrophy
A 74-year-old female presents with a several-month history of gradually increasing dyspnea on exertion, swelling in her feet and lower legs, and having to sleep sitting up due to increased shortness of breath while lying flat. She has been healthy otherwise, with no known heart disease or hypertension, and she has no significant family history of heart disease. An echocardiogram shows an ejection fraction of 20% and a thin-walled, diffusely enlarged left ventricle.
Which one of the following is the most likely diagnosis?
(check one)
A. Dilated cardiomyopathy
B. Hypertrophic cardiomyopathy
C. Restrictive cardiomyopathy
D. Arrhythmogenic right ventricular cardiomyopathy
E. Athlete's heart
Answer: A. Dilated cardiomyopathy
This combination therapy is specifically recommended in African American patients with NYHA III–IV HFrEF on optimal therapy.
What is hydralazine plus isosorbide dinitrate?
HFpEF diagnosis with TTE
Diastolic Function and Filling Pressures
E/e′ ≥ __#_?
15
Loop diuretic that is safe to be used for those who have sulfa allergies?
What is Ethacrynic acid.
Which one of the following is true regarding brain natriuretic peptide (BNP)?
a. BNP is released from the atria in response to volume overload.
b. BNP levels reflect degree of ventricular hypertrophy.
c. BNP undergoes hepatic metabolism, so levels are unaffected by renal dysfunction.
d. BNP is released from the ventricles in response to ventricular stretch.
D. BNP is released from the ventricles in response to ventricular stretch.