Classifications, Signs, and Symptoms
What is the LVEF cutoff that determines HFrEF and HFpEF?
HFrEF: LVEF </= 40%
HPpEF: LVEF >/= 50%
What is the best treatment for patients with HFmrEF?
GDMT!
There are no prospective RCTs for patients with HFmrEF
Appear to respond to medical therapies similarly with HFrEF
What is first line treatment in GDMT?
ARNI/ACE/ARB
Which type of diuretic is the strongest? What are some examples of these agents?
Loop Diuretics
Furosemide, Bumetanide, Torsemide
What stage and class of HF is this patient in?
HFrEF
Stage C
NYHA Class III
Select all that apply: Which of the following are symptoms of heart failure?
1. Paroxysmal nocturnal dyspnea (PND)
2. Productive cough
3. Orthopenea
4. Edema
5. Nocturia
1. Paroxysmal nocturnal dyspnea (PND)
2. Productive cough
3. Orthopenea
4. Edema
5. Nocturia
What is the best treatment for patients with HFimpEF?
GDMT!
Continue GDMT to prevent relapse of HF and LV dysfunction, even in patients who become asymptomatic
List the drug classes that are included in HFrEF GDMT?
ARNI/ACE/ARB
Evidence-based BB
MRA
SGLT2i
Diuretics PRN
What should be monitored with loop diuretics?
Electrolytes: K>4 and Mg>2
Weight
BP/HR
I/Os
SCr/BUN
What GDMT is recommended for her stage of HF?
ARNI > ACE/ARB
BB
MRA
SGLT2I
Which HF classification would you assign to the following patient based off of SYMPTOMS?
QA is a 68 YO female with PMH of HFrEF who presents to the cardiology clinic with increasing SOB over the past few months. On exam she has peripheral edema, a S3 gallop is heard, and JVP > 4 cm is present. She reports that she can no longer walk around the block or go up the stairs in her house without SOB or fatigue. She only feels better with rest.
NYHA III
How does the pathophysiology of HFpEF differ from HFrEF?
HFpEF: ventricle muscle stiffens and cannot relax enough to fully fill with blood. Diastolic dysfunction
HFrEF: ventricle muscle is weak and can't contract enough to pump blood. Systolic dysfunction.
What is the major contraindication when initiating Entresto?
Requires 36 hour washout if previously on ACE/ARB
A patient is currently on 20 mg IV, but the provider wants to switch them to torsemide. What is the equivalent PO torsemide dose?
Torsemide 20 mg PO
Provide a recommendation for diuretic therapy for this patient. What labs need to be monitored while admitted?
Furosemide 20 mg PO QD
BMP, I/Os, weight, BP/HR, renal function
Select all the apply: Which of the following factors can exacerbate HF?
1. Uncontrolled HTN
2. Pregnancy
3. Anemia
4. Emotional stress
5. Infection
1. Uncontrolled HTN
2. Pregnancy
3. Anemia
4. Emotional stress
5. Infection
What is the best strategy to managing HFpEF before initiating other agents?
Hint: what causes HFpEF?
What is the criteria to initiate a MRA in a patient?
Stage 3 HFrEF
EF < 35% AND SCr </= 2.5 mg/dL in men
EF </= 2 mg/dL in women
AND K+ < 5mmol/L
Diuretics must be added to what agents for GDMT and why?
Vasodilators: ARNI/ACE/ARB
Thiazide diuretics reduce blood volume by promoting sodium and water excretion
This volume loss activates compensatory mechanisms:RAAS and SNS
Increases vasoconstriction and worsens afterload
Which home medications should be discontinued?
Diltiazem
Isosorbide mononitrate - not working
Ibuprofen
Select all that apply: Which of the following medications can exacerbate HF?
1. Diltiazem
2. Vancomycin
3. Chemotherapy
4. Prednisone
5. Pioglitazone
1. Diltiazem
2. Vancomycin
3. Chemotherapy
4. Prednisone
5. Pioglitazone
What drug class has the highest level of recommendation to use daily in HFpEF to reduce hospitalizations?
SGLT2i
CV protective benefits
What 3 agents could be added onto GDMT for a patient with stage C HFrEF whose HF is progressing despite GDMT?
Ivabradine
Digoxin
Vericiguat
Our patient is reaching high levels of diuretic use with minimal response. They are currently receiving furosemide 80 mg PO BID. What are 3 next steps we could take in increase diuretic response?
1. Switch to another loop diuretic
2. Add metolazone to furosemide
3. Start IV furoesmide
List the HF GDMT recommended for this patient in order that they should be started
1. BB (to replace current antianginal therapy
2. ARNi
3. SGLT2I
4. MRA