Classification
What ejection fraction is associated with HFprEF?
EF > 50%
What is the most common cause of HFpEF?
Hypertensive LV hypertrophy
Which drug class can reduce both morbidity and mortality in heart failure patients?
ACEI and ARB
What ejection fraction is associated with HFrEF?
EF < 40%
What is a common biomarker that helps in the diagnosis and prognostication of patients with heart failure? Which range has the highest likelihood of HF?
proBNP (secreted from the ventricles in response to ventricular overload)
>400: 95% likelihood of CHF
Which drug class reduces mortality rates in heart failure patients who've had a prior MI? When should it be started?
B-blockers
* euvolemic and stable
What EF is associated with HFpEF, borderline?
EF 41-49%
What would you hear on auscultation in a patient with HF?
S3/S4 heart sounds
An S3 gallop indicates rapid ventricular filling, while an S4 gallop indicates ventricular hypertrophy (reduced compliance).
Which drug class would you start in a patient with chronic symptomatic HFrEF (class III) who can tolerate an ACEi or ARB?
ARNI = ARB + neprilysin inhibitor
What are the components of NYHA Functional Classification I-II?
I: no limitation of physical activity
II: slight limitation of physical activity, comfortable at rest
What is one therapeutic precaution to keep in mind when treating a patient with HFpEF?
Diuresis due to being preload dependent
What is the MOA of SGLT2 inhibitors in the setting of heart failure?
triggers osmotic diuresis, natriuresis and decreases arterial pressure and stiffness
A 68-year-old man comes to the emergency department because of a 1-week history of worsening bouts of shortness of breath at night. He has had a cough for 1 month occasionally productive of frothy sputum. He has type 2 diabetes mellitus and long-standing hypertension. Two years ago, he was diagnosed with Paget disease of bone during a routine health maintenance examination. He has smoked a pack of cigarettes daily for 20 years. His temperature is 37.0°C (98.6°F), pulse is 110/min, respirations are 25/min, and blood pressure is 145/98 mm Hg. Current medications include metformin, alendronate, hydrochlorothiazide, and enalapril. Physical examination shows bibasilar crackles. Cardiac examination shows a dull, low-pitched sound during late diastole that is best heard at the apex. There is no jugular venous distention or peripheral edema.
Echocardiography shows a left ventricular ejection fraction of 55%. Which of the following is the most likely underlying cause of this patient’s current condition?
A) Destruction of alveolar walls
B) Diuretic overdose
C) Myxomatous degeneration
D) Impaired myocardial relaxation
D) Chronic uncontrolled hypertension is the most common cause of HFpEF. Chronic hypertension increases the afterload against which the left ventricle (LV) contracts. As a compensatory mechanism, the myocardium undergoes concentric hypertrophy to maintain cardiac output. Over time, the compensatory response of LV thickening is associated with the maladaptive change of interstitial myocardial fibrosis, which leads to an increase in LV stiffness and impaired myocardial relaxation. As a result, patients develop an increase in left ventricular filling pressures and reduced ventricular filling with normal ventricular contraction (i.e., diastolic heart failure).
What are the components of the NYHA Functional Classification III-IV?
III: Marked limitation of physical activity, comfortable at rest but less than ordinary activities causes symptoms of heart failure
IV: Unable to carry out any physical activity without symptoms of HF, or symptoms of HF at rest
Which diabetic drug is contraindicated in patients with heart failure and why?
TZDs: increase renal sodium and water reabsorption, leading to fluid retention
Which drug class is contraindicated in patients with heart failure and can cause adverse cardiovascular events? What is the MOA behind the contraindication?
Non dihydropyridine calcium channel blockers: verapamil and diltiazem
MOA: negative inotropic effect
A 69-year-old man comes to the physician with a 9-month history of worsening shortness of breath on exertion and need to urinate at night. He occasionally has palpitations but does not have chest pain. The patient had a transient ischemic attack 5 years ago for which he underwent right-sided carotid endarterectomy. He has hypertension and type 2 diabetes mellitus. Current medications include metformin, lisinopril, aspirin, and simvastatin. He appears fatigued. His pulse is 61/min, respirations are 25/min, and blood pressure is 120/75 mmHg. Pulse oximetry shows an oxygen saturation of 96%. Examination shows cold extremities. There are no murmurs or rubs on cardiac auscultation. Fine, bilateral crackles are heard at the lung bases. There is 2+ lower extremity edema. An ECG shows sinus rhythm and T wave inversions in leads V1 to V4. Which of the following agents is most likely to improve the patient's long-term survival?
A) Eplerenone
B) Amlodipine
C) Ivabradine
D) Dobutamine
E) Furosemide
A) Aldosterone receptor antagonists such as eplerenone are associated with improved survivalin patients with CHF NYHA class II to IV, LVEF < 35%, and/or after myocardial infarction (likely present in this post-TIA patient with an ECGshowing T wave inversions in leads V1 to V4). The mechanism by which an aldosterone antagonistdecreases mortality is likely due to the prevention of cardiac myocyte remodeling after a MI