Heart Failure Case discussions

Heart failure 2016guidelines

Each of the following statements regarding therapy for heart failure with reduced ejection fraction is correct EXCEPT:

A. Angiotensin-converting enzyme (ACE) inhibitors improve survival in heart failure more than the combination of hydralazine plus isosorbide dinitrate

B. Digoxin therapy decreases hospitalizations in patients with chronic heart failure

C. ARNI are indicated as first line treatment in chronic heart failure to reduce morbidity and mortality.

D. Spironolactone reduces mortality in patients with class III to IV heart failure symptoms

E. The aldosterone antagonist eplerenone reduces mortality in patients with class II to III heart failure

A 56-year-old man with ischemic cardiomyopathy and an ejection fraction (EF) of 25% comes for an outpatient clinic visit complaining of dyspnea and fatigue with minimal exertion (New York Heart Association class III). His medical regimen includes lisinopril, carvedilol, eplerenone, and furosemide, as well as aspirin and atorvastatin. Resting electrocardiography reveals sinus rhythm with a QRS complex duration of 160 milliseconds and left bundle branch morphology. He is being considered for implantation of a biventricular pacemaker. Which of the following statements about cardiac resynchronization therapy (CRT) is correct?

A. CRT reduces mortality in patients with class III or IV heart failure only when combined with an implantable cardioverter-defibrillator (ICD)B. A patient with right bundle branch block is as likely to respond to CRT as a patient with left bundle branch block and similar QRS durationC. CRT improves myocardial performance without increasing myocardial oxygen consumptionD. Echocardiographic measures of dyssynchrony are part of the standard selection criteria for CRT

A 72-year-old diabetic man with long-standing dilated cardiomyopathy presents for evaluation of dyspnea at rest. He has been hospitalized three times within the past year for decompensated heart failure and recently underwent a cardiopulmonary exercise test showing a peak oxygen consumption of 10 mL/kg/min during maximal effort. His past medical history is notable for prior placement of an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death, and prostatectomy 1 year earlier for adenocarcinoma. For the last 6 months he has been intolerant of beta blockers because of hypotension. He has a supportive family, adheres to therapeutic recommendations, and does not use tobacco.

Physical examination reveals a blood pressure of 92/78 mm Hg, resting heart rate of 106 beats/min, body mass index of 26 kg/m2, jugular venous pressure of 10 cm H2O, clear lungs, an S3 apical gallop, and cool extremities but no evidence of hepatomegaly or ascites. Laboratory studies are notable for the following: sodium, 126 mEq/L; potassium, 4.6 mEq/L; blood urea nitrogen, 34 mg/dL; and creatinine 2.5 mg/dL. Liver function tests and the complete blood cell count are normal. Electrocardiography shows sinus tachycardia and LBBB with QRS complex duration of 120 milliseconds. Echocardiography demonstrates a dilated left ventricle with an ejection fraction of 20%, mild mitral regurgitation, and normal right ventricular size and function.

Which of the following is the most appropriate consideration for this patient?A. Cardiac resynchronization therapyB. Urgent listing for cardiac transplantationC. Listing for combined heart-kidney transplantationD. Implantation of a left ventricular assist deviceE. Implantation of a biventricular assist device

All of the following statements regarding therapy for patients with heart failure are true EXCEPT

A. ACE inhibitors are indicated in patients with heart failure and left ventricular dysfunction irrespective of the functional New York Heart Association classification

B. Digoxin has been shown to decrease heart failure hospitalizations

C. Spironolactone has been shown to decrease mortality in patients with class III to IV symptoms

D. Regular physical exercise does not reduce mortality in patients with chronic heart failure

E. Empagliflozin is the first choice OHG in diabetics

What you need to know ?

EF ?Clinical diagnosis

What you need to know ?

– Which is a class I recommendation in heart failure?

– Echocradiography

– CMR

– BNP

– Coronary angiography

What you need to know ?

Empagliflozin ?

EMPA-REG OUTCOME® trial

What you need to know ?

ARNI “Enteresto” Paradigm HF Concerns ?

What you need to know?

ACEIS or ARBs ? N3 PUFA Glitazones.. HISDN

What you need to know?

Mortality benefit in HF ?Emmmm….

What you need to know?

CRT indication??

LBBB

Non LBBB

Pacing indication

What you need to know?

HFpEF ?S/S, LA volume, LV mass,

E/E’, BNPTTT

What you need to know?

Antihypertensive choice ?? AF in chronic heart failure

What you need to know?

– LVAD?– 2 months

– 25%, 12 ml/kg/min

– 3 in 12

– Inotrope dependence

– Hypoperfusion. (20 mmHg, 80mmHg, 2 L/min/m2)

– RV ?