** Heart Failure - high yield
Universal Definition and Classification of Heart Failure
Heart Failure is a clinical syndrome with current or prior symptoms and/or signs caused by structural and/or functional cardiac abnormality
Corroborate by at least 1 of the following:
high natriuretic peptide levels
objective evidence of cardiogenic pulmonary or systemic congestion
HF stages have been revised to emphasize the symptomatic nature of HF as a clinical syndrome:
At risk for HF (Stage A): Patients at risk of HF but w/o current or prior symptoms or signs of HF and w/o structural cardiac changes or high biomarkers of heart disease
Pre‐HF (new) (Stage B): Patients w/o current or prior symptoms or signs of HF w/ evidence: structural heart disease, abnormal cardiac function, high antriuretic peptide or troponin
Symptomatic HF (Stage C): Patients w/ current or prior symptoms or signs of HF caused by a structural and/or functional cardiac abnormality
Advanced HF (Stage D): Severe symptoms and/or signs of HF at rest, recurrent hospitalization despite GDMT, refractory or intolerant to GDMT, requiring advanced therapies, mechanical circulatory support, or palliative car
Classification by Ejection Fraction
HF w/ reduced EF (HFrEF) is HF with LVEF < 40%
HF w/ mildly reduced EF (HFmrEF) is HF with LVEF 41-49%
HF w/ preserved EF (HFpEF) is HF w/ LVEF > 50%
HF w/ improved EF (HFimpEF) is HF w/ baseline LVEF of <40% , a 10-point increase from baseline LVEF, and a 2nd LVEF of > 40%
** Acute decompensated heart failure - key point
What are the three most common loop diuretics for acute decompensated heart failure? Furosemide, Torsemide, Bumetanide
Different strategies to monitor short-term responsiveness to IV loop diuretics
Urine output (goal > 150 ml/hr)
Urine sodium (goal > 50-70 mEq/L)
If the goal urine output is < 150 ml/hr or the spot urine sodium is < 50 mEq/L two hours after the initial IV diuretic dose, then the dose should be doubled and the parameters re-checked.
When the goals are met, the same dose can be administered every 6-12 hours until volume overload resolves.
** Hypertension - key point
How to manage hypertension
If a patient presents with an elevated blood pressure of 120-129/<80
the best approach is to recommend non-pharmacologic therapy and re-assess in 3-6 months.
If a patient presents with stage 1 hypertension (130-139/80-89)
1st consider whether the patient has clinical ASCVD (i.e., stroke, CAD, PAD) or has more than a 10% 10-year risk of heart disease or stroke using the ASCVD risk calculator.
If the patient does not meet these criteria, there is no indication to start antihypertensive medication. Reassess the patient's blood pressure in 3-6 months.
If the patient has clinical ASCVD or a 10-year risk of more than 10%, consider treatment.
1st-line: thiazide diuretics, CCBs, ACE-inhibitors or ARBs.
Beta-blockers are NOT first line (in most cases)
If a patient presents with stage 2 hypertension BP >/= 140/90
Recommendations include: non-pharmacologic therapy and 2 drug combination are preferred.
Is it better to titrate to a max dose of 1 BP medication or use multiple BP medications at a lower dose?
Multiple BP meds at a lower dose shown to effectively lower BP with fewer side effects
Resistant Hypertension
If the clinic blood pressure (BP) exceeds 130/80 and the patient takes a minimum of three blood pressure medications, including a diuretic at the maximum or maximum tolerated doses, it is advisable to assess the patient for resistant hypertension.
Step 1 in management
To ensure accurate assessment, it is crucial to rule out pseudo-resistance by confirming medication adherence and conducting a 24-hour ambulatory blood pressure (BP) monitoring or home BP monitoring, in order to exclude the white coat effect.
Ensure that the patient is receiving a three-drug regimen, including a RAS blocker (renin-angiotensin system blocker), a calcium channel blocker (CCB), and a diuretic, at the maximum or maximally tolerated dose.
Step 2 in management
Please substitute the diuretic with chlorthalidone, as it has a longer half-life and can be administered to patients with chronic kidney disease (CKD), as demonstrated in the CLICK trial.
Step 3 in management
Add a mineralocorticoid-receptor antagonist, such as spironolactone or eplerenone.