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Cardiology High-Yield

** 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.

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