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Questions and Answers
What percentage of the adult population in developed countries is affected by heart failure?
What percentage of the adult population in developed countries is affected by heart failure?
Which condition is NOT typically considered a common cause of heart failure?
Which condition is NOT typically considered a common cause of heart failure?
What is the estimated yearly mortality rate for patients with stable heart failure?
What is the estimated yearly mortality rate for patients with stable heart failure?
Among the listed conditions, which is NOT considered a factor contributing to diseased myocardium?
Among the listed conditions, which is NOT considered a factor contributing to diseased myocardium?
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Patients admitted to the hospital with acute heart failure face what approximate mortality rate per year?
Patients admitted to the hospital with acute heart failure face what approximate mortality rate per year?
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Which of the following is classified under abnormal loading conditions that can lead to heart failure?
Which of the following is classified under abnormal loading conditions that can lead to heart failure?
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What is a common infectious cause of myocarditis that can lead to heart failure?
What is a common infectious cause of myocarditis that can lead to heart failure?
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In which demographic does the prevalence of heart failure significantly increase?
In which demographic does the prevalence of heart failure significantly increase?
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Which congenital defect is characterized by a reversed arrangement of the great arteries?
Which congenital defect is characterized by a reversed arrangement of the great arteries?
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What initial diagnostic test is used to measure natriuretic peptides in suspected heart failure patients?
What initial diagnostic test is used to measure natriuretic peptides in suspected heart failure patients?
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Which investigation is NOT essential for the diagnosis of chronic heart failure?
Which investigation is NOT essential for the diagnosis of chronic heart failure?
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Which of the following is a type of arrhythmia characterized by rapid electrical impulses in the atria?
Which of the following is a type of arrhythmia characterized by rapid electrical impulses in the atria?
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In the context of heart failure, what role do neurohormonal mechanisms play?
In the context of heart failure, what role do neurohormonal mechanisms play?
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Which of the following signs is an indicator of potential heart failure?
Which of the following signs is an indicator of potential heart failure?
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What is the purpose of echocardiography in the context of heart failure?
What is the purpose of echocardiography in the context of heart failure?
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Which type of heart failure is characterized by preserved ejection fraction?
Which type of heart failure is characterized by preserved ejection fraction?
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What is the primary purpose of using mineralocorticoid receptor antagonists (MRAs) in patients with HFrEF?
What is the primary purpose of using mineralocorticoid receptor antagonists (MRAs) in patients with HFrEF?
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When using MRAs, what should be monitored closely in patients?
When using MRAs, what should be monitored closely in patients?
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What is sacubitril's mechanism of action as part of the ARNI?
What is sacubitril's mechanism of action as part of the ARNI?
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Which class of medication is recommended to enhance natriuresis in patients with HFrEF?
Which class of medication is recommended to enhance natriuresis in patients with HFrEF?
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What is the goal of diuretic therapy in the management of HFrEF?
What is the goal of diuretic therapy in the management of HFrEF?
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In which situation are angiotensin II type 1 receptor blockers (ARBs) recommended?
In which situation are angiotensin II type 1 receptor blockers (ARBs) recommended?
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How do loop diuretics differ from thiazide diuretics in their action?
How do loop diuretics differ from thiazide diuretics in their action?
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Why might SGLT2 inhibitors reduce the need for loop diuretics in HFrEF treatment?
Why might SGLT2 inhibitors reduce the need for loop diuretics in HFrEF treatment?
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What is the purpose of short-term mechanical circulatory support (MCS)?
What is the purpose of short-term mechanical circulatory support (MCS)?
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Which of the following conditions is NOT a trigger for acute heart failure?
Which of the following conditions is NOT a trigger for acute heart failure?
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What is a primary recommendation for patients being considered for long-term MCS?
What is a primary recommendation for patients being considered for long-term MCS?
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Which surgical treatment is appropriate for aortic stenosis?
Which surgical treatment is appropriate for aortic stenosis?
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In patients with advanced heart failure, what is a significant condition that may prevent cardiac transplantation?
In patients with advanced heart failure, what is a significant condition that may prevent cardiac transplantation?
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Which of the following substances can exacerbate acute heart failure?
Which of the following substances can exacerbate acute heart failure?
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What defines acute heart failure (AHF)?
What defines acute heart failure (AHF)?
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Which of the following factors is associated with the increased risk of acute heart failure due to metabolic/hormonal derangements?
Which of the following factors is associated with the increased risk of acute heart failure due to metabolic/hormonal derangements?
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What is the primary indication for Ivabradine in heart failure patients?
What is the primary indication for Ivabradine in heart failure patients?
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In which patients is the combination of hydralazine and isosorbide dinitrate indicated?
In which patients is the combination of hydralazine and isosorbide dinitrate indicated?
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Which of the following treatments is not recommended for symptomatic patients with HFrEF?
Which of the following treatments is not recommended for symptomatic patients with HFrEF?
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Which criterion must be met for a patient to be eligible for cardiac resynchronization therapy (CRT)?
Which criterion must be met for a patient to be eligible for cardiac resynchronization therapy (CRT)?
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What role does digoxin play in the treatment of heart failure?
What role does digoxin play in the treatment of heart failure?
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What is the purpose of the implantable cardioverter-defibrillator (ICD) in heart failure management?
What is the purpose of the implantable cardioverter-defibrillator (ICD) in heart failure management?
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Which of the following is a common contraindication for using Ivabradine?
Which of the following is a common contraindication for using Ivabradine?
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What is the primary benefit of short-term mechanical circulatory support (MCS)?
What is the primary benefit of short-term mechanical circulatory support (MCS)?
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Study Notes
Heart Failure Epidemiology and Prognosis
- Heart failure (HF) affects approximately 1-2% of the adult population in developed countries.
- Prevalence increases with age, reaching around 10% for individuals aged 70 years or older.
- HF carries a poor prognosis with high rates of hospitalization and mortality.
- Mortality rates range from 6-7% per year for patients with stable HF to 25% or more per year for those hospitalized with acute HF.
Heart Failure Etiology
-
Diseased Myocardium:
- Coronary artery disease (CAD) is a primary cause.
-
Cardiomyopathy:
- Dilated
- Hypertrophic
- Restrictive
- Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
- Peripartum
- Takotsubo
- Toxin-induced (alcohol, cocaine, iron, copper)
-
Endomyocardial Disease:
- Endomyocardial fibrosis/eosinophilia
- Radiotherapy
- Carcinoid
-
Drug-Induced:
- Anthracyclines
- Trastuzumab
- Vascular endothelial growth factor inhibitors
- Proteasome inhibitors
- Antidepressants
- Antiarrhythmics
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Anesthetics
-
Infectious:
- Viral myocarditis
- Bacterial infections
- Spirochetes
- Fungi
- Protozoa
- Parasites (Chagas disease)
- Rickettsiae
-
Noninfectious:
- Giant cell myocarditis
- Autoimmune diseases (e.g., Graves' disease, rheumatoid arthritis, connective tissue disorders, systemic lupus erythematosus)
- Hypersensitivity and eosinophilic myocarditis
-
Infiltration:
- Malignancy
- Amyloidosis
- Sarcoidosis
-
Storage Diseases:
- Glycogen storage diseases
- Hemochromatosis
- Fabry disease
-
Endocrine Disorders:
- Thyroid disease
- Parathyroid disease
- Acromegaly
- Hypercalcemia
- Addison's disease
- Diabetes
- Metabolic Syndrome
- Phaeochromocytoma
-
Nutritional Disease:
- Thiamine, vitamin B1, and selenium deficiencies
-
Neuromuscular Disease:
- Friedreich's ataxia
- Muscular dystrophy
-
Abnormal Loading Conditions:
- Hypertension
-
Valvular Diseases:
- Primary valve disease
- Secondary valve disease
- Congenital valve disease
-
Congenital Defects:
- Shunt defects
- Congenitally corrected/repaired transposition of great arteries
- Repaired tetralogy of Fallot
- Ebstein's anomaly
-
Pericardial Disease:
- Pericardial effusion
- Constrictive pericarditis
- Infiltrative pericarditis
-
Arrhythmias:
- Atrial tachyarrhythmia
- Ventricular tachyarrhythmia
Heart Failure Pathophysiology
- Compensatory mechanisms attempt to maintain adequate cardiac function.
- Important adaptations include the Neurohormonal derangement, as shown in Figure 1.
Chronic Heart Failure Diagnosis
- Presence of symptoms and/or signs of HF
-
Essential Initial Investigations:
-
Laboratory Tests:
- Serum urea, electrolytes, creatinine, full blood count, liver and thyroid function tests, transferrin saturation, and ferritin levels.
- Natriuretic Peptides (NPs): BNP and NT-proBNP can be used for initial diagnosis, especially when echocardiography is not immediately available.
- 12-lead Electrocardiogram (ECG): Used to assess heart rhythm, heart rate, QRS morphology, and duration, as well as other abnormalities.
- Chest Radiography (X-ray): Useful for detecting alternative pulmonary or other diseases contributing to dyspnea, identifying pulmonary congestion/edema, and aiding in diagnosis of acute HF particularly.
-
Echocardiography: Used to assess myocardial structure and function, aiding in diagnosis of:
- Heart failure with reduced ejection fraction (HFrEF)
- Heart failure with mildly reduced ejection fraction (HFmrEF)
- Heart failure with preserved ejection fraction (HFpEF)
-
Laboratory Tests:
- Investigations to Determine the Underlying Etiology of Chronic Heart Failure
Chronic Heart Failure Treatment
-
Mineralocorticoid Receptor Antagonists (MRA): Spironolactone or eplerenone are recommended with an ACE-I and beta-blocker in patients with HFrEF to reduce mortality and hospitalization risk.
- Caution: MRAs should be used with caution in patients with impaired renal function and potassium levels ˃5.0 mmol/L.
-
Angiotensin Receptor-Neprilysin Inhibitor(ARNI): Sacubitril/valsartan fixed-dose combination is recommended as a replacement for ACE-I. This combination further reduces HF hospitalization and death risk in patients with symptomatic HFrEF despite optimal treatment with ACE-I, ARB, beta-blocker, and MRA.
- Mechanism: Sacubitril (neprilysin inhibitor) slows degradation of NPs, bradykinin, and other peptides.
-
Sodium-Glucose Co-transporter 2 Inhibitors (SGLT2 Inhibitor): Dapagliflozin or empagliflozin are recommended for patients with HFrEF to reduce hospitalization and death risk.
- Mechanism: SGLT2 inhibitors enhance natriuresis and stimulate osmotic diuresis by inhibiting SGLT2 in the kidney's proximal tubule.
Other Treatments Recommended in Selected Symtpomatic Patients with HFrEF
-
Diuretics: Aim is to achieve and maintain euvolemia with the lowest possible dose.
- Loop diuretics: More intense and shorter diuresis than thiazides.
- Combination of loop and thiazide diuretics: Can be used for resistant edema.
- Angiotensin II Type 1 Receptor Blockers (ARBs): Recommended for patients who cannot tolerate ACE-I or ARNI due to side effects.
-
If-Channel Inhibitor: Ivabradine is considered to reduce HF hospitalization and cardiovascular death in symptomatic patients with LVEF ≤35%, in sinus rhythm, resting heart rate 70 bpm despite optimal beta-blocker treatment, or those who cannot tolerate or have contraindications for beta-blockers.
- Mechanism: Ivabradine slows heart rate by inhibiting the If channel in the sinus node and should only be used in patients with sinus rhythm.
- Combination of Hydralazine and Isosorbide Dinitrate: Fixed-dose combination given to self-identified black patients with HFrEF and NYHA Class III-IV despite optimal treatment with ACE-I, beta-blocker, and MRA to reduce HF hospitalization and death risk.
-
Digoxin: May be considered in symptomatic patients in sinus rhythm despite optimal treatment with ACE-I (or ARB), beta-blocker, and MRA to reduce hospitalization risk.
- May also be helpful in patients with symptomatic HF and atrial fibrillation (AF).
Treatments Not Recommended in Symptomatic Patients with HFrEF
- Thiazolidinediones (glitazones)
- NSAIDs or COX-2 inhibitors
- Non-dihydropyridine calcium channel blockers (e.g., diltiazem or verapamil)
- Addition of an ARB to the combination of an ACE-I and an MRA.
Device Treatment in Patients with HFrEF
- Implantable Cardioverter-Defibrillator (ICD): Recommended to reduce sudden death risk in patients who have recovered from a ventricular arrhythmia causing hemodynamic instability.
- Cardiac Resynchronization Therapy (CRT): Recommended for symptomatic patients with HF in sinus rhythm, QRS duration 130 msec, LBBB QRS morphology, and LVEF ≤35% despite optimal medical therapy.
-
Short-Term Mechanical Circulatory Support (MCS): Indicated to reverse critical end-organ hypoperfusion and hypoxia during cardiogenic shock.
- Used as a bridge to decision (BTD), bridge to recovery (BTR), or bridge to bridge (BTB) for either long-term MCS or urgent heart transplantation.
- Long-Term MCS: Recommended for patients with advanced HF despite optimal medical or device therapy. Patients must have good compliance, appropriate capacity for device handling, and psychosocial support.
Surgical Treatment in Patients with HFrEF
- Aortic valve replacement: Surgical (SAVR) or transcatheter (TAVI) for aortic stenosis.
- TEE mitral valve repair: For mitral regurgitation.
- Coronary artery bypass graft (CABG): For coronary artery disease.
- Cardiac transplantation: Recommended for patients with advanced HF refractory to medical or device therapy and without absolute contraindications.
Acute Heart Failure (AHF)
- AHF refers to rapid or gradual onset of symptoms and/or signs of HF, severe enough to require urgent medical attention.
- Triggers for AHF:
- Acute coronary syndrome (ACS)
- Excessive rise in blood pressure.
- Infection (e.g., pneumonia, infective endocarditis, sepsis).
- Tachyarrhythmias (atrial fibrillation, ventricular tachycardia).
- Non-adherence to diet/drug therapy.
- Toxic substances (alcohol, recreational drugs).
- Drugs (e.g., NSAIDs, corticosteroids, negative inotropic substances, cardiotoxic chemotherapeutics).
- Exacerbation of chronic obstructive pulmonary disease (COPD).
- Pulmonary embolism (PE).
- Surgery and perioperative complications.
- Increased sympathetic drive, stress-related cardiomyopathy.
- Metabolic/hormonal derangements (e.g., thyroid dysfunction, diabetic ketoacidosis, adrenal dysfunction, pregnancy and peripartum related abnormalities).
- Cerebrovascular insult.
- Acute mechanical cause:
- Myocardial rupture complicating ACS (free wall rupture, ventricular septal defect, acute mitral regurgitation).
- Chest trauma or cardiac intervention.
- Acute native or prosthetic valve incompetence secondary to endocarditis.
- Aortic dissection or thrombosis.
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Description
Explore the critical aspects of heart failure, including its prevalence, age-related risks, and poor prognosis. Understand the various causes of heart failure, ranging from coronary artery disease to drug-induced factors among others. This quiz covers essential information for anyone studying cardiac health.
