Heart Failure - Cardiology Exam II

What do you do for patients with hypertension in Stage A?

Optimal control of BP

What do you do for patients with type 2 diabetes and CVD or high risk for CVD in stage A HF?

SGLT2 inhibitor

What do you do for patients with CVD in stage A HF?

Optimal management of CVD

What do you do for patients with exposure to cardiotoxic agents in stage A heart failure?

Multidisciplinary evaluation for management

What do you do for patients with first degree relatives with genetic or inherited cardiomyopathies? Keep in mind your patient is in Stage A HF.

Genetic screening and counseling

What do you do for patients at risk for HF in stage A?

Natriuretic peptide biomarker screening

Validated multivariable risk scores

What do you do for patients in stage B HF and have LVEF less then 40%?

Ace inhibitors

What do you do for patients with a recent MI and LVEF less then 40%? Stage B

ARB if ACEi intolerant

What do you do for patients with LVEF less then 40%? Stage B

Beta Blocker

What do you give patients with LVEF less then 30% with a greater than one year survival and greater then 40 day post MI? Stage B

Implantable Cardioverter-Defibrillator

What do you do for patients with nonischemic cardiomyopathy in stage B?

Genetic counseling and testing

A 60-year-old woman with type 2 diabetes, hypertension, and a family history of heart failure presents for her annual physical. She has no symptoms of dyspnea or fatigue. Her BP is 144/86 mmHg, and her A1c is 8.1%. She has no known CAD or heart failure.

What is the most appropriate therapy to prevent progression to clinical heart failure?

The patient is in Stage A, she has type 2 diabetes and is at a high risk for CVD. Her blood pressure is also high, we need to get that under control.

SGLT2i consider also adding antihypertensives such as ACEi if her blood pressure isn't reaching goal BP with SGLT2i alone.

A 55-year-old man with hypertension and obesity is newly diagnosed with cardiovascular disease after a stress test. He has no current symptoms of heart failure. BP is 138/88 mmHg. No history of MI. EF is normal.

What non-symptom-based step should be taken to reduce his heart failure risk?

Patient is Stage A - Risk for Heart Failure

This patient needs optimal management of CVD.

We can prescribe statin to lower hyperlipidemia we can also prescribe acei to lower bp. This patient may also benefit from lifestyle counseling

A 62-year-old woman had an MI 2 months ago and was recently found to have an EF of 30% on echocardiogram. She is asymptomatic, on lisinopril and carvedilol.

Which therapy should be considered at this stage?

This patient is in stage B - pre heart failure.

Since it has been over 40 days since her MI and she has HFrEF with EF 30% or less, she qualifies for Implantable cardioverter defibrillator (ICD)

A 58-year-old man with no HF symptoms is found to have an EF of 40% on echocardiogram. He has not had a recent MI, but has long-standing poorly controlled hypertension.

What medication class is appropriate to initiate at this stage?

The patient is in stage B, pre heart failure.

Since LVEF is 40% or less you can give ACE inhibitor + Beta Blocker

A 45-year-old woman has a first-degree relative who died of sudden cardiac death from hypertrophic cardiomyopathy. She has no symptoms herself but is anxious about her risk.

What is the most appropriate next step in evaluating her HF risk?

Genetic Screening and counseling

A 65-year-old man is 6 weeks post-MI. He is asymptomatic but an echocardiogram shows LVEF of 28%. He is on an ACEi and beta blocker.

What additional intervention should be considered to reduce his risk of sudden cardiac death?

Stage B with EF ≤30%, >40 days post-MI, no symptoms, and good life expectancy = ICD candidate

What constitutes HF with reduced EF?

HF with LVEF less then or equal to 40%

What constitutes mildly reduced EF?

HF with LVEF 41-49%

What constitutes HF with mildly reduced EF?

HF with LVEF 41-49%

What constitutes HF with improved EF?

HF with a baseline LVEF of less than or equal to 40% and a subsequent measurement showing EF greater then 40% and clinical improvement in heart failure symptoms

What is normal - HFpEF?

EF 50-70%

A 72-year-old man with a history of long-standing hypertension and COPD presents with progressive swelling in his legs, increasing abdominal fullness, and fatigue. He denies chest pain or shortness of breath at rest. On examination, he has jugular venous distension, 2+ pitting edema in both lower extremities, and a positive hepatojugular reflux. His liver is palpably enlarged, and there is shifting dullness on abdominal percussion. Lung exam is clear. Echocardiogram shows a normal left ventricular ejection fraction, but dilated right atrium and ventricle with elevated pulmonary artery pressures.

What is the most likely diagnosis?

Right sided heart failure.

A 72-year-old man with a history of ischemic cardiomyopathy and a previous myocardial infarction presents with worsening lower extremity swelling, abdominal bloating, and increased fatigue over the past month. He also reports shortness of breath with exertion and has been sleeping with three pillows at night due to dyspnea. He denies recent chest pain. Medications include lisinopril and furosemide.

On physical exam, blood pressure is 128/82 mmHg, pulse 90 bpm, and respiratory rate 18/min. You observe jugular venous distension, a positive hepatojugular reflux, bilateral pitting edema, and dullness to percussion at the lung bases. Cardiac auscultation reveals an S3 gallop. Echocardiogram reveals an LVEF of 30% with global hypokinesis. Right ventricular dilation is also noted.

What is the most likely explanation for this patient's right-sided heart failure?

Progressive pulmonary congestion and increased pulmonary pressures from left-sided systolic heart failure

A 64-year-old man presents with progressive dyspnea on exertion, orthopnea, and lower extremity swelling. Echo shows LVEF of 30%. He has NYHA Class II symptoms. He is not yet on any heart failure medications.

What is the best initial management approach for this patient?

Start GDMT: ARNI (or ACEi/ARB), beta blocker, MRA, SGLT2i, and loop diuretic as needed.

This is Stage C HFrEF.

Initiate guideline-directed medical therapy (GDMT) immediately to reduce symptoms, hospitalizations, and mortality.

A 70-year-old woman with NYHA Class III symptoms and an EF of 33% has sinus rhythm, a QRS duration of 160 ms, and left bundle branch block (LBBB) on ECG. Despite optimal GDMT for 3 months, she remains symptomatic.

What is the next best step?

Refer for Cardiac Resynchronization Therapy with Defibrillator (CRT-D)Explanation: Indications for CRT-D

NYHA II-IV, EF ≤35%, NSR, QRS ≥150 ms with LBBB, and on GDMT

A 68-year-old African American male with heart failure and EF of 35% has NYHA class III symptoms despite being on ARNI, beta blocker, MRA, and SGLT2i. His blood pressure is stable, and renal function is normal.

What therapy should be added to further improve mortality and symptoms?

Hydralazine + nitrates

ICD and CRT-D are additional options depending on rhythm, QRS, and EF

A 74-year-old man with ischemic cardiomyopathy and EF of 25% has had 3 hospitalizations for decompensated heart failure in the last 4 months. He is on maximum doses of ARNI, beta blocker, MRA, and SGLT2i. He continues to have dyspnea at rest. He is not eligible for transplant due to age and comorbidities.

What is the most appropriate next step in management?

Refer for palliative care and consider mechanical circulatory support (MCS)

This is Stage D refractory heart failure. If transplant is not an option, durable MCS and palliative care should be considered to improve quality of life and symptom control.

A 61-year-old man was previously diagnosed with HFrEF (EF 28%) and started on full GDMT. After 1 year, he reports feeling great, and a follow-up echocardiogram now shows an EF of 50%. He asks if he can stop his medications.

What is the most appropriate response?

Continue current heart failure medications

This is HF with improved EF (HFimpEF). Even though EF normalized, patients are at high risk of relapse if GDMT is stopped. Lifelong treatment is recommended.

A 71-year-old woman with HFrEF (EF 30%) and NYHA class III symptoms remains dyspneic despite 3 months of optimal GDMT. ECG shows sinus rhythm with a QRS duration of 158 ms and LBBB.

What is the most appropriate next intervention?

Cardiac resynchronization therapy with defibrillator (CRT-D)

Indicated in:

EF ≤35%

NYHA II-IV

NSR, QRS ≥150 ms, and LBBB

A 70-year-old African American man with EF of 32% and NYHA class III symptoms remains symptomatic despite ARNI, beta blocker, MRA, and SGLT2i. He is in sinus rhythm, QRS is 110 ms, and renal function is normal.

What additional therapy should be considered?

Hydralazine and nitrates

A 75-year-old man with HFrEF (EF 25%) has had 4 hospitalizations for acute decompensated heart failure in the past 6 months despite full GDMT. He remains symptomatic at rest. His comorbidities preclude transplant eligibility. He is open to procedures that might help him survive longer.

What is the most appropriate intervention?

Refer for durable mechanical circulatory support (MCS)

This is Stage D refractory HF. If transplant is not an option, consider LVAD or other MCS devices for survival extension.