Fam med case 31

What are the serum BNP levels that suggest heart failure?

< 100: No heart failure; >300: Mild heart failure; >600: Moderate heart failure; >900: Severe heart failure

What is the preferred treatment for systolic heart failure-- ACE/ARBs or loop diuretics?

ACE/ARBs are preferred. Loop diuretics help with symptomatic relief of fluid retention. Loop diuretics such as furosemide (Lasix) have a central role in the management of CHF to improve symptoms in patients with fluid retention. Fluid overload should be minimized so that other medications (such as ACE inhibitors and beta blockers) can work better. In patients with diastolic dysfunction(or Heart Failure with Preserved Ejection Fraction), excessive diuresis can worsen failure by decreasing left ventricular filling, so diuretics should be used with caution.

Which of the following is not a risk factor for CAD? A. Hypertension B. Female gender C. Smoking D. Diabetes

B has been selected by the expert. The correct answer is B. Hypertension, smoking, and diabetes (along with elevated lipid levels, obesity, and sedentary lifestyle) are modifiable risk factors for CAD. Non-modifiable risk factors include older age (men>45 and women >55), family history of CAD in a first-degree relative at a young age, and male gender.

Which of the following are major risk factors for atherosclerotic cardiovascular disease (ASCVD)? Select all that apply. A. Changes in vision B. Diabetes C. Elevated HDL cholesterol levels D. Father had a myocardial infarction at age 72 E. Female gender F. History of dizziness G. Hypertension H. Older age (men over 45, women over 55) I. Tobacco use

B, G, H, I have been selected by the expert.

What % risk is considered low vs high for CV risk?

less than 10%: Low; More than 80%: High

What is a key Radiographic Findings of Congestive Heart Failure?

Cardiomegaly, engorged vessels of the lungs, fluid in lungs (effusion)

What are 4 key modifiable risk factors factors for Coronary Artery Disease?

1. diabetes 2. high blood pressure, whether controlled or uncontrolled 3. current tobacco use 4. abnormal lipid levels, particularly high LDL-c and low HDL-c

What role does amlodipine play in management of heart failure?

Amlodipine has been demonstrated to increase peripheral edema and therefore may be avoided. In patients with angina however, the vasodilatory effects may improve symptoms.

What are 2 key modifiable risk factors factors for Coronary Artery Disease?

1. older age (men over 45, women over 55) 2. family history

A 56-year-old male presents for care at the ED complaining of dry cough for the past three days. He notes that this problem started a few days after his family's annual fish fry and barbecue and has been worsening since. He has no known past medical history but mentions that he has not seen a doctor in years. He notes that the cough is worse at night often waking him from sleep. He is unable to lie flat on his back and has started using three to four pillows to sleep comfortably. He also reports increased swelling in his legs that worsens throughout the day. He denies having any chest pain or palpitations and also does not believe he has had any sick contacts. He does not know his family history since he was adopted as a child. He has not had any fevers, sweats, or chills. On exam, you observe a tachypneic, obese man in mild distress. On chest auscultation, he has an S3, bilateral rales at the lung bases, and 2+ pitting edema in the lower legs bilaterally. What is the most likely diagnosis? A. New onset heart failure B. Pneumonia C. Sleep apnea D. Anxiety

A has been selected by the expert. The correct answer is A. The patient's description of the cough (worse at night, unable to lie flat, wakes from sleep), physical exam findings (obesity, rales in the lung bases, pitting edema), and history (started after a fish fry/BBQ) point to CHF as the most likely diagnosis. A lack of fever points away from pneumonia and a lack of description of snoring or pauses during sleep points away from sleep apnea. Anxiety would not cause the symptoms or physical exam findings described here.

Given her intermediate pre-test probability, which of the following tests have an established role in the diagnosis of CAD in Mrs. Hernandez? Select all that apply. A. Exercise treadmill testing (ETT) B. Stress echocardiography C. Coronary artery calcium scoring (CAC Score) D. CT angiography E. Nuclear stress testing (with either Thallium or Sestamibi)

A, B, E have been selected by the expert. **CAC scoring and CT angiography are newer testing modalities that are not widely used, each requiring an expensive multidetector-row CT scanner.

Select from the following list all the pharmacologic treatments that have a role in the management of Grade C systolic heart failure (i.e. structural heart disease with prior or current symptoms of HF). Select all that apply. A. Angiotensin converting enzyme (ACE) inhibitors B. Amlodipine (Norvasc) C. Angiotensin receptor blockers (ARBs) D. Digoxin E. Loop diuretics F. Metoprolol succinate (Toprol-XL) G. Pioglitazone (Actos) for improved glucose control in type II diabetes H. Eplerenone

A, C, D, E, F, H have been selected by the expert.

Mrs. Hernandez is a 66-year-old woman with poorly controlled diabetes and hypertension and recent non-adherence to medications who presents with a one-week history of progressive dyspnea on exertion, orthopnea, PND, and new bilateral lower extremity edema. She denies chest pain, palpitations, fever, chills, or cough. On exam, she is hypertensive and tachycardic with audible S3 and has bibasilar crackles with bilateral lower extremity edema to the ankle, but a negative hepatojugular reflux. What are the possible etiologies for new onset CHF? From the following, select the top four diagnoses on your differential for Mrs. Hernandez's presenting symptoms and signs on history and physical exam. A. Myocardial infarction (MI) B. Anemia C. Arrhythmia D. Ischemic cardiomyopathy E. Non-ischemic cardiomyopathy F. Pulmonary embolism G. Diastolic dysfunction due to uncontrolled hypertension H. Thyroid dysfunction I. Valvular disease

A, C, D, G have been selected by the expert. NOTE**Mrs. Hernandez may have CHF due to ischemic cardiomyopathy given her history of multiple CAD risk factors (age, poorly controlled hypertension and diabetes). Her CHF could be due to diastolic dysfunction only (especially considering her non-adherence to anti-hypertensives). She may have suffered a silent MI that precipitated the development of her symptoms, or she may be suffering from an intermittent cardiac arrhythmia that is impairing the pump function of her heart. NOTE**Arrhythmias cause heart failure by impeding the forward flow of blood through the heart. After CAD, the second most common cause of CHF is diastolic dysfunction, often due to uncontrolled hypertension.

What are the ACCF/AHA Stages of Heart failure?

A-D where A = At risk for HF but without structural heart disease or symptoms of HF; B=Structural heart disease present, but no signs or symptoms of HF; C=Structural heart disease with prior or current symptoms of HF; D=Refractory HF requiring specialized interventions

What is the role of ACEi's in systolic heart failure?

ACE inhibitors represent the mainstay of management of systolic heart failure. Multiple randomized trials have demonstrated reductions in mortality and hospitalizations among patients treated with these medications. They also have key roles in the management of both diabetes and coronary artery disease.

What is the role of ARBs in systolic heart failure and why would you use them over ACEi's?

ARBs have been demonstrated to improve mortality in patients with systolic failure. Given that they are more expensive than ACE inhibitors, they are typically reserved for patients who can't tolerate ACEs due to side effects such as cough. An ACE inhibitor should not be combined with an ARB, due to evidence of harms when they are combined.

What is Exercise treadmill testing (ETT)?

An initial diagnostic test for suspected CAD in patients with intermediate risk (10-80%). A major exception to this rule is for patients in whom the baseline EKG is not interpretable (which includes those with Wolff-Parkinson-White syndrome, a paced heart rhythm, a left bundle branch block, or more than 1 mm of ST depression at baseline). **NOTE: The negative predictive value of a normal ETT in a patient with reasonably high risk is not very good. For example, in a patient with a 50% pre-test probability, a negative ETT would lead to a post-test probability of 30%, which is still too high to effectively rule out CAD. Furthermore, some have argued that ETTs are less predictive of CAD in women compared to men.

A patient presents with new-onset 1 mm of ST-depression with T-wave inversions in V4, V5 and V6. Of these three choices, which is the best option for managing this patient's condition right now? Choose the single best answer. A. Directly admit Mrs. Hernandez to a hospital bed with telemetry. B. IV furosemide in the office and oral furosemide at home. C. Send Mrs Hernandez by ambulance to the emergency department for stabilization and likely admission.

Answer: C If your patient has new-onset CHF and you are unsure of the exact precipitating factors (particularly MI), it is safest to send the patient directly to the Emergency Department via an ambulance. Admitting your patient directly to the floor may lead to an unacceptable delay in care, as floor nurses have too many patients to manage the initial work-up and stabilization of an acutely ill patient.

Mr. Turner is a 60-year-old male with a past medical history of hypertension and diabetes who presents with fatigue. Upon further questioning, you realize that Mr. Turner does not have trouble falling asleep but has difficulty staying asleep because he often wakes up short of breath. He also notes that he has swelling in his ankles and feet. He denies having any chest pain or palpitations. On exam, you find that his heart has a regular rate and rhythm. You observe hepatojugular reflux and notice 2+ pitting edema in his legs bilaterally. What is the pathophysiology of his condition? A. Death of the myocardial cells due to lack of oxygen leading to dysfunction of the heart B. Decreased compliance of the ventricles leading to dysfunctional filling of the heart C. Decreased forward flow of blood from the heart due to dysfunction of the ventricles D. Dysfunction of the pacemaker cells of the atrium Submit

B has been selected by the expert. The correct answer is B. In CHF, decreased compliance of the ventricles leads to increased filling pressures, which leads to congestion. Answer A is describing the pathophysiology of a myocardial infarction, which may lead to CHF, but is not always the cause. Answer C is describing a situation (perhaps an arrhythmia) in which ventricular dysfunction causes abnormal flow of blood from the heart. Answer D is also describing a situation that would lead to an arrhythmia.

Which 3 beta blockers are especially helpful and have been proven to reduce mortality in heart failure?

Bisoprolol, carvedilol, metroprolol (sustained release). **Certain Beta-blockers such as metoprolol succinate have a central role in the management of both diastolic and systolic heart failure. Specifically, bisoprolol, carvedilol, and sustained-release metoprolol have been shown to reduce mortality in patients with NYHA Class II and III systolic heart failure (Grade C failure). Physicians need to have caution when starting beta-blocker therapy, since their negative inotropic and chronotropic effects can worsen failure initially. Generally, they should not be started in the setting of decompensated failure, and should be titrated up to maximal doses very slowly.

Which of the following interventions have been shown to have a role in the management of coronary artery disease? Select all that apply. A. Aim for a hemoglobin A1c (HgA1C) of 6% or less B. Continue treatment with angiotensin-converting enzyme (ACE) inhibitor C. Control her blood pressure (less than 140/90 mmHg for diabetics) D. Treat with aspirin to reduce cardiovascular mortality when appropriate E. Use a statin to reduce her risk F. Use ezetimibe to bring her LDL cholesterol to less than 70 mg/dL G. Weight loss to bring her body mass index to 24 kg/m2 as soon as possible H. Provide a pneumococcal vaccine every five years I. Add a beta-blocker even if her blood pressure is normal

B, C, D, E, I have been selected by the expert. NOTE ON A, A1C**Several guidelines recommend treatment to reduce HbA1c levels to less than 7%; however, clinical trials have not demonstrated reductions in cardiovascular events or mortality with intensive glucose control. NOTE ON G, BMI**Weight loss is generally beneficial for heart disease risk, however rapid changes and large fluctuations in weight have been associated with an increased risk. NOte ON I, BETA BLOCKERS**Multiple studies have demonstrated the effectiveness of beta-blockers in preventing second MIs among patients who have had one, and current guidelines recommend their use whether or not patients have hypertension. Beta blockers have been shown to decrease anginal symptoms, improve exercise tolerance, and decrease ST depressions in patients with stable CAD. They have only been shown to improve survival in patients with prior MI or HFrEF.

For what conditions is Brain natriuretic peptide (BNP) testing diagnostic?

Brain natriuretic peptide (BNP) testing can help differentiate heart failure from non-cardiac conditions in patients with dyspnea. A normal BNP effectively rules out CHF. However, an elevated BNP cannot distinguish diastolic from systolic heart failure. It is a substance elaborated in the ventricles in response to changes in pressure and myocyte stretching that occur when heart failure develops and worsens

What role do calcium channel blockers play in management of heart failure?

Calcium channel blockers do not have a major role in the management of heart failure

A 56-year-old male presents for care at the ED complaining of dry cough for the past three days. He notes that this problem started a few days after his family's annual fish fry and barbecue and has been worsening since. He has no known past medical history but mentions that he has not seen a doctor in years. He notes that the cough is worse at night often waking him from sleep. He is unable to lie flat on his back and has started using three to four pillows to sleep comfortably. He also reports increased swelling in his legs that worsens throughout the day. He denies having any chest pain or palpitations and also does not believe he has had any sick contacts. He does not know his family history since he was adopted as a child. He has not had any fevers, sweats, or chills. On exam, you observe a tachypneic, obese man in mild distress. On chest auscultation, he has an S3, bilateral rales at the lung bases, and 2+ pitting edema in the lower legs bilaterally. What diagnostic test would you perform first? A. Exercise stress test B. Pharmacologic stress test C. Echocardiogram D. EKG

D has been selected by the expert. The correct answer is D, an EKG can quickly help determine whether the patient is in sinus rhythm, whether there is ischemia or infarction, or whether there is Left Ventricular Hypertrophy. These findings may help you determine the etiology of this patient's CHF. Other tests (especially an echocardiogram) may be indicated at some point during the patient's work-up, but may not be appropriate first tests to order. Specifically, cardiac stress testing is more useful in ascertaining the diagnosis and prognosis of coronary artery disease than in congestive heart failure, although they are often a concurrent part of an extensive workup.

Mr. Jones is a 63-year-old male with no significant past medical history who presents with increased swelling in his legs and shortness of breath. He reports that he has smoked two packs per day for the past 20 years. He does not exercise regularly and notes that he has always been overweight. Mr. Jones notes that his maternal uncle died of a heart attack at age 43. He denies having any chest pain or palpitations and his exam is notable only for 2+ pitting edema in the lower extremities. His most recent labs show HDL of 50, LDL 101, and a blood glucose of 112. Which of the following risk factors has most likely contributed to Mr. Jones' problem? A. Diabetes B. Elevated HDL C. Heart attack in uncle D. Male gender

D has been selected by the expert. The correct answer is D, male gender is Mr Jones' main risk factors for CAD. With a blood glucose of 112, he is in the pre-diabetic range, but does not have a formal diagnosis of diabetes. His HDL is on the high side, but this is a protective factor. His uncle, though he did have a heart attack at a young age, is not a first-degree relative.

What is Diastolic heart failure (aka Heart failure with preserved EF) and in whom do we most commonly see it?

Diastolic heart failure occurs when signs and symptoms of heart failure are present, but left ventricular function is preserved (ejection fraction >45%). It is caused by impaired LV filling and abnormal LV relaxation and is most commonly related to uncontrolled hypertension. The incidence of diastolic heart failure increases with age and is more common in older women.

What role does digoxin play in systolic heart failure?

Digoxin provides SYMPTOM reduction. **Digoxin in randomized trials has demonstrated improved symptoms and reduced hospitalizations in patients with NYHA class II, III, and IV systolic failure. Classes II and III fall under the umbrella of Grade C in the newer grading system. Physicians need to be cautious about digoxin toxicity, particularly in patients with renal insufficiency.

What role does Eplerenone (a spirolactone) play in systolic heart failure?

Eplerenone reduced both the risk of death and the risk of hospitalization among patients with systolic heart failure whose ejection fraction was no more than 35% and who had mild symptoms (EMPHASIS-HF study). Other trials have demonstrated improvements in mortality for patients with NYHA class III and IV heart failure who are treated with spironolactone, but the efficacy of this particular potassium-sparing agent has not been demonstrated in NYHA Class II heart failure.

What is good about the use of ACEi's in diabetics with HTN?

Has renal protective effects in diabetics in addition to lowering blood pressure.

What diagnosis are you suspicious of when you observe this constellation of symptoms in a patient: 1. Crackles in the lung bases and dullness to percussion 2. Jugular venous distention 3. Point of maximal impulse (PMI) that is laterally displaced from the mid-clavicular line towards the axillary line 4. S3 from rapid ventricular filling or poor left ventricular functioning 5. Enlarged liver, hepato-jugular reflux (distention of the jugular vein upon manual pressure on the liver), and distention and shifting dullness indicating ascites 6. Lower extremity edema and weak pulses 7. Sacral edema

Heart Failure

What are Stress echocardiography and Nuclear stress testing used for and how do they compare in terms of efficacy with exercise treadmill testing?

Initial diagnostic tests for suspected CAD in patients with intermediate risk (10-80%). Both tests have specificities and particularly sensitivities that are better than those for ETT. The choice of which of these two tests to order depends heavily on regional practice patterns and test availability.

What is something to consider when using an oral glucose lowering agent like metformin in an obese patient?

Metformin is a good choice for an oral hypoglycemic given overweight status, although the use of insulin mitigates the metformin advantage of not causing weight gain.

What effect do natriuretic peptides have that make them beneficial to the failing heart?

Natriuretic peptides have been found to have beneficial effects on the failing heart. These include systemic and pulmonary vasodilation, neurohormonal suppression (renin-angiotensin system, norepinephrine, aldosterone, endothelin-1), promotion of natriuresis and diuresis, antiproliferative and antifibrotic effects. In addition BNP does not increase myocardial oxygen consumption, is not proarrhythmic and does not cause kaliuresis.

What is acute coronary syndrome?

The American Heart Association defines acute coronary syndrome as an umbrella term used to cover any group of clinical symptoms compatible with acute myocardial ischemia. This term includes unstable angina as well as both ST-segment elevation and non-ST-segment elevation myocardial infarction (STEMI and NSTEMI). Atypical symptoms of ACS are particularly common in diabetics, women, and the elderly.

What is the general rule of thumb for diastolic heart failure treatment?

The management of diastolic failure has been studied less than systolic failure. The general principles of treatment are to minimize fluid overload with diuretics, control BP, slow HR, and manage comorbid CHD. Many physicians start with either a beta-blocker or non-dihydropyridine calcium channel blocker (such as diltiazem) in order to slow down the heart rate, increase the ventricular filling time, and decrease the blood pressure.

In an echocardiogram, the left ventricular filling velocities (E/A ratio) can be measured. What does that indicate?

The ratio of left ventricular filling velocities (E/A ratio) is a marker of diastolic dysfunction. The E/A ratio is reduced when diastolic dysfunction is present.

What are the specific criteria the nuclear stress test can evaluate and how does it do that??

The test is useful to help determine: blood flow to heart muscle at rest and during exercise, extent of damage from an MI, cause of chest pain (angina), and safe level of exercise for the patient. It also can be used to help determine clinical management of the patient. MECHANISM: The patient either exercises on a treadmill or is given pharmaceutical stimulation. Imaging (with injected thallium or technitium) is done during exercize and at rest. The patient is then placed in a gamma camera scanner which produces images which are then analyzed by computer. Areas of abnormal perfusion or myocardial damage are pictured in the images.

What is non-ischemic cardiomyopathy?

There are four main types, including dilated, hypertrophic, arrhythmogenic right ventricular dysplasia (ARVD) and restrictive cardiomyopathy. It should be considered a possible diagnosis with new onset CHF.

What role do thiazolidinediones (DMII drugs) play in management of heart failure?

Thiazolidinediones such as rosiglitazone (Avandia) and pioglitazone (Actos) have been demonstrated to worsen heart failure. They are contraindicated in this setting.

What is an echocardiogram?

Two-dimensional echocardiography measures the size of the chambers, the thickness of the walls, size of the cavity, and looks at movement of heart structures. Doppler assesses blood flow (direction and velocity) through the valves and chambers.

What is a point of consideration with thiazides in treatment of HTN in diabetics?

Works synergistically with the ACE inhibitor and therefore an effective addition for blood pressure control, though it can also increase blood sugar.