2. What is heart failure:
• Clinical syndrome that occurs in patients who, because of an
inherited or acquired abnormality of cardiac structure and/or
function, develop a constellation of clinical symptoms and signs
that lead to frequent hospitalizations, a poor quality of life, and
a shortened life expectancy.
(Harrison’s ref)
3. EPIDEMIOLOGY
• About 20 million people affectd worldwild
• In india prevelance ranges from 1.3 to 4.6million
• Sex ratio(1:1 ratio)
• mean age75
• black.>>white
• Mortality rates are less in AHF with preserved fuction than with
depressed EF(2.8 and 3.9% respectively).
4. TYPES OF HF
•Can be divided in to TWO categories on the basis of EF
•(1) depressed EF (commonly referred to as systolic
failure)
•EF<40%
•(2) preserved EF (commonly referred to as diastolic
failure)
•EF >50%
5. ACUTE HEART FAILURE SYNDROME
It includes
A. acute decompensated HF (ADHF)de novo
B. acute decompensation of chronic HF (ADCHF).
6. Continue…..
•ADHF: (de novo)
• (approximately 20% of all AHFS ).
• present for the first time with symptoms of HF.
• Mostly stage A and B.
•Worsening chronic HF OR ADCHF
• history of chronic HF (HF stage C) and present with an episode of
decompensation.
• Mostly stage C and D
14. ….. Index event causes structural / functional or both type of damage to heart
↓pumping capacity of heart
Comensatory mechanism activates
Adrenergic
RAS
Cytokine system activation
CO maintained
Patient remains asymptomatic for variable times
Sustained activation of these mechanism leads to secondary end organ damage and cardiac remodeling,↓compliance of heart
muscles, cardiac stiffness HENCE DECREASE CARDIAC OUTPUT AND DECOMPENSATION
Transition to asymptomatic to symptomatic heart failure
16. SYMPTOMS AND SIGNS
SYMPTOMS SIGN
TYPICAL MORE SPECIFIC
Breathlessness Elevated JVP
Orthopnoea Hepatojugular reflux
PND Third heart sound (gallop rhythm)
Reduced exercise tolerance Laterally displaced apical impulse
Fatigue , tiredness. increased time to recover after exercise Cardiac murmur
Ankle swelling
ESC Guidelines for the diagnosis and treatment
of acute and chronic heart failure 2012
17. LESS TYPICAL LESS SPECIFIC
Nocturnal cough Peripheral edema (ankle , sacral ,scrotal)
Wheezing Pulmonary crepitations
Wt gain>2 Kg/week Pleural effusion
Weight loss (In advanced HF) Tachycardia
Bloated feeling Irregular pulse
Loss of appetite Tachypnoea (>16/min)
Confusion (especially in the elderly) Hepatomegaly
Depression Ascites
Palpitations Tissue wasting ( cachexia)
Syncope
ESC Guidelines for the diagnosis and treatment
of acute and chronic heart failure 2012
18. STAGING OF HEART FAILURE
• Stage A: patient who is at high risk for developing HF but has
NO structural disorder of the heart;
•Stage B: patient with a structural disorder of the heart but who
has never developed symptoms.
•Stage C: patient with a structural heart disease with symptoms.
•Stage D: patient with end-stage disease who requires
specialized treatment strategies such as mechanical circulatory
support, continuous inotropic infusions, cardiac transplantation,
or hospital care
19. NYHA Functional Classification
CLASS SYMPTOMS
• Class I (mild) :No limitation of physical activity . .
• Class II (mild) : Slight limitation of physical activity Comfortable at rest, but
ordinary physical activity results in symptoms
• Class III (moderate) :Marked limitation of physical activity .Comfortable at rest,
but less than ordinary activity causes symptoms
• Class IV (severe) : Symptoms at rest If any physical activity is undertaken,
discomfort is increased
.
22. ACC/AHA guidelines for evidence based diagnosis and
management:
• Class I: Conditions for which there is evidence for and/or general agreement
that the procedure or treatment is useful and effective.
• Class II: Conditions for which there is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of a procedure or
treatment.
• Class IIa: The weight of evidence or opinion is in favor of procedure or
treatment.
• Class IIb: Usefulness/efficacy is less well established by evidence or opinion.
• Class III: Conditions for which there is evidence and/or general agreement
that procedure or treatment is not useful/effective and in some cases can be
harmful
23. LEVELS OF EVIDENCE
• Level A: Good scientific evidence suggests that benefits of the clinical
service outweigh the potential risks.
• Level B: At least fair scientific evidence suggests that benefits of the
clinical service outweighs the potential risks.
• Level C: At least fair scientific evidence suggests that there are
benefits provided by the clinical service, but the balance between
benefits and risks are too close for making general recommendations.
• Level D: At least fair scientific evidence suggests that the risks of the
clinical service outweighs potential benefits. Clinicians should not
routinely offer the service to asymptomatic patients.
24. Recommendations for the Evaluation of Patients With
HF
CLASS I
• history and physical examination. (Level of Evidence: C)
• assessment of patient’s ability to perform daily living activities. (Level of
Evidence: C)
• assessment of volume status. (Level of Evidence: C)
• CBC, urinalysis, s.electrolytes , RFTs, blood glucose, LFTs and TFTs. (Level of
Evidence: C)
• ECG and chest x ray (Level of Evidence: C)
• 2-D echo with Doppler or radionuclide ventriculography to assess left
ventricular systolic function. (Level of Evidence: C)
• Cardiac catheterization with coronary arteriography in agina patient. (Level of
Evidence: B)
25. CLASS IIa
• Cardiac catheterization with coronary arteriography in patients with chest pain who
have not had evaluation of their coronary anatomy. (Level of Evidence: C)
• Noninvasive imaging to detect ischemia and viability in patients with known coronary
artery disease and no angina who are being considered for revascularization. (Level of
Evidence: C)
• exercise testing with high-risk patients who are candidates for cardiac
transplantation. (Level of Evidence: B)
• Echo in asymptomatic 1* relatives of patients with idiopathic DCMP (Level of
Evidence: C)
• Repeat measurement of ejection fraction selected patients. (Level of Evidence: C)
• Screening for hemochromatosis. (Level of Evidence: C)
• S.ANA,RF, URINE VMA, and metanephrines in selected patients. (Level of Evidence: C)
26. CLASS IIb
•Noninvasive imaging to detect CAD in patients with LVD. (Level
of Evidence: C)
•Endomyocardial biopsy when an inflammatory or infiltrative
disorder of the heart is suspected. (Level of Evidence: C)
•HIV status. (Level of Evidence: C)
27. CLASS III
• Endomyocardial biopsy in the routine (Level of Evidence: C)
• Routine Holter monitoring or signal-averaged ECHO. (Level of
Evidence: C)
• Repeat coronary arteriography or noninvasive testing for ischemia in
patients for whom CAD has previously been excluded as the cause of
left ventricular dysfunction. (Level of Evidence: C)
• S. NE or ET. (Level of Evidence: C)
28. Assessment of LV Function
(2-D) echo/Doppler
1. LV size and function
2. valvular abnormality
3. RWMA .
(MRI)
1. gold standard for assessing LV mass and volumes.
2. determining the cause of HF(infiltrative disorders).
EF = SV
. EDV
• measure of contractility
30. BIOMARKERS
• Myocyte Injury
• Cardiac-specific troponins I and T
• Creatine kinase MB fraction
• Myocyte Stress
• Brain natriuretic peptide
• N-terminal pro-BNP
• Midregional fragment of proadrenomedullin
• ST2
• New Biomarkers
• Chromogranin
• Galectin 3
• Osteoprotegerin
• Adiponectin
• Growth differentiation factor 15
31. BNP
•B-type (BNP) and N-terminal pro-BNP used which are released
from the failing heart
•More ↑ HF with depressed EF.
•90% sensitive and 76% specific
normal <100pg/mL
Gray zone 100-400pg/mL
Consistent with HF >400pg/mL
32. LIMITATION
Levels also elevated in patients with
•ACS
•Hyperdynamic states
•cor pulmonale
•Impaired renal function
Levels decrease in obesity
BNP not recommended to guide therapy
34. Major
•PND or orthopnea
•↑JVP (OR CVP > 16 mm Hg)
•Rales or acute pulmonary edema
•Cardiomegaly
•Hepatojugular reflex
•Circulation time > 25 seconds
•Response to diuretic (weight loss > 4.5 kg in 5 days)
36. Flow chart for evaluation of heart failure
Suspected HF
Hx examination,ECG,cxray,routine
Inconsistent with HF Equivocal with HF Consistent with HF
Consider alt. diagnosis Natriuretic peptide,2d echo HF diagnosis made
Normal NP mild NP High NP
N echo Abn echo N echo Abn echo N echo Abn echo
HF
unlikely
HF likely HF possible but
consider another
diagnosis
HF likely HF possible but
consider another
diagnosis
HF
confirmed
40. CLASS I
• Control of hypertension (Level of Evidence: A)
• Treatment of lipid and thyroid disorders (Level of Evidence: B)
• Avoidance of high risk behaviors (Level of Evidence: C)
• ACE inhibitors IF h/O of cardiovascular risk factors. (Level of
Evidence: B)
• Control of ventricular rate in patients with supraventricular
tachyarrhythmias. (Level of Evidence: B)
• Periodic evaluation for signs and symptoms of HF. (Level of Evidence:
C)
41. CLASS IIa
• Noninvasive evaluation of left ventricular function in patients with a strong
family history of cardiomyopathy or in those receiving cardiotoxic
interventions. (Level of Evidence: C)
42. ClASS III
• Exercise . (Level of Evidence: C)
• ↓ dietary salt. (Level of Evidence: C)
• Routine testing to detect left ventricular dysfunction in patients without signs
or symptoms of HF or evidence of structural heart disease. (Level of Evidence:
C)
• nutritional supplements to prevent the development of structural heart
disease. (Level of Evidence: C)
44. CLASS I
• ACE inhibition if history of MI regardless of ejection fraction. (Level of Evidence:
A)
• ACE inhibition if reduced ejection fraction, regardless of MI. (Level of Evidence:
B)
• Beta-blockade in patients with a recent MI regardless of ejection fraction.
(Level of Evidence: A)
• Beta-blockade in patients with a reduced ejection fraction, regardless of MI.
(Level of Evidence: B)
• Valvulotomy or valvuloplasty for significant stenosis or regurgitation. (Level of
Evidence: B)
• Regular evaluation for signs and symptoms of HF. (Level of Evidence: C)
• Measures listed as class I recommendations for patients in stage A. (Levels of
Evidence: A, B, and C as appropriate).
45. CLASS IIb
• Long-term treatment with systemic vasodilators in patients with severe AR.
(Level of Evidence: B)
46. CLASS III
• digoxin in patients with LVD who are in sinus rhythm. (Level of Evidence: C)
• ↓ dietary salt . (Level of Evidence: C)
• Exercise . (Level of Evidence: C)
• nutritional supplements to treat structural heart disease or prevent the
development of symptoms of HF. (Level of Evidence: C)
48. CLASS I
• Diuretics if fluid retention. (Level of Evidence: A)
• ACE inhibition in all patients unless contraindicated. (Level of Evidence: A)
• Beta-adrenergic blockade in all stable patients unless contraindicated. Patients
should have no or minimal evidence of fluid retention and should not have
required treatment recently with an intravenous positive inotropic agent. (Level
of Evidence: A)
• Digitalis unless contraindicated. (Level of Evidence: A)
• Withdrawal of drugs haing adverse effect on clinical status of patients (e.g.,
nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most
calcium channel blocking drugs). (Level of Evidence: B)
• class I recommendations for patients in stages A and B (Levels of Evidence: A, B,
and C as appropriate).
49. CLASS IIa
• Spironolactone if class IV symptom (Level of Evidence: B)
• Exercise to improve clinical status in ambulatory patients. (Level of Evidence: A)
• Angiotensin receptor blockade in patients who are being treated with digitalis,
diuretics, and a beta-blocker and who cannot be given an ACE inhibitor because
of cough or angioedema. (Level of Evidence: A)
• A combination of hydralazine and a nitrate in patients who are being treated
with digitalis, diuretics, and a beta-blocker and who cannot be given an ACE
inhibitor because of hypotension or renal insufficiency. (Level of Evidence: B)
50. CLASS IIb
• Addition of an ARB to an ACE inhibitor. (Level of Evidence: B)
• Addition of a nitrate, alone or in combination with hydralazine, to
an ACE inhibitor in patients who are also being given digitalis,
diuretics, and a beta-blocker. (Level of Evidence:B)
51. CLASS III
• Long-term intermittent use of an infusion of a positive inotropic drug. (Level of
Evidence: C)
• Use of an ARBs before a beta-blocker in patients with HF who are taking an ACE
inhibitor. (Level of Evidence: A)
• CCB drug as a treatment for HF. (Level of Evidence: B)
• nutritional supplements (coenzyme Q10, carnitine, taurine, and antioxidants) or
hormonal therapies (growth hormone or thyroid hormone) for the treatment of
HF. (Level of Evidence: C)
53. CLASS I
• Meticulous identification and control of fluid retention. (Level of Evidence: B)
• Referral for cardiac transplantation in eligible patients. (Level of Evidence: B)
• Referral to an HF program with expertise in the management of refractory HF.
(Level of Evidence: A)
• Measures listed as class I recommendations for patients in stages A, B, and C.
(Levels of Evidence: A, B, and C as appropriate).
54. CLASS II b
• Pulmonary artery catheter placement to guide therapy in patients with
persistently severe symptoms. (Level of Evidence: C)
• Mitral valve repair or replacement for severe secondary mitral regurgitation.
(Level of Evidence: C)
• Continuous intravenous infusion of a positive inotropic agent for palliation of
symptoms. (Level of Evidence: C)
55. CLASS III
• Partial left ventriculectomy. (Level of Evidence: C)
• Routine intermittent infusions of positive inotropic agents. (Level of
Evidence: B)
56. Recommendations for Management of HF and
Preserved Systolic Function
• Class I
• BP control. (Level of Evidence: A)
• Control of ventricular rate in patients with atrial fibrillation. (Level of Evidence:
C)
• Diuretics to control pulmonary congestion and peripheral edema. (Level of
Evidence: C)
• Class IIa
• Coronary revascularization in patients with coronary artery disease in whom
symptomatic or demonstrable myocardial ischemia is judged to have an
adverse effect on diastolic function. (Level of Evidence: C)
57. CLASS IIb
• Restoration of sinus rhythm in patients with atrial fibrillation. (Level of
Evidence: C)
• Use of beta-adrenergic blocking agents, ACE inhibitors, angiotensin receptor
blockers, or calcium antagonists in patients with controlled hypertension to
minimize symptoms of HF. (Level of Evidence: C)
• Digitalis to minimize symptoms of HF. (Level of Evidence: C)
58. Management of Acute Heart Failure Syndromes
•PHASE I
•deals primarily with urgent treatment and stabilization, most
often occurring in the emergency department.
•Phase II
•consists of in-hospital management
•Phase III
•focuses on close monitoring during the early postdischarge
period
59. Phase I
• promptly recognize and treat life-threatening conditions and treat accordingly
• Measures are
• OXYGEN AND INTRAVENOUS MORPHINE
• NONINVASIVE VENTILATION
• DIURETICS
• VASODILATORS
• INOTROPES WITH VASODILATORY PROPERTIES
• VASOPRESSOR AGENTS
60. Phase II: Management in the Hospital
• TREATMENT OF CLINICAL AND HEMODYNAMIC CONGESTION.
• PERIPHERAL ULTRAFILTRATION: modality to remove sodium and water in
hospitalized HF patients who are refractory to pharmacologic therapy
• IMPLEMENTATION OF EVIDENCE-BASED INTERVENTIONS KNOWN TO IMPROVE
OUTCOMES IN HEART FAILURE
• REVASCULARIZATION: (CAD)
• RECOMMENDATIONS PRIOR TO DISCHARG
61. Phase III: Management After Discharge and
During the Vulnerable Phase
• follow-up is advised typically within 1 month after discharge.
• early follow-up with monitoring of BP, body weight, RFTs, BNP; and
finally to modify post discharge therapy if needed.
63. Neprilysin Inhibition — A Novel Therapy for Heart
Failure (LCZ696)PARADIGM-HF STUDY
• a dual inhibitor of angiotensin II receptor and neprilysin,
• ARNI [Angiotensin Receptor–Neprilysin Inhibitor VERSUS ACEI to Determine
Impact on Global Mortality and Morbidity in Heart Failure Trial),
• fixed-dose combination of valsartan and AHU-377 (a neprilysin
inhibitor prodrug) in a 1:1 ratio.
• dose - 200 mg BD.
• results in an increased concentration of natriuretic peptides.
• RAAS inhibition is likely to be augmented by the enhancement of natriuretic
peptide activity
• It was found superior to enalapril in reducing mortality
64. LCZ696 VERSUS ENALAPRIL
•LCZ696 is superior to enalapril because of having:
1. More compliance
2. Less adverse effects (10.7% vs. 12.3%)
3. More effective in lowering mean systolic BP .
4. More effective reduction in mortality and morbidity
published on August 30, 2014 in NEJM.org.
65. SOLUBLE GUANYLATE CYCLASE ACTIVATOR
• Cinaciguat:
• Causes smooth muscle vasodialation
• Under COMPOSE program PHASE II TRIAL
66. CHIMERIC NATRIURETIC PEPTIDES
• (CD-NP) : C-type natriuretic peptide (CNP) + dendroaspis NP (DNP).
• Causes less hypotension than BNPs
• Under trials
70. Actin
Tropomyosin
TnI
TnT
Ca2+
cTnC
Myosin head (S1 fragment)
Calcium sensitisation - enhanced systolic contraction of myofilaments - allows
normal diastolic relaxation (inotropic and lusitropic effect of Levosimendan)
LEVOSIMENDAN
A calcium sensitizer and ATP-dependent potassium channel
opener that has positive inotropic and vasodilatory effect.
71. Cardiac myocin activator
• omecamtiv mecarbil (CK1827452) -
• Concentration-dependent increase in SV and EF
72. ISTAROXIME: Na/K-ATPase INHIBITOR
• Na/K-ATPase inhibitor(unrelated to cardiac glycosides)
• Augments contractility by stimulating calcium entry via the sarcolemmal Na/Ca-
exchanger.
73. istaroxime VERSUS digoxin
Former is better because of
•wider margin of safety
•More rapid onset and effect.
•Istaroxime improve both systolic and diastolic function.
76. Conivaptan
• Dual antagonist demonstrating 10 times affinity for V1a (compared with V2
receptors).
• Advantages over V2-receptor antagonists -inhibition of V1a-mediated arterial
vasoconstriction and myocardial remodeling.
• Significant aquaresis while decreasing systemic vascular resistance and improving
systolic function.
• In patients with symptomatic systolic heart failure (NYHA class III )despite appropriate
therapy adding of conivaptan
• significantly increases urine output
• reduces PCWP and right atrial pressure
78. • Renally synthesized isoform of ANP – urodilatin
• Acts on inner medullary-collecting duct and binds to natriuretic peptide type A
receptors to promote sodium excretion
• Urodilatin is resistant to biological inactivation by neutral endopeptidase.
79. Ularitide (synthetic analogue of urodilatin) 24-h infusion in Diastolic HF causes
• Early significant decreases in PCWP
• Decreased N-terminal pro-BNP
• Decreased systemic vascular resistance
• Increased cardiac index
• Improved dyspnea
• Decreased need for diuretic and nitrate therapy
Improvements however, were transient, failing to persist throughout the 24-h
drug infusion.
Additional studies are required to establish safety as well as a therapeutic
benefit in terms of clinical end points.
80. Promotes glucose utilization through inhibition of carnitine
palmitoyl transferase-1 an enzyme critical to mitochondrial
uptake of FFAs (partial inhibition of fatty acid oxidation)
PERHEXILINE
81. •Perhexiline–
• treated ischemic and non-ischemic heart failure patients (LVEF <40%, and NYHA functional class
II or III symptoms) have-
Increase in left ventricular ejection fraction
Peak exercise oxygen consumption
Increased peak systolic velocity at rest and maximaLdobutamine stress by 15% and 25%.
• Adverse events - transient nausea and dizziness.
• Beneficial in patients with recurrent angina despite maximal medical management
• Other agents (optimizing myocyte energetics) include
• Trimetazidine
• ranolazine and
• etomoxir
83. CRT
indication:
• cardiac dys-synchrony (a QRS duration > 0.12 m sec),
• ejection fraction ≤35%,
• who are in sinus rhythm and are in NYHA functional Class III or Class IV in spite of
optimal medical therapy
• NYHA Class III-IV heart failure patients with an ejection fraction <35% who are in atrial
fibrillation or
• who have a frequent dependence on ventricular pacing
84. Implantable Cardioverter Defibrillator (ICD)
indication -
• For secondary prevention to prolong survival in patients with
History of cardiac arrest,
Ventricular fibrillation,
Hemodynamically destabilizing ventricular tachycardia
85. • Recommended for primary prevention of sudden cardiac death to reduce total mortality in
patients with
Non ischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-MI
An LVEF of 35% or less
NYHA functional Class II or III symptoms while receiving chronic optimal medical therapy
and
Who have reasonable expectation of survival, with a good functional status for longer
than 1 year.
86. patients with Ischemic cardiomyopathy who are at least 40 days
post -Ml
LVEF ≤30%,
NYHA functional Class I on chronic optimal medical therapy and
Have reasonable expectation of survival with a good functional
status for more than 1 year
87. CONTRAINDICATION
ICD therapy is not warranted in patients with
Refractory heart failure (stage D)
Concomitant diseases that would shorten their life
expectancy independent of heart failure
88. VENTRICULAR ASSIST DEVICES
DEFINITION :Mechanical devices which is used to replace or reproduce the pump function of
Left and / or Right ventricle.
VADs can replace
the left ventricle (LVAD)
the right ventricle (RVAD)
both ventricles (BIVAD)
BASIC PRINCIPLE:
VADs Improves arterial blood flow (end organ perfusion)
Improves ventricular unloading
89. INDICATION
• Bridge to recovery: the heart muscle is damaged and needs to
rest in order to heal.
• patients awaiting heart transplantation or in patients who have
rejected a transplanted heart
• when patient has contraindication to heart transplant
Side effect :
• Blood element destruction
• Thromboembolism
• Infection
92. INDICATION
(1) Cardiogenic shock : in cases where irreversibility of course is clear requiring
• Mechanical support or
• High-dose inotropic or
• Vasopressor drugs
(2) Chronic progressive, refractory, or stage D heart failure symptoms (despite
optimal therapy)
93. (3) Recurrent life-threatening arrhythmias despite maximal interventions, including
implanted defibrillators
(4) Refractory angina without potential for revascularization
(5) Adult patients with repaired congenital heart disease developing progressive heart
failure
94. CONTRAINDICATION
ABSOLUTE : Pulmonary arterial hypertension- pulmonary vascular
resistance >50mmHg systolic ( that cannot be reduced )
RELATIVE
1) Advanced age>70 years
2) Irreversible hepatic & renal disease
3) Addictions to alcohol or illicit drugs
95. 4) Social or psychiatric disorders
5)Active infection
6)Severe osteoporosis
7)Cachexia or obesity
8)Current smoker
96. Myocardial repair and regeneration
• Replacement of dead or dysfunctional cardiac myocytes through cell-based
therapies represents a logical and novel option for the treatment of HF.
• Stem and progenitor cells
Three types :
a) embryonic stem (ES) cells,
b) inducible pluripotent stem cells, and
c) adult stem cells
98. Routes of Application
• Intracoronary infusion
• Catheter-based intra myocardial needle injection
• Direct intra myocardial injection during surgery
• Coronary artery Infusion balloonBone
99.
100. DRAWBACK
• Cardiac tumor formation
• Cells migrate out of the vasculature into the surrounding tissue thus unperfused regions of
myocardium are targeted less efficiently
• Cell can obstruct the microcirculation after intra-arterial administration, leading to
embolic myocardial damage
• OTHER ROUTES
• Catheter based intra-myocardial injection
• Direct intra-myocardial injection
102. Gene Therapy
• Another emerging approach to the treatment of HF.
• adeno virus used
• Different techniques for in vivo cardiac gene transfer
A Coronary perfusion
B Intra-myocardial injection
C Pericardial injection
D Aortic clamping
E Cross-clamping of the aorta and pulmonary artery
107. • Istraroxime is a
A) adenosine receptor antagonist
B) Na/K-ATPase inhibitor
C) calcium sensitizer
D) carnitine palmitoyl transferase inhibitor
108. BNP level is increased in all except
A)Pulmonary HTN
B)Obesity
C)Renal failure
D)Pulmonary embolism
109. Levosimendan S/E are all except
A)Hypotention
B)Atrial fibrillation
C)Ventricular Tachycardia
D)Hyperkalemia
110. CRT recommened (class I indication) in pt having all of the following
except
A)Atrial fibrillation
B)widened QRS duration (>120 ms)
C)LVEF<35%
D)Sinus rhythum
111. Absolute C/I of heart transsplantation is
A) Pulmonary arterial hypertension
B) Advanced age>70 years
C) Irreversible hepatic disease
D)Severe osteoporosis
