The document discusses guidelines and considerations for treatment of heart failure. It presents several cases and questions regarding therapies like ACE inhibitors, ARNI, aldosterone antagonists, cardiac resynchronization therapy, implantable devices, and transplantation. Key factors discussed include ejection fraction, NYHA class, QRS duration, exercise capacity, and guideline recommendations for optimizing treatment based on a patient's characteristics and symptoms.

1. Heart failure
2016
guidelines

2.  Each of the following statements regarding therapy for heart failure
with reduced ejection fraction is correct EXCEPT:
A. Angiotensin-converting enzyme (ACE) inhibitors improve survival in heart failure
more than the combination of hydralazine plus isosorbide dinitrate
B. Digoxin therapy decreases hospitalizations in patients with chronic heart failure
C. ARNI are indicated as first line treatment in chronic heart failure to reduce morbidity
and mortality.
D. Spironolactone reduces mortality in patients with class III to IV heart failure
symptoms
E. The aldosterone antagonist eplerenone reduces mortality in patients with class II to
III heart failure

3.  A 56-year-old man with ischemic cardiomyopathy and an ejection
fraction (EF) of 25% comes for an outpatient clinic visit
complaining of dyspnea and fatigue with minimal exertion (New
York Heart Association class III). His medical regimen includes
lisinopril, carvedilol, eplerenone, and furosemide, as well as
aspirin and atorvastatin. Resting electrocardiography reveals sinus
rhythm with a QRS complex duration of 160 milliseconds and left
bundle branch morphology. He is being considered for
implantation of a biventricular pacemaker. Which of the following
statements about cardiac resynchronization therapy (CRT) is
correct?

4. A. CRT reduces mortality in patients with class III or IV heart failure
only when combined with an implantable cardioverter-defibrillator
(ICD)
B. A patient with right bundle branch block is as likely to respond to
CRT as a patient with left bundle branch block and similar QRS
duration
C. CRT improves myocardial performance without increasing
myocardial oxygen consumption
D. Echocardiographic measures of dyssynchrony are part of the
standard selection criteria for CRT

5.  A 72-year-old diabetic man with long-standing dilated
cardiomyopathy presents for evaluation of dyspnea at rest. He has
been hospitalized three times within the past year for
decompensated heart failure and recently underwent a
cardiopulmonary exercise test showing a peak oxygen consumption
of 10 mL/kg/min during maximal effort. His past medical history is
notable for prior placement of an implantable cardioverter-
defibrillator (ICD) for primary prevention of sudden cardiac death,
and prostatectomy 1 year earlier for adenocarcinoma. For the last 6
months he has been intolerant of beta blockers because of
hypotension. He has a supportive family, adheres to therapeutic
recommendations, and does not use tobacco.

6. Physical examination reveals a blood pressure of 92/78 mm Hg,
resting heart rate of 106 beats/min, body mass index of 26
kg/m2, jugular venous pressure of 10 cm H2O, clear lungs, an S3
apical gallop, and cool extremities but no evidence of
hepatomegaly or ascites. Laboratory studies are notable for the
following: sodium, 126 mEq/L; potassium, 4.6 mEq/L; blood urea
nitrogen, 34 mg/dL; and creatinine 2.5 mg/dL. Liver function tests
and the complete blood cell count are normal.
Electrocardiography shows sinus tachycardia and LBBB with QRS
complex duration of 120 milliseconds. Echocardiography
demonstrates a dilated left ventricle with an ejection fraction of
20%, mild mitral regurgitation, and normal right ventricular size
and function.

7. Which of the following is the most appropriate consideration for this
patient?
A. Cardiac resynchronization therapy
B. Urgent listing for cardiac transplantation
C. Listing for combined heart-kidney transplantation
D. Implantation of a left ventricular assist device
E. Implantation of a biventricular assist device

8. All of the following statements regarding therapy for
patients with heart failure are true EXCEPT
A. ACE inhibitors are indicated in patients with heart failure and left
ventricular dysfunction irrespective of the functional New York Heart
Association classification
B. Digoxin has been shown to decrease heart failure hospitalizations
C. Spironolactone has been shown to decrease mortality in patients
with class III to IV symptoms
D. Regular physical exercise does not reduce mortality in patients
with chronic heart failure
E. Empagliflozin is the first choice OHG in diabetics

9. What you need to know ?
EF ?Clinical
diagnosis

10. What you need to know ?
– Which is a class I recommendation in heart failure?
– Echocradiography
– CMR
– BNP
– Coronary angiography

11. What you need to know ?
Empagliflozin ?
EMPA-REG OUTCOME® trial

12. What you need to know ?
 ARNI “Enteresto”
 Paradigm HF
 Concerns ?

13. What you need to know?
 ACEIS or ARBs ?
 N3 PUFA
 Glitazones..
 HISDN

14. What you need to know?
Mortality benefit in HF ?
Emmmm….

15. What you need to know?
CRT indication??
LBBB
Non LBBB
Pacing indication

16. What you need to know?
HFpEF ?
S/S, LA volume, LV mass,
E/E’, BNP
TTT

17. What you need to know?
 Antihypertensive choice ??
 AF in chronic heart failure

18. What you need to know?
– LVAD?
– 2 months
– 25%, 12 ml/kg/min
– 3 in 12
– Inotrope dependence
– Hypoperfusion. (20 mmHg, 80mmHg, 2 L/min/m2)
– RV ?