Saturday, November 26, 2016

Step 2 CK: Mortality benefit in Congestive Heart Failure (CHF)

Another USMLE Step 2 CK important topic :D

Things that have a mortality benefit in CHF mnemonic: "ABCDES"
B: Beta blockers
CD: implantable Cardiac Defibirillator
E: Epelerenone
S: Spironolactone

Reading material from UpToDate! =)

1. ACE inhibitors improve survival in patients with left ventricular systolic dysfunction (left ventricular EF [LVEF] ≤40 percent), ranging from asymptomatic left ventricular dysfunction to moderate or severe HFrEF.

For patients with HFrEF (LVEF ≤40 percent) with current or prior symptoms of HF who are ACE inhibitor intolerant due to cough, use ARB.

Angiotensin II receptor blockers (ARBs) are an alternative to ACE inhibitors in patients who cannot tolerate ACE inhibitor for reasons other than renal dysfunction or hyperkalemia.

For patients who cannot take either an ACE inhibitor or ARB, use a combination of hydralazine plus isosorbide dinitrate as an alternative.

2. Beta blockers, particularly carvedilol, metoprolol succinate, and bisoprolol, improve overall and event-free survival in patients with NYHA class II to III HF and probably in class IV HF.

3. Spironolactone and eplerenone, which compete with aldosterone for the mineralocorticoid receptor, prolong survival in selected patients with HF as demonstrated in randomized controlled trials.

Eplerenone is associated with fewer endocrine side effects than spironolactone (Like gynecomastia!).

4. Because patients with heart failure and cardiomyopathy are at risk for malignant ventricular arrhythmias, and sudden cardiac death (SCD) is often the first presentation of a ventricular arrhythmia, there is a significant therapeutic role for the primary prevention of SCD. Randomized clinical trials have established a clear role for primary prevention implantable cardioverter-defibrillators (ICDs) in selected patients.

The single best indication for placement of an ICD in an adult is an ejection fraction less than 35%.

For patients with LVEF ≤35 percent, class III or IV heart failure, and a QRS duration ≥120 milliseconds, a combined CRT-D device (biventricular pacing combined with an ICD) should be used. The benefit appears to be greatest in patients with a left bundle branch block and QRS duration ≥150 milliseconds.

5. If you are really interested in newer therapies and research, read about:
Angiotensin receptor-neprilysin inhibitor (Sacubitril or LCZ696)
N-3 polyunsaturated fatty acids
Mechanism of Sacubitril: Inhibition of neprilysin (a neutral endopeptidase) raises levels of several endogenous vasoactive peptides, including natriuretic peptides, bradykinin, and adrenomedullin and may thus have beneficial hemodynamic effects in patients with HF.
Mechanism of Ivabradine: Ivabradine is a selective inhibitor of the sinoatrial pacemaker modulating “f-current” (If). It slows the sinus rate by prolonging the slow depolarization phase.)

For the USMLE Step 2 CK exam:
If the patient is fluid overloaded and symptomatic, give diuretics first. They provide symptomatic relief!
O2 + Diuretics + Nitrates + Morphine ALL provide symptomatic relief, nitrates are the fastest.
If the patient is still symptomatic, give dobutamine.
Digoxin, long term, is also used for symptomatic relief but has no mortality benefit.
Dobutamine - Acute exacerbation of CHF.
Digoxin - Refractory CHF for chronic use.

That's all!
I left my heart in cardiology <3


  1. Guess some ultra lucky guy in cardiology got a chance to examine it :D
    I think I can feel the level of endorphins
    Good luck :)


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