2 - Acute Heart Failure

Question 1

How’s the overall prognosis for HF? (In case you’ve forgotten)

Answer 1

Shitty.

50% of pts dead within 5 yrs

Question 2

Define HF

Answer 2

Complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood

Question 3

Briefly describe natriuretic peptides

Answer 3

Produce vasodilation, natriuresis, decreased levels of endothelin, and inhibition of the RAAS and sympathetic nervous system

ANP - made in atria
BNP - secreted mainly from ventricle
CNP - localized in the endothelium

Question 4

Pts with acute-on-chronic HF tend to present with:

Answer 4

Gradual sxs and weight gain over days to weeks

Question 5

High output HF is distinguishable by:

Answer 5

A relatively normal ejection fraction

Is often caused by anemia or thyrotoxicosis

Question 6

Two main classifications for HF:

Answer 6

HFrEF  = <60% 
HFpEF = >60%

Question 7

FYI

Answer 7

sorrynotsorry

There’s a good deal of pathophys of HF - since we already learned it I’m not making cards on it

Slide 14

Question 8

How will a HF patient commonly present in the ED?

Answer 8

Dyspnea

Big differential with that (HF, COPD, Asthma, Pneumonia, ACS)

Question 9

Because of the broad differential with your typical HF patient, how do you dx it?

Answer 9

There is no single diagnostic test for HF, it is a clinical diagnosis based on history and presentation

Question 10

Risk factors for acute HF

Answer 10

HTN
DM
Valvular heart dz (i.e. aortic stenosis, MV stenosis)
Old age
Male
Obesity

Question 11

What sxs has the highest sensitivity for HF?

Answer 11

DOE

Question 12

What sxs has the most specificity for HF?

Answer 12

PND
Orthopnea
Edema

Question 13

Physical exam findings suggestive of HF?

Answer 13

(+) abdominojugular reflex and (+) JVD

Question 14

Precipitating causes of acute HF

Answer 14

Excessive salt of fluid intake

Rx non-adherence

Renal failure (especially missed dialysis)

Substance abuse

Poorly controlled HTN

Iatrogenic (rx’s)

Question 15

CXR for HF can show:

Answer 15

Pulmonary venous congestion

Cardiomegaly

Interstitial edema

Question 16

ECG for HF?

Answer 16

Non specific, but point to the cause

Question 17

BNP testing helpful when:

Answer 17

The cause of dyspnea is unclear after a standard evaluation

Question 18

BNP value where HF is likely?

Answer 18

500 pg/mL

Question 19

Use of POC US in the setting of HF?

Answer 19

Can help determine the cause of dyspnea (i.e. cardiac tamponade) but is NOT a substitute for comprehensive echocardiography

Question 20

What are sonographic B lines?

Answer 20

The equivalent of CXR Kerley B lines

Ring-down artifacts that arise from the interface of the visceral and parietal pleura when there is swelling of the lung’s interlobular septa due to lymphatic congestion as is seen in pulmonary edema

Specific for alveolar and interstitial edema

Question 21

In the setting of acute HF, what is a bigger concern - hypoxemia or hypercarbia?

Answer 21

Hypoxia is bigger concern, so make oxygenation a priority

Question 22

How to reduce the need for intubation in HF pts?

Answer 22

Combine CPAP

PLUS

Meds (i.e. lasix, NTG, what-have-you)

Those two approaches combined work way better than one or the other

Question 23

For hypertensive HF (and likely subsequent APE), most important med (after O2) is:

Answer 23

Nitro - decreases MAP, reduces preload (and afterload, at high doses)

Can be given either SL, transdermal, or (if necessary), IV (as nitroprusside)

Question 24

Txt flow for APE 2/2 CHF:

Answer 24

O2
Bi-PAP / CPAP or intubation (if necessary)
NTG
Lasix

Question 25

In the setting of hypertensive HF, don’t give lasix without first giving:

Answer 25

Nitro

Question 26

Causes of HOTN after vasodilator use:

Answer 26

Excessive vasodilation (you just gave too much nitro)

Hypertrophic obstructive cardiomyopathy

RV infarction

Intravascular volume depletion

Cardiogenic shock / AMI

AS

Anaphylaxis

Sepsis

Question 27

Describe txt for normotensive HF:

Answer 27

Pt may have normal V/S, oxygenation, ventilation, but present with SOB, orthopnea, JVD, rales, etc

In this case, you can treat with diuresis first

Won’t work will in pts with severe renal dysfunction

Question 28

Whats a good starting dose for lasix for the HF patient?

Answer 28

40mg / IV

Question 29

Rare AE of lasix?

Answer 29

Ototoxicity (if used in conjunction with aminoglycosides)

Question 30

What if lasix isn’t working?

Answer 30

Try doubling the dose

Question 31

If all diuretic and medical strategies fail, consider:

Answer 31

Mercy-killing the patient
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Or, you know, ultrafiltration

Question 32

Morphine for txt’ing HF?

Answer 32

Relieves congestion and anxiety but is associated with AE’s, including increased mortality…so, just don’t do it.

Question 33

Nesiritide:

Answer 33

Vasodilator with recombinant human BNP

2nd line agent

Question 34

Meds to avoid in HF

Answer 34

Oral CCB’s
Amlodipine (unless you’ve got a really good reason)
NSAIDs

Question 35

Disposition for HF pts?

Answer 35

Really based on clinical judgement - multifactorial

That said…
High risk stuff - renal dysfunction, low BP, low Na+ and elevated BNP or cardiac troponin

Question 36

Features of R-sided failure (aka Cor pulmonale)

Answer 36

Fatigue

Increased peripheral venous pressure

Ascites

Hepatomegaly / splenomegaly

JVD

Anorexia / GI distress

Weight gain

Dependent edema

Question 37

Features of L-sided failure:

Answer 37

Restlessness
Confusion
Orthopnea
Tachycardia
Exertional dyspnea
Fatigue
Cyanosis

PND
Elevated pulmonary capillary wedge pressure

Cough
Wheezes
Crackles
Hemoptysis
Tachypnea

Question 38

Are you a coronary artery?

Answer 38

Cause you’re all wrapped around my heart