2 - Acute Heart Failure Flashcards
How’s the overall prognosis for HF? (In case you’ve forgotten)
Shitty.
50% of pts dead within 5 yrs
Define HF
Complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood
Briefly describe natriuretic peptides
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
Pts with acute-on-chronic HF tend to present with:
Gradual sxs and weight gain over days to weeks
High output HF is distinguishable by:
A relatively normal ejection fraction
Is often caused by anemia or thyrotoxicosis
Two main classifications for HF:
HFrEF = <60% HFpEF = >60%
FYI
sorrynotsorry
There’s a good deal of pathophys of HF - since we already learned it I’m not making cards on it
Slide 14
How will a HF patient commonly present in the ED?
Dyspnea
Big differential with that (HF, COPD, Asthma, Pneumonia, ACS)
Because of the broad differential with your typical HF patient, how do you dx it?
There is no single diagnostic test for HF, it is a clinical diagnosis based on history and presentation
Risk factors for acute HF
HTN DM Valvular heart dz (i.e. aortic stenosis, MV stenosis) Old age Male Obesity
What sxs has the highest sensitivity for HF?
DOE
What sxs has the most specificity for HF?
PND
Orthopnea
Edema
Physical exam findings suggestive of HF?
(+) abdominojugular reflex and (+) JVD
Precipitating causes of acute HF
Excessive salt of fluid intake
Rx non-adherence
Renal failure (especially missed dialysis)
Substance abuse
Poorly controlled HTN
Iatrogenic (rx’s)
CXR for HF can show:
Pulmonary venous congestion
Cardiomegaly
Interstitial edema
ECG for HF?
Non specific, but point to the cause
BNP testing helpful when:
The cause of dyspnea is unclear after a standard evaluation
BNP value where HF is likely?
500 pg/mL
Use of POC US in the setting of HF?
Can help determine the cause of dyspnea (i.e. cardiac tamponade) but is NOT a substitute for comprehensive echocardiography
What are sonographic B lines?
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
In the setting of acute HF, what is a bigger concern - hypoxemia or hypercarbia?
Hypoxia is bigger concern, so make oxygenation a priority
How to reduce the need for intubation in HF pts?
Combine CPAP
PLUS
Meds (i.e. lasix, NTG, what-have-you)
Those two approaches combined work way better than one or the other
For hypertensive HF (and likely subsequent APE), most important med (after O2) is:
Nitro - decreases MAP, reduces preload (and afterload, at high doses)
Can be given either SL, transdermal, or (if necessary), IV (as nitroprusside)
Txt flow for APE 2/2 CHF:
O2
Bi-PAP / CPAP or intubation (if necessary)
NTG
Lasix
In the setting of hypertensive HF, don’t give lasix without first giving:
Nitro
Causes of HOTN after vasodilator use:
Excessive vasodilation (you just gave too much nitro)
Hypertrophic obstructive cardiomyopathy
RV infarction
Intravascular volume depletion
Cardiogenic shock / AMI
AS
Anaphylaxis
Sepsis
Describe txt for normotensive HF:
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
Whats a good starting dose for lasix for the HF patient?
40mg / IV
Rare AE of lasix?
Ototoxicity (if used in conjunction with aminoglycosides)
What if lasix isn’t working?
Try doubling the dose
If all diuretic and medical strategies fail, consider:
Mercy-killing the patient . . . . . . . . . . . . Or, you know, ultrafiltration
Morphine for txt’ing HF?
Relieves congestion and anxiety but is associated with AE’s, including increased mortality…so, just don’t do it.
Nesiritide:
Vasodilator with recombinant human BNP
2nd line agent
Meds to avoid in HF
Oral CCB’s
Amlodipine (unless you’ve got a really good reason)
NSAIDs
Disposition for HF pts?
Really based on clinical judgement - multifactorial
That said…
High risk stuff - renal dysfunction, low BP, low Na+ and elevated BNP or cardiac troponin
Features of R-sided failure (aka Cor pulmonale)
Fatigue
Increased peripheral venous pressure
Ascites
Hepatomegaly / splenomegaly
JVD
Anorexia / GI distress
Weight gain
Dependent edema
Features of L-sided failure:
Restlessness Confusion Orthopnea Tachycardia Exertional dyspnea Fatigue Cyanosis
PND
Elevated pulmonary capillary wedge pressure
Cough Wheezes Crackles Hemoptysis Tachypnea
Are you a coronary artery?
Cause you’re all wrapped around my heart
