46. Heart failure Flashcards
In patients with newly diagnosed heart failure determine what?
the underlying cause, as treatment will differ.
In patients with heart failure periodically assess functional impairment using validated tools. Name them (2)
- New York Heart Association class
- activities of daily living
Describe sx : Heart failure (7)
- Breathlessness
- Fatigue
- Weight gain
- Peripheral edema
- Orthopnea
- Paroxysmal nocturnal dyspnea (LR
- Confusion in elderly
Name risks : Heart failure (9)
- Hypertension
- Ischemic heart disease (LR 3.1)
- Valvular heart disease
- Diabetes mellitus
- Alcohol, substance use
- Chemotherapy/radiation therapy
- Family history cardiomyopathy
- Smoking
- Hyperlipidemia
Describe physical exam : Heart failure (8)
- Bilateral lung crackles
- Elevated JVP
- Positive abdominal jugular reflex
- Peripheral edema
- Laterally isplaced apex
- S3 , S4 or any heart murmur
- Low BP or HR>100
- Note: In heart failure with narrow pulse pressure, think high output heart failure (eg. anemia, thyrotoxicosis)
Name types of heart failure (3)
- HFrEF (reduced) : LVEF <40%
- HFmrEF (mid-range) : LVEF 40-49%
- HFpEF (preserved) : LVEF >50%
Describe : HFmrEF (mid-range) (3)
- LVEF 40-49%
- Elevated natriuretic peptide
- Relevant structural heart disease (LVH +/- LAE) or diastolic dysfunction
Describe : HFpEF (preserved) (4)
- 💡 A preserved ejection fraction on a routine echocardiogram does not rule out the clinical syndrome of heart failure
- LVEF >50%
- Elevated natriuretic peptide
- Relevant structural heart disease (LVH +/- LAE) or diastolic dysfunction
Describe : NYHA classification for severity of symptoms
- I = No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
- II = Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
- III = Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
- IV = Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
Name labs : Heart failure
- CBC
- Ferritin
- Glucose
- Electrolytes
- Creat/eGFR
- TSH
- UA
- LFTs
- Lipids & A1c (risk factor management)
Consider if diagnosis uncertain or if high suspicion
* Troponin → r/o ACS and prognosis
* NT-proBNP >125pg/mL → consider echocardiography. HF unlikely if < 300; highly likely if > 900 (1800 if age >75)
* BNP>50 pg/mL → consider echocardiography. HF unlikely if < 100; highly likely if >400
Name investigations heart failure (besides labs) (4)
- ECG
- Lung ultrasound
- CXR
- Echocardiography
What to look for in ECG for heart failure (5)
- Afib
- new T-wave change Q waves
- LVH
- LBBB
- HR>100
What to look for in lung ultrasound for heart failure (2)
- B-profile bilaterally
- pleural effusion
What to look for in CXR for heart failure (5)
- Cardiomegaly
- pulmonary venous redistribution
- pulmonary edema
- pleural effusion
- Kerley B lines
What to look for in echocardiography for heart failure (6)
- Decreased LVEF
- Increased LV diameter/LVH
- Wall motion abnormalities, diastolic dysfunction
- Increased RV size, RV dysfunction
- Valve dysfunction
- Elevated pulmonary arterial pressures (PAP)
Describe ACUTE management heart failure
💡 LMNOP (Lasix, Modify medications, Nitroglycerine, Oxygen, Position (upright) +/- Positive Pressure (BiPAP)
- Oxygen ≥ 90-92%
- NIPPV (BiPAP > CPAP) if SpO2 < 90% despite supportive O2
- Position upright
- Hypotension (cardiogenic shock)→ Pressor (eg. Norepinephrine) to maintain ** MAP 65-80**
- Hypertension (SCAPE)→ High-dose nitroglycerin IV
- If suspect total body hypovolemia vs hyperovlemia
- Consider consultations (e.g., cardiology, ICU) for advanced measures (e.g., intra-aortic balloon pumps, LVAD, ECMO, etc.)
Describe ACUTE management of heart failure if HYPERTENSION
**High-dose nitroglycerin IV
**
* Nitroglycerine (NTG) SL 0.4mg x 3 q5 mins until IV nitroglycerine started (note SL nitro only 40% bioavailable)
* Nitroglycerine 100mcg/min IV infusion, increase by 20mcg/min every 10 mins until sBP decreases
* Then maintain until improvement in symptoms, then gradually reduce IV infusion until stop
* Alternatively may give intermittent nitroglycerin bolus 1-2mg IV q3-5 minutes
* Avoid in PDE5 inhibitors (e.g., sildenafil) or concomitant inferior STEMI (preload dependent)
In heart failure, names signs that susject total body hypovolemia (2)
- no B-lines on lung ultrasound
- hypoperfusion
If suspect total body hypovolemia in heart failure, what to do ?
Consider careful fluid bolus challenge (250mL isotonic crystalloid)
In heart failure, names signs that susject total body HYPERvolemia (4)
- B-lines on lung ultrasound
- pedal edema
- jugular vein distension
- history of nonadherence to diuretics or missed hemodialysis
True or False
Many patients may be euvolemic and have a maldistribution of fluids into the lungs
True
If suspect total body hypervolemia in heart failure, what to do ? (2)
- Furosemide (Lasix) 20-80mg IV bolus (once stable)
- Monitor diuretic effect ~q6h while stabilizing
How to give furosemide in heart failure (if hypervolemia) ? (3)
- Furosemide (Lasix) 20-80mg IV bolus (once stable)
- If taking regular furosemide at home, can give home PO dose as IV
- Consider the addition of acetazolamide 500mg IV daily to improve loop diuretic efficiency
How to monitor diuretic effect in heart failure (if hypervolemia) ? (4)
- Monitor diuretic effect ~q6h while stabilizing
- Monitor daily weights and urine output, goals: urine output 3-5 L; 0.5-1.5 kg weight loss
- Increase/decrease diuretic by ~25-50% to meet above criteria
- If not responsive, consider adding metolazone 1.25-5mg one to seven times per week
Name Discharge Goals of heart failure (3)
- Improvement in clinical status (i.e., presenting symptoms & vital signs resolved and stable, return to “dry” weight, comorbidities under control)
- Supportive investigations : Imaging evidence of resolution of congestion (CXR, ultrasound)
- BNP or NT-proBNP : Consider discharge home if > 30% ↓ from admission value (along with clinical improvement)
For ambulatory patients (i.e., outpatients), an increase in BNP/NT-proBNP of > ____ from baseline warrants more frequent follow-up +/- intensification of HF therapy
30%
Describe Lifestyle Management in CHRONIC management
1.Treat risk factors
- HTN, DM, smoking, obesity
- Annual influenza vaccine
- Periodic pneumococcal pneumonia vaccine
2.Sodium restriction between 2-3g/day
3.Weight daily if fluid retention
Describe pharmacologic management of HFrEF (LVEF < 40% and symptoms)
Quadruple Therapy
* IECA (or ARA if not tolerated)
* BB (Careful initiating in NYHA III-IV)
* Antagonistes de l’aldostérone (Monitor potassium, creatinine) : Target Spironolactone 50mg
* SGLT2 Inhibitor
In quadruple therapy, name IECA and ARA used
- IECA: Ramipril 10mg, Perindopril 8mg, or Lisinopril 20-35mg
- ARA: Candesartan 32mg
In quadruple therapy, name BB used (2)
- Bisoprolol 10mg
- Metoprolol CR/XL 200mg
In quadruple therapy, name Antagonistes de l’aldostérone used (1)
Monitor potassium, creatinine
Spironolactone 50mg
In quadruple therapy, name SGLT2 Inhibitor used (2)
Target
* Jardiance 10-25mg
* or Dapagliflozin 10mg
What to do if persistent/worsening symptoms despite adequate quadruple therapy ?
- Convert from IECA/ARA to un inhibiteur du récepteur de l’angiotensine-néprilysine (ARNi)
- Sacubitril/Valsartan 200mg BID (97mg:103mg)
Describe management : HFpEF (2)
💡 There is less evidence supporting the benefit of pharmacotherapy for patients with preserved EF (HFpEF).
For patients with HFpEF consider SGLT2 and Antagonistes de l’aldostérone as first-line therapies.
Additional therapies should be considered for patients with HFrEF and persistent NYHA II-IV symptoms, despite optimization of quadruple therapy.
Name them.
Diuretic at lowest effective dose to maintain euvolemia
Consider (with specialist involvement)
- Ivabradine if sinus rhythm and HR ≥ 70 bpm despite BB
- Vasodilators (e.g., hydralazine/Isosorbide dinitrate) if renal intolerance to ACEi/ARB/ARNI
- Digoxin (e.g., if poorly controlled AF despite BB)
- Device therapy (implantable cardioverter-defibrillator, Cardiac Resynchronization Therapy) if LVEF ≤ 35% and NYHA I-IV (ambulatory)
