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résidence - fm learner > 46. Heart failure > Flashcards

46. Heart failure Flashcards

1
Q

In patients with newly diagnosed heart failure determine what?

A

the underlying cause, as treatment will differ.

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2
Q

In patients with heart failure periodically assess functional impairment using validated tools. Name them (2)

A
  • New York Heart Association class
  • activities of daily living
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3
Q

Describe sx : Heart failure (7)

A
  • Breathlessness
  • Fatigue
  • Weight gain
  • Peripheral edema
  • Orthopnea
  • Paroxysmal nocturnal dyspnea (LR
  • Confusion in elderly
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4
Q

Name risks : Heart failure (9)

A
  • Hypertension
  • Ischemic heart disease (LR 3.1)
  • Valvular heart disease
  • Diabetes mellitus
  • Alcohol, substance use
  • Chemotherapy/radiation therapy
  • Family history cardiomyopathy
  • Smoking
  • Hyperlipidemia
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5
Q

Describe physical exam : Heart failure (8)

A
  • 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)
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6
Q

Name types of heart failure (3)

A
  • HFrEF (reduced) : LVEF <40%
  • HFmrEF (mid-range) : LVEF 40-49%
  • HFpEF (preserved) : LVEF >50%
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7
Q

Describe : HFmrEF (mid-range) (3)

A
  • LVEF 40-49%
  • Elevated natriuretic peptide
  • Relevant structural heart disease (LVH +/- LAE) or diastolic dysfunction
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8
Q

Describe : HFpEF (preserved) (4)

A
  • 💡 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
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9
Q

Describe : NYHA classification for severity of symptoms

A
  • 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.
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10
Q

Name labs : Heart failure

A
  • 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

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11
Q

Name investigations heart failure (besides labs) (4)

A
  • ECG
  • Lung ultrasound
  • CXR
  • Echocardiography
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12
Q

What to look for in ECG for heart failure (5)

A
  • Afib
  • new T-wave change Q waves
  • LVH
  • LBBB
  • HR>100
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13
Q

What to look for in lung ultrasound for heart failure (2)

A
  • B-profile bilaterally
  • pleural effusion
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14
Q

What to look for in CXR for heart failure (5)

A
  • Cardiomegaly
  • pulmonary venous redistribution
  • pulmonary edema
  • pleural effusion
  • Kerley B lines
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15
Q

What to look for in echocardiography for heart failure (6)

A
  • Decreased LVEF
  • Increased LV diameter/LVH
  • Wall motion abnormalities, diastolic dysfunction
  • Increased RV size, RV dysfunction
  • Valve dysfunction
  • Elevated pulmonary arterial pressures (PAP)
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16
Q

Describe ACUTE management heart failure

A

💡 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.)
17
Q

Describe ACUTE management of heart failure if HYPERTENSION

A

**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)

18
Q

In heart failure, names signs that susject total body hypovolemia (2)

A
  • no B-lines on lung ultrasound
  • hypoperfusion
19
Q

If suspect total body hypovolemia in heart failure, what to do ?

A

Consider careful fluid bolus challenge (250mL isotonic crystalloid)

20
Q

In heart failure, names signs that susject total body HYPERvolemia (4)

A
  • B-lines on lung ultrasound
  • pedal edema
  • jugular vein distension
  • history of nonadherence to diuretics or missed hemodialysis
21
Q

True or False
Many patients may be euvolemic and have a maldistribution of fluids into the lungs

A

True

22
Q

If suspect total body hypervolemia in heart failure, what to do ? (2)

A
  • Furosemide (Lasix) 20-80mg IV bolus (once stable)
  • Monitor diuretic effect ~q6h while stabilizing
23
Q

How to give furosemide in heart failure (if hypervolemia) ? (3)

A
  • 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
24
Q

How to monitor diuretic effect in heart failure (if hypervolemia) ? (4)

A
  • 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
25
Q

Name Discharge Goals of heart failure (3)

A
  • 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)
26
Q

For ambulatory patients (i.e., outpatients), an increase in BNP/NT-proBNP of > ____ from baseline warrants more frequent follow-up +/- intensification of HF therapy

A

30%

27
Q

Describe Lifestyle Management in CHRONIC management

A

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

28
Q

Describe pharmacologic management of HFrEF (LVEF < 40% and symptoms)

A

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

29
Q

In quadruple therapy, name IECA and ARA used

A
  • IECA: Ramipril 10mg, Perindopril 8mg, or Lisinopril 20-35mg
  • ARA: Candesartan 32mg
30
Q

In quadruple therapy, name BB used (2)

A
  • Bisoprolol 10mg
  • Metoprolol CR/XL 200mg
31
Q

In quadruple therapy, name Antagonistes de l’aldostérone used (1)

A

Monitor potassium, creatinine
Spironolactone 50mg

32
Q

In quadruple therapy, name SGLT2 Inhibitor used (2)

A

Target
* Jardiance 10-25mg
* or Dapagliflozin 10mg

33
Q

What to do if persistent/worsening symptoms despite adequate quadruple therapy ?

A
  • Convert from IECA/ARA to un inhibiteur du récepteur de l’angiotensine-néprilysine (ARNi)
  • Sacubitril/Valsartan 200mg BID (97mg:103mg)
34
Q

Describe management : HFpEF (2)

A

💡 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.

35
Q

Additional therapies should be considered for patients with HFrEF and persistent NYHA II-IV symptoms, despite optimization of quadruple therapy.
Name them.

A

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)

résidence - fm learner (25 decks)

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