CONGESTIVE HEART FAILURE (CHF) 1. What is the _Mechanism of Action (MOA)_ of Dobutamine, Inamrinone, and Milrinone? 2. When would you use these Medications in a patient with Pulmonary Edema ?

1. Increase Cardiac Contractility and cause VASODILATION Inamrinone & Milrinone = PDE Inhibitors Dobutamine = Positive Inotrope 2. Used as _Further Management_ of Acute Pulmonary Edema cases AFTER the clock is moved forward 30 - 60 minutes AND there is no response to Preload Reduction

5. MTB Step 3 - Congestive Heart Failure (CHF) Flashcards by Jason Wright

CONGESTIVE HEART FAILURE (CHF)

The Mechanism that matters for CHF has to do with the Difference in Treatment between which (2) Types of CHF?

Systolic Dysfunction w/ a Low EF
Diastolic Dysfunction w/ a Normal EF

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CONGESTIVE HEART FAILURE (CHF)

What is the Typical Clinical Manifestation for a patient with CHF?

Shortness of Breath, particularly on exertion, in a person with ANY of the following:

Edema
Rales on lung exam
Ascites
JVD
S3 Gallop
Orthopnea
Paroxysmal Nocturnal Dyspnea
Fatigue

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CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Rales on Lung Exam in a patient with CHF?

Increased Hydrostatic Pressure develops in the Pulmonary Capillaries from Left Heart Pressure overload.

This causes Transudation of Liquid into the Alveoli.

During Inhalation, the Alveoli open with a “Popping” sound referred to as RALES.

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CONGESTIVE HEART FAILURE (CHF)

Which of the Clinical Manifestations of CHF is considered the Worst?

PULMONARY EDEMA

Pulmonary Edema is a Clinical Diagnosis

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CONGESTIVE HEART FAILURE (CHF)

What (4) Therapeutic Treatments are considered the Mainstay of Therapy for Acute Pulmonary Edema?

Morphine
Oxygen
Nitrates
Furosemide

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CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Action for Carvedilol?

Carvedilol - a Beta-1 and Beta-2 receptor Antagonist, as well as an Alpha-1 receptor Antagonist.

Beta-1 = Anti-ARRHYTHMIC*
Beta-2 = Anti-ISCHEMIC*
Alpha-1 = Anti-HYPERTENSIVE*

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CONGESTIVE HEART FAILURE (CHF)

What (5) Diagnostic Tests should be ordered on First-Screen on CCS, and at the Same Time as the Initial Therapy (eg, Morphine, Oxygen, Nitrates, Furosemide)?

ECG
Echocardiogram
Continuous Oximeter
Chest X-Ray (CXR)
Arterial Blood Gas (ABG)

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CONGESTIVE HEART FAILURE (CHF)

What are (2) Findings on ECG in a patient with CHF?

Sinus Tachycardia
Atrial & Ventricular arrhythmia

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CONGESTIVE HEART FAILURE (CHF)

Which Diagnostic Test allows for distinguishing Systolic from Diastolic dysfunction in a patient with CHF?

Echocardiogram

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CONGESTIVE HEART FAILURE (CHF)

What are (4) Findings on CXR in a patient with CHF?

Cardiomegaly
Pulmonary Vascular Congestion
Effusion
Cephalization of Flow

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CONGESTIVE HEART FAILURE (CHF)

What is (1) Finding on Oximetry in a patient with CHF?

Hypoxia

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CONGESTIVE HEART FAILURE (CHF)

What is (1) Finding on ABG in a patient with CHF?

Respiratory ALKALOSIS

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CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of “Cephalization” of Flow in a patient with CHF, as seen on CXR?

The bottoms of the lungs are generally more “Full” of Blood because of gravity.

As fluid builds up in the lungs, it fills the vessels from the bottom to the top.

This moves the fluid toward the Head (Cephalization)

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CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Action (MOA) of Dopamine?

Increases Cardiac Contractility and causes VASOCONSTRICTION (alpha-1-agonist)

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CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Action (MOA) of Dobutamine, Inamrinone, and Milrinone?
When would you use these Medications in a patient with Pulmonary Edema?

Increase Cardiac Contractility and cause VASODILATION
- Inamrinone & Milrinone = PDE Inhibitors
- Dobutamine = Positive Inotrope
Used as Further Management of Acute Pulmonary Edema cases AFTER the clock is moved forward 30 - 60 minutes AND there is no response to Preload Reduction

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CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Respiratory Alkalosis in a patient with CHF, as seen on ABG?

Fluid Overload ⇒ Hypoxia

Hypoxia ⇒ Hyperventilation*
Hyperventilation ⇒ Decreased pCO₂*
Decreased pCO₂ ⇒* Alkalosis

CONGESTIVE HEART FAILURE (CHF)

Where should you Place patients with Pulmonary Edema and Myocardial Infarction (MI)?

Intensive Care Unit (ICU)

CONGESTIVE HEART FAILURE (CHF)

“An 80-yo woman is admitted to the ICU for Acute Pulmonary Edema. She has Rales to the Apices and JVD. Her ECG shows V-Tach. What is the Best Therapy for this patient?”

Synchronized Cardioversion - used when V-Tach is associated with Acute Pulmonary Edema

CONGESTIVE HEART FAILURE (CHF)

What is the medication Nesiritide and what is it used for?

Nesiritide is a synthetic version of Atrial Natriuretic Peptide that is used for Acute Pulmonary Edema as part of Preload Reduction.

It decreases symptoms of Shortness of Breath.*
NO mortality benefit*
NO clear indication for answering Nesiritide*

CONGESTIVE HEART FAILURE (CHF)

What is Brain Natriuretic Peptide (BNP) Level and what is it used for?

BNP level is a Blood Test that can be used to establish a diagnosis of CHF in a patient who is Short of Breath.
If the presentation is not clear, a BNP level can be used to help distinguish between PE, Pneumonia, Asthma, and CHF.
BNP level goes UP in CHF but is Nonspecific (Low Specificity)
A Normal BNP level excludes CHF (High Sensitivity)

CONGESTIVE HEART FAILURE (CHF)

“A patient comes with Pulmonary Edema. A Right Heart Catheter is placed.” What is most likely to be found on the following measurements?:

Cardiac Output (CO)
Systemic Vascular Resistance (SVR)
Left Atrial Pressure (LAP) / Wedge Pressure
Right Atrial Pressure (RAP)

CO = Decreased
SVR = Increased
LAP = Increased
RAP = Increased

CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism for Decreased CO in a patient with Pulmonary Edema from CHF?

Pump Failure ⇒ Backup of Blood into LA ⇒ Increased LAP

Left Atrial Pressure (LAP)** is a.k.a. **Wedge Pressure
LV Failure** = **Increased LAP** = **Increased Wedge Pressure
Right Heart Catheterization - inflated balloon blocks pressure from behind catheter, making catheter tip pick up flow from “in front,” or downstream.

CONGESTIVE HEART FAILURE (CHF)

In a patient with Cardiogenic Shock, what is most likely to be found on the following measurements?:

Cardiac Output (CO)
Systemic Vascular Resistance (SVR)
Left Atrial Pressure (LAP) / Wedge Pressure
Right Atrial Pressure (RAP)

CO = Decreased
SVR = Increased
LAP = Decreased
RAP = Decreased

CONGESTIVE HEART FAILURE (CHF)

In a patient with Septic Shock, what is most likely to be found on the following measurements?:

Cardiac Output (CO)
Systemic Vascular Resistance (SVR)
Left Atrial Pressure (LAP) / Wedge Pressure
Right Atrial Pressure (RAP)

CO = Increased
SVR = Decreased
LAP = Decreased
RAP = Decreased

**CONGESTIVE HEART FAILURE (CHF)** What is the _Mechanism_ of Measuring ***Increased Left Atrial Pressure (LAP) / "Wedge" Pressure*** in a patient with *CHF*?

The inflated Balloon blocks pressure from behind the catheter, making the catheter tip pick up flow from "in front," or downstream. ***"Downstream" for the pulmonary capillaries means the Left Atrium.*** ***LV Failure = Increased LA Pressure = Increased "Wedge" Pressure***

**CONGESTIVE HEART FAILURE (CHF)** What _Test_ should *ALL* patients, having been _stabilized_ from ***Acute Pulmonary Edema***, *have*, and *why*?

**Echocardiogram -** establish whether there is Systolic Dysfunction with Low EF or Diastolic Dysfunction with a Normal EF

**CONGESTIVE HEART FAILURE (CHF)** The _Long-Term Management_ (*Chronic CHF*) of ***Dilated Cardiomyopathy*** or ***Systolic Dysfunction*** is based on the use of Which (**3**) _Medications_ that also have a **Mortality Benefit**?

1. **ACEIs / ARBs** 2. **Beta-Blockers -** *_only_* *Metoprolol, Carvedilol, Bisoprolol* 3. **Spironolactone -** an anti-androgenic that lowers mortality but has only been proven to do so for more advanced, symptomatic disease. * ***AE** = Gynecomastia and ED in men: switch to Eplerenone (lowers mortality in CHF without the anti-androgenic side effects of spironolactone).*

**CONGESTIVE HEART FAILURE (CHF)** What are (**2**) _Medications_ given in the _Long-Term Management_ of ***Chronic CHF*** that do *NOT* have a mortality benefit?

1. **Diuretics** 2. **Digoxin -** used to decrease symptoms and decrease the frequency of hospitalization.

**CONGESTIVE HEART FAILURE (CHF)** Which _2-Drug Combination_ is given for the _Long-Term Management_ of ***CHF*** in patients where **ACEIs / ARBs** _cannot_ be used?

**Hydralazine + Nitrates** ## Footnote Hydralazine reduces Afterload

**CONGESTIVE HEART FAILURE (CHF)** What **CHF Medication** has an _Adverse Effect_ of ***Transient Excess Brightness of Vision***?

**Ivabradine**

**CONGESTIVE HEART FAILURE (CHF)** 1. What is the _Mechanism of Action_ (_MOA_) of **Ivabradine**? 2. Under what _Condition_ would you *Add* **Ivabradine**?

1. **SA Nodal Inhibitor** of "**Funny Channels**" that ***Slows the HR***. 2. Add it to ***Systolic Dysfunction*** if the ***HR is \> 70 bpm*** or ***Beta-Blockers CAN'T be used***. ## Footnote *There is NO mortality benefit with Ivabradine*

**CONGESTIVE HEART FAILURE (CHF)** What **2-Drug Combination** can be _used instead_ of an **ACEI** in _Chronic Management_ of ***CHF*** and gives the _same Mortality Benefit_ for ***Systolic Dysfunction***?

**Sacubitril/Valsartan** ## Footnote Sacubitril is a Neprilysin Inhibitor and is added ONLY to an ARB.

**CONGESTIVE HEART FAILURE (CHF)** What (**2**) _Drug Classes_ are *used* in the _Chronic Management_ of ***CHF*** due to ***Diastolic Dysfunction** (Normal EF)*?

1. **Beta-Blockers -** *Metoprolol, Carvedilol, Bisoprolol* 2. **Diuretic -** you have to be careful NOT to overuse diuretics

**CONGESTIVE HEART FAILURE (CHF)** What (**7**) _Medications or_ _Drug Classes_ are *used* in the _Chronic Management_ of ***CHF*** due to ***Systolic Dysfunction** (Low EF)*?

1. **ACEI** or **ARB** 2. **Sacubitril/Valsartan (***Combination Drug if can't give ACEI only***)** 3. **Hydralazine + Nitrates (***2-drug combo if can't give ACEI or ARB***)** 4. **Beta-Blockers -** *Metoprolol, Carvedilol, Bisoprolol* 5. **Spronolactone** or **Eplerenone** 6. **Diuretics** 7. **Digoxin**

**CONGESTIVE HEART FAILURE (CHF)** ## Footnote CHRONIC MANAGEMENT OF CHF "A 69 yo man is seen in the office for further management of CHF. He currently has no symptoms and good exercise tolerance. He has been on Lisinopril, Metoprolol, Spironolactone, and Furosemide for the last 6 months. His EF is 23%." What _Treatment_ is *most likely* to **benefit** this patient?

**Implantable Cardioverter/Defibrillator** ## Footnote Patients with an EF \< 35% that PERSISTS are candidates for this treatment

**CONGESTIVE HEART FAILURE (CHF)** ## Footnote CHRONIC MANAGEMENT OF CHF When is a **Biventricular Pacemaker** (a.k.a. **Cardiac Resynchronization Therapy**) the answer for ***CHF***?

***SEVERE Congestive Heart Failure*** (***CHF***) = an **EF \< 35%** + **QRS duration \> 120 msec**. ## Footnote Wide QRS = Left & Right Ventricles NOT beating in sync Biventricular PM Decreases Mortality for these patients

**CONGESTIVE HEART FAILURE (CHF)** ## Footnote CHRONIC MANAGEMENT OF CHF What is the _Mechanism_ of **Biventricular Pacemaker**?

* ***Wide QRS*** means _Ventricles are not beating together_. * This means ***Inefficient Forward Flow***. * **Biventricular Pacemaker** brings _both Ventricles back to beating at the same time_. * The _effect is instant_.

**CONGESTIVE HEART FAILURE (CHF)** ## Footnote CHRONIC MANAGEMENT OF CHF What _Condition_ is an ***Absolute Contraindication*** to the use of **Beta-Blockers**?

***Symptomatic Bradycardia***