ADHF & Cardiogenic Shock

Question 1

What is heart failure?

Answer 1

Co is insufficient to meet the body’s needs
Results from any structural or functional impairment of ventricular filling or ejection of blood

Incurable, chronic, progressive condition

Question 2

-classifications of heart failure

Answer 2

Class A: high risk for development (HTN, DM, CAD, Fam Hx)

Class B: structural heart disease but no symptoms
-P/T has previous MI, LV systolic dysfunction, asymptomatic valvular disease

Class C: structural heart disease with symptomatic heart failure
-dyspnea, fatigues fluid retention

Class D: refractory end-stage heart failure
- marked symptoms at rest despite maximal medicaltherapy

Question 3

What are the new York heart association classifications of heart failure?

Answer 3

Class I: no limitation of physical activity, no symptoms (lines up with stage B)

Class II: slight limitation of physical activity. Comfortable at rest. Ordinary activity results in fatigue, palpitation,dyspnea

Class III: marked limitation of physical activity, comfortable at rest-less than ordinary activity causes symptoms
- classes II and III align with stage C

Class IV: unable to curry out any physical activity without symptoms. Symptoms of heart failure at rest
-sage D

Question 4

What symptoms does venous congestion (fluid overload) cause?

Answer 4

Dyspnea
Orthopnea/pnd
Cough
Peripheral edema
Nausea, anorexia, distension

Question 5

What symptoms does tissue hypoperfusion cause?

Answer 5

Dysrhythmias
Fatigue
Altered mental status
Dizziness
Palpitations
Ventricular dyssynchrony

Question 6

What are the three cardinal manifestations of heart failure?

Answer 6

1.) dyspnea
-SOB, Orthopnea, PND

2.) fatigue and activity intolerance

3.)fluid retention
Pulmonary, splanchnic, peripheral edema
-JVD, elevated PAOP/CVP, pulmonary congestion, abd dissension, ankle or sacral edema

Question 7

What is the first physiologic goal in managing heart failure?

Answer 7

Decrease preload
-May use a vasodilator in order to make it easier fur the heart to push the flow forward to decrease blood backup

By decreasing Afterload with a vasodilator, we can decrease preload

Question 8

What is HFrEF and HFpEF?

Answer 8

HFrEF: heart failure with reduced ejection fraction
Ejection traction less than or equal to 40%

HFpEF: heart failure with preserved ejection fraction
EF: >= 50%

Question 9

What four medications do all heart failure patients need upon discharge?

Answer 9

1. ARNI or ACE or ARB ( ARNI preferred)
2. GDMT
3. ?

Question 10

What options are available for stage lv (Class D) heart failure patients (beyond medications)?

Answer 10

Palliative care
Transplant
Left-ventricular assist device
Investigational studies

Always talk to the patient about what their particular care goals are

Question 11

What are the goals of medication therapy for heart failure patients?

Answer 11

SBP < 130mmHg
HR< 70
- slower heartrate to give the ventricles time to fill

Blood pressure control is the most important treatment for HFpEF and may reduce hospitalizations

Question 12

What is acute decompensated heart failure (ADHF)?

Answer 12

Sudden or gradual worsening of symptoms requiring unplanned medical intervention
- dyspnea is the most common presenting symptom

Includes a continue of severity up to und including pulmonary edema and cardiogenic shock

Question 13

What test helps to differentiate between respiratory symptoms caused by ADHF?

Answer 13

Serum BNP

Question 14

What are common precipitating factors of ADHF?

Answer 14

Acute myocardial ischemia
Concurrent infections
Arrhythmia
Pulmonary embolus
Other acute CV disorders

Comorbid conditions; endocrine abnormalities
(Diabetes, thyroid), COPD, sleep-disordered breathing

Question 15

Symptoms of acute pulmonary edema from heart failure

Answer 15

Breathlessness
Anxious
Pink, frothy sputum
Orthopnea
Respiratory distress
Diaphoresis
Hypoxia (it severe)

Evidence of high preload!

Acute pulmonary edema is the most severe manifestation of
Pulmonary venous congestion

Question 16

What happens to the alveoli in acute pulmonary edema?

Answer 16

Capillaries become leaky, letting more fluid into the space between the capillary and alveolar sacs impairing gas exchange

Creates hypoventilation → hypoxemia → lactic acidosis

Question 17

Why does heart failure continue to progress?

Answer 17

Stroke volume cannot increase in response to the increased demand, so responses are dependent on increased heart rate

Increased heart rate leads to decreased ventricular tilling time
Hr may be limited by drugs/devices (chronotropic incompitence)

Question 18

What factors are threatened in acute decompensatory heart failure?

Answer 18

Cardiac output
Preload
Afterload
Contractility
Arterial oxygen content

Question 19

How do you reduce congestion (preload)?

Answer 19

IV diuretics: first line therapy
Ultrafiltration to pull off fluid
IV vasodilators: for relief of dyspnea and to make forward flow easier
-Nitroglycerin
-Nitroprusside
Sodium restriction
Fluid restriction <2L ONLY if serum Na+ <130

Question 20

How does nitroglycerin reduce preload?
Why is it used?

Answer 20

Vasodilator
-Reduces preload by reducing Afterload

Effective in heart failure
Inexpensive
Safe
-Tachycardia and tachyphylaxis

Question 21

What is nitroprusside?

Answer 21

IV vasodilator
-Reduces preload and Afterload

Considered dangerous
- as nitric oxide is released, so is cyanide which is excreted by the kidneys
- potential for cyanide or thiocyanide toxicity