Assesment Of HF Flashcards
Which HF patients should get cathed
Anyone presenting with HF who gas angina or ischemia unless no revascularization options (class I) Or chest pain (class ii)
Which HF patients should have noninvasive imaging
To define likelyhood of cad
How does spect work?
Retained by viable myocytes
Stitch trial
What modalities?
Define viability? (%, segments)
80% spect, 20% dob echo
Uptake 50% in 11 segments
P.03, P.21 if adjust for other variables
Patterns of gadilinium in dcm
30% mid wall
15% sub endocardium (like cad)
Utility of MRI in sarcoid
FDG pet?
Very useful. Predicts future sd (11 xrate).
Can follow rx.
Utility of sympathetic innervation by mIBG
If h/m > 1.6 survival greater than 85%
Who should get serial Ef
Change in clinical status Optimizing rx (4-6 months)
What is rvswi. What numbers are concerning
(Mpap-wedge)Ci/hr
>300
Fick co
Vo2(125)/a-v o2 differencexhgbx14
Class 1 indications for bx
New onset HF (less than 2w)
2-12 weeks with arrhythmia, av block, or fail to respond to care
Which Stage a patients should get echoes
Cad, valvular disease, fh in first degree relative
Afib, ECG Abn, ventricular arrhythmia, Abn physical exam
Recs for initial assessment of HF
Thorough h and p
Careful hx of drugs, alternatives etc
Ability of adl
Volume status, orthostatic
Labs to get in initial assessment
CBC, UA, lytes, lipids, Hgb a 1c, lft thyroid
What imaging should be done in initial assessment.
Cxr, echo, radionucleotide, coronary angiograms if angina or
How does 6 min walk test work
Need a 100 foot hallway
Change of 50m significant
Not useful for monitoring pharmacologics, but made a difference in CRT
Who should get cpet
Dispensaries between objective and physical findings Distinguishing HF from non HF causes Candidacy for cardiac transplant Need for cardiac rehab Employment capabilities
What is anerobic threshold
Change in vco2/vo2 slope or when ve/vO2> ve/vc02
Defined by highest oxygen uptake obtained without a sustained increase in lactate.
Rer
Ratio of co2/o2
If below 1 have not reached anaerobic threshold
Ve/vco2 slope
If greater than 35 bad prognostic predictor as is oscillatory breathing.
When do you get an echo in patients with HF
4-6 months after optimization of therapy and if change in clinical status
Ongoing assessment of HF
Functional capacity volume status labs assess prognosis.
Cpex class I Class 2
Rer >1.05
Beta blocker <12, no 14
Class 2a if 50% of predicted
2b should base on lean body mass in the obesse
What is dyspnea index
End expiratory ve/mvv
Closer to 1 worse the pulmonary function
Minnesota vs Kccq
Minnesota lower is better
Kccq higher is better.
Who should get angiography
Cor angiography is reasonable if known or suspected cad and HF.
Guidelines for noninvasive imaging in HF
HF, known cad and no angina
2b to assess ischemic disease
Utility of spect/thallium
Thallium goes thru na potissium exchanger
Define scar by MRI
Look for gdfm uptake
Imaging of cardiac amyloid
Diffuse sub endocardial t1
Pet scans in sarcoidosis
Hyper enhanced fdg
Determine prognosis in hemochromatosis
Look at t2 star.
What is 23 mibg
Look at h/m ratio. If greater than 2/1
If you have heart failure and angina
Get angiography
Impact of viability
If you have viability
- Predicts mortality
- Predicts improvement
- Viability imaging predicts outcomes
Cass trial
Randomized trial of med therapy versus surgery.
No aspirin bb ace etc
Only 3 v cad had improvement.
Bari
Multivessel cad: pci versus bypass
Less than 10% had HF
Stitch trial
No difference in medicine or surgery
Ef <35
Could not have left main disease.
Who should have Cabg
Left main or equivelant, plad with 2 or 3 v disease
Significant viability
Mitral valve surgery
- Should not do if secondary to ventricular dilation.
Indications for as surgery
Symptoms, low ef, undergoing Cabg
Low flow low gradient echo
2a to do dobutamine.
Define contractile reserve in aortic stenosis
Contractile reserve if cardiac index increased by 20%
Aortic insufficiency guidelines
Class I symptomatic or asymptotic if ef < 50.
Pulm pressures in constriction and restriction
Restriction has higher pulmonary pressures.
Constriction
B bump high peaked e prime
Balloon pump inflation
Early inflation loose dichrotic notch
Late inflation occurs before dichrotic notch
Late deflation goes into s2
Early deflation minimizes Afterload reduction
Indications for vad bt
Listed
1A or1b
Nyha 4
Criteria for dt
Lv ef
Dependence on inotropes for 14 days
Dependence on iabp for 7 days
Who should get an echo
Hx:Cad, valvular, fh of 1st degree,
ekg:Afib/flutter, EKG lvh lbb or q waves, ventricular arrhythmias
Pe: cardiomegally, s3, or murmurs.
Who should get an ace
Ef< 40
CVD
DM plus risk factor or smoker
What to ask about at follow up
Functional capacity Weight Compliance Arrhythmias Ischemia
The 10 commandments of sympomatic heart failure (10 class Ia guidelines).
- All Class I
- Diuretics/Salt restriction
- ACE
- Beta Blocker
- Arb if no ACE. Spirinolactone and Hydral/NTG for AA
- Avoid NSAIDs, antiarryhtmics and ccbs
7 Exercise Training - AICD for secondary prevention for all patients with reduced lv function
- AICD for primary prevention
- CRT if 120 with or without ICD
Afib goals in hf
rate or rhythm control
What is breathing reserve:
What is dyspnea index
Mvv-peak Ve/ mvv
Should be >30%
Mvv = fev1X35
DI= peak ve/mvv (should be <. 50)
2 things hemodynamically that favor construction
Redp > 1/3 rvesp
Discordance
3 things that favor restriction
Pas > 50
Lvedp-rvesp > 5
Concordance
Differences between central and obstructive sleep apnea
Central: 5 apneac episodes/hr
Obstructive: 10 s of effort but no breathing
Cpex variables that predict mortality.
Vo2 < 35 Lean vo2< 19 Predicted less than 50% O2 pulse less than 10cc At < 11 cc
Who are stage a patients
Diabetes, metabolic syndrome
Hypertensive, atherosclerosis, obesity
Using cardiac toxins
Fhx of cm
Eight 1a things to do for initial assesment of HF
- Pe: Bp, volume status, orthostasis
- Hx of toxins
- Functional status/adls
- EKG
- Echo
- Cath if have angina
- Labs: CBC, chem, UA, lfts, lipids thyroid hormone
A c x v y
A atria fills (s4, pr ) X atrial relaxes Qrs C av valve closes V atria fills (s2, tp segment). Y tricuspid valve opens up.
When does pa diastolic and systolic occur
Diastolic occurs with peak qrs
Systolic occurs at t wave