B P6 C49 Diagnosis and Management of Acute Heart Failure Flashcards
The prevalence of HF is projected to continue to increase over time due to a convergence of several epidemiologic trends:
(1) The aging of the population, given the age-related incidence of HF
(2) The reduction in hypertension-related mortality and the greatly improved survival after myocardial infarction (MI), resulting in more patients living with chronic heart failure
(3) The availability of effective therapy for prevention of sudden death
On the basis of available registry data, _____% of patients hospi- talized have heart failure with preserved ejection fraction (HFpEF).
40-50%
The in-hospital mortality of patients with HFpEF appears to be lower com- pared with that of patients with HFrEF, but post-discharge rehospitalization rates and long-term mortality after hospitalization are similarly high for _____.
Both
Patients with AHF and HFpEF are more likely to be rehospitalized for and to die from non-CV causes than patients with AHF and HFrEF, reflecting their _____.
More advanced age and greater burden of comorbidity
There are significant differences in the epidemiology of AHF based on age, race, and gender. AHF disproportionally affects older people, with a mean age of _____ years in large registries
75 years
In the ADHERE registry women admitted for AHF were older than men (74 vs. 70 years), and more frequently had _____ systolic function (51% vs. 28%).
Preserved
Differences in ethnic groups have been studied most extensively in the United States and have focused primarily on differences between African American and white patients. In the _____ registry, African American patients admitted with AHF were younger (64 vs. 75 years), more likely to have left ventricular (LV) systolic dysfunction (57% vs. 51%) with a lower mean EF (35% vs. 40%), hypertensive cause for heart failure (39% vs.19%), renal dysfunction, and diabetes compared to the non–African American group.
Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF)
_____ is the most prevalent concurrent condition, present in approximately two-thirds of the patients, whereas _____ is present in about half and _____ in over one-third.
Hypertension: 2/3
CAD: 1/2
Dyslipidemia: 1/3
The interaction between heart failure status and diabetes has been a subject of substantial interest, given the evolving data that some classes of anti-diabetic drugs, specifically the _____, have a favorable impact on heart failure outcomes
Sodium-glucose co-transporter-2 (SGLT-2) inhibitors
Glucagon-like peptide-1 (GLP-1) agonists
Alternatively, some patients may have no prior history of HF but abnormal substrate (e.g., stage B patients with asymptomatic LV dysfunction) with a first presentation of heart failure (_____ heart failure)
De Novo Heart Failure
For patients with normal substrate (normal myocardium),a substantial insult to cardiac performance (e.g.,_____) is generally required to lead to the clinical presentation of AHF.
Acute myocarditis
For patients with abnormal substrate at baseline (asymptomatic LV dysfunction), smaller perturbations (e.g., _____) may precipitate an AHF episode.
Poorly controlled hypertension
Atrial fibrillation
Ischemia
For patients with a substrate of compensated or stable chronic HF, _____, are all common triggers for decompensation.
Medical or dietary nonadherence
Drugs: NSAIDs or thiazolidinediones
Infectious processes
Regardless of the substrate or initiating factors, a variety of “amplifying mechanisms” perpetuate and contribute to the episode of decompensation.These include _____, all of which may contribute to the propagation and worsening of the AHF episode.
(1) Neurohormonal and inflammatory activation
(2) Ongoing myocardial injury with progressive myocardial dysfunction
(3) Worsening renal function
(4) Interactions with the peripheral vasculature
Systemic or pulmonary congestion often due to a _____ dominates the clinical presentation of most patients hospitalized for AHF
High ventricular diastolic pressure
_____can be seen as a final common pathway producing clinical symptoms leading to hospitalization
Congestion
An oversimplified view of AHF pathophysiology is that _____ lead to symptoms of congestion and clinical presentation, and normalization of volume status with diuretic therapy results in restoration of homeostasis
Gradual increases in intravascular volume
Although patients present with signs and symptoms of systemic congestion such as dyspnea, rales, elevated jugular venous pressure (JVP), and edema, this state is often preceded by “_____ congestion,” defined as high ventricular diastolic pressures without overt clinical signs.
Hemodynamic congestion
It has been postulated that hemodynamic congestion may contribute to the progression of HF because it may result in increased wall stress as well as in renin- angiotensin-aldosterone system (RAAS) and sympathetic nervous system (SNS) activation.
This may trigger a variety of molecular responses in the myocardium, including _____.
Myocyte loss and increased fibrosis
In addition, elevated diastolic filling pressures may decrease _____, resulting in sub-endocardial ischemia that may further exacerbate cardiac dysfunction.
Coronary perfusion pressure
Increased LV filling pressures can also lead to acute changes in ventricular architecture (more spherical shape),contributing to worsening _____.
Mitral regurgitation
Changes in systolic function and decreased arterial filling can initiate a cascade of effects that are adaptive in the short term but maladaptive when elevated chronically, including stimulation of the SNS and RAAS. Activation of these neurohormonal axes leads to _____.
Vasoconstriction
Sodium and water retention
Volume redistribution from other vascular beds
Increases in diastolic filling pressures
Clinical symptoms
In patients with underlying ischemic heart disease, initial defects in systolic function may initiate a vicious cycle of _____.Increased LV filling pressures and changes in LV geometry can worsen functional mitral regurgitation, further decreasing cardiac output.
Decreasing coronary perfusion
Increased myocardial wall stress
Progressively worsening cardiac performance
Importantly, abnormalities in diastolic function are present in heart failure patients regardless of EF. The impairment of the diastolic phase may be related to _____.
Passive stiffness
Abnormal active relaxation of the left ventricle
Both