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
Hypertension, tachycardia, and myocardial ischemia (even in the absence of CAD) can further impair diastolic filling. All of these mechanisms contribute to higher LV end-diastolic pressures, which are reflected back to the _____.
Pulmonary capillary circulation
One underappreciated aspect of myocardial function in AHF relates to the interdependence of the left and right ventricles. Because of the constraints of the pericardial space, distention of either ventricle due to increased filling pressures can result in direct impingement of _____ of the other ventricle
Diastolic filling
In a representative analysis of data from the _____ study using a highly sensitive assay, 90% of patients enrolled had a troponin T level above the 99th percentile upper reference limit at baseline, and troponin elevation was associated with post-discharge outcomes out to 180 days
RELAX-AHF
The precise mechanisms mediating myocardial injury in AHF are poorly defined, but _____ may all contribute to myocyte injury even in the absence of epicardial CAD
Increased myocardial wall stress
Decreased coronary perfusion pressure
Increased myocardial oxygen demand
Endothelial dysfunction
Activation of the neurohormonal and inflammatory pathways
Platelet activation
Altered calcium handling
Specific therapeutic interventions that may increase myocardial oxygen demand (such as _____) or decrease coronary artery perfusion pressure (such as some _____) may exacerbate myocardial injury and further contribute to the cycle of decompensation
Increase O2 demand: positive inotropic agents
Decrease CaPP: Vasodilators
The kidney plays two fundamental roles relative to the pathophysiology of HF:
(1) It modulates loading conditions of the heart by controlling intravascular volume
(2) it is responsible for neurohormonal outputs (i.e.,the RAAS system)
Although often assumed to be related to low cardiac output and renal blood flow, careful hemodynamic studies have repeatedly confirmed that the strongest predictor of worsening renal function in heart failure patients relates to _____, which is reflected back to the renal veins and leads directly to changes in GFR.
Elevated central venous pressure (CVP)
_____ renal function in the setting of ongoing clinical improvement is generally reflective of successful decongestion and does not portend a poor prognosis
Worsening renal function
Abnormalities of endothelial function related to _____ dependent regulation of vascular tone are well described in heart failure.
Nitric oxide
_____, which is related to but distinct from blood pressure, increases cardiac loading conditions and is associated with incident heart failure and worse outcomes.
Arterial stiffness
_____ in the setting of AHF redistributes blood centrally, increasing pulmonary venous congestion and edema.
Peripheral vasoconstriction
As noted earlier, elevated CVP reduces _____, resulting in greater fluid retention, which further elevates venous pressures
Renal function
Abnormal vascular compliance also predisposes these patients to marked blood pressure liability with relatively minor changes in intravascular volume, causing _____.The effects of this vascular abnormality are amplified by LV diastolic dysfunction.
Precipitous increases in afterload and ultimately in LV filling pressures resulting in pulmonary congestion
Peripheral arterial vasoconstriction increases _____ resulting in worsening of pulmonary edema and dyspnea.
Afterload
LV filling pressures
Post-capillary pulmonary venous pressures
The clinical observation that vasodilator treatment can improve dyspnea in many acutely hypertensive patients without significant diuresis has led to the concept that _____ mismatch can lead to increased diastolic filling pressures in the setting of minimal total body volume changes
Afterload-contractility mismatch
Increased plasma concentrations of _____ have all been reported in patients with AHF—all of these axes are associated with vasoconstriction and volume retention, which could contribute to myocardial ischemia and congestion,thus exacerbating cardiac decompensation
Norepinephrine
Plasma renin activity
Aldosterone
Endothelin-1 (ET-1)
Pro-inflammatory cytokines such as tumor necrosis factor-alpha and interleukin-6 are elevated in patients with AHF and have direct _____ effects on the myocardium as well as increasing capillary permeability and inducing endothelial dysfunction
Negative inotropic effects ( TNFa and IL-6)
The initial evaluation of the patient with AHF focuses on the following critical aspects:
(1) establishing a definitive diagnosis of AHF as rapidly and efficiently as possible;
(2) emergent treatment for potentially life- threatening conditions (e.g., shock, respiratory failure);
(3) identifying and addressing any relevant clinical triggers or other condition requiring specific treatment (e.g.,acute coronary syndrome [ACS],acute pulmonary embolism, etc.);
(4) risk stratification in order to triage patient to appropriate level of care (e.g., intensive care unit [ICU], telemetry unit, observation unit);
(5) defining the clinical profile of the patient (based on blood pressure, volume status, and renal function) in order to rapidly implement the most appropriate therapy
In suspected patients with AHF, these constitutes the immediate phase (initial 60-120 mins)
C - acute Coronary syndrome
H - Hypertensive emergency
A - Arrhythmia
M - acute Mechanical cause
P - Pulmonary embolism
In suspected patients with AHF, these constitutes the urgent phase after first medical contact
Check for cardiogenic shock and respiratory failure
There are several relevant domains to consider in classifying patients with AHF. These include:
(1) Substrate (i.e., whether there is a prior history of structural heart disease or a background of chronic HF)
(2) Severity (from mild symptoms to cardiogenic shock)
(3) Acuity (gradual onset vs. sudden/acute onset)
(4) Triggers (which may be readily apparent or unknown)
_____ makes up about 20% of hospitalizations for AHF. These patients may have no prior history of cardiovascular disease or risk factors (e.g.,acute myocarditis),but more commonly,t hey have a background of risk factors for HF (stage A heart failure according to the American College of Cardiology/American Heart Association [ACC/AHA] guidelines) or preexisting structural heart disease (stage B heart failure according to the ACC/AHA guidelines)
New-onset or de novo heart failure
Cardiogenic shock is relatively uncommon (_____% of AHFS presentations in EuroHeart Failure Survey II [EHFS II]) in broad community registries but more common in tertiary care settings.
4%
The fact that many patients may have slowly developing symptoms over days to weeks presents the possibility that early intervention with _____ may prevent some hospitalizations
Intensified therapy
AHF may be triggered by very clear precipitants or alternatively the reason for decompensation may be obscure.In the OPTIMIZE-HF registry, 61% of enrolled subjects had an identifiable clinical precipitant, with _____ being the most common.
Pulmonary processes (15%)
Myocardial ischemia (15%)
Arrhythmias (14%)
More than one precipitant was identified in a substantial minority of the study population. Of the identified triggers, _____ was associated with the highest in-hospital mortality (8%), whereas _____ had a much better prognosis (<2% in-hospital mortality for each)
Worsening renal function: Highest in-hospital mortality
Better prognosis: nonadherence to diet or medication or uncontrolled hypertension
Dyspnea is the most common symptom and is present in over _____% of patients presenting with AHF.
90%
_____, or the sensation of dyspnea on bending over, is a commonly reported symptom that has recently been validated experimentally
Bendopnea
SBP is typically normal or elevated in patients with AHF, with almost 50% presenting with SBP greater than _____ mm Hg
140 mm Hg
The combination of _____ can result in elevations of SBP consistent with hypertensive urgencies or emergencies (12% of patients had an SBP over 180 mm Hg on admission).
Underlying hypertension
Marked increase in sympathetic stimulation that accompanies AHF
Patients with very low SBP are uncommon, with only _____% of patients in ADHERE presenting with an SBP less than 90 mm Hg.
2%
A high pulse pressure may alert the physician to a high output state including the possibility of _____.
Unrecognized thyrotoxicosis
Aortic regurgitation
Anemia
_____ is a useful measure that is an indirect marker of cardiac output
Pulse pressure (the difference between systolic and diastolic blood pressure)
The _____ is a barometer of systemic venous hypertension and is the single most useful physical examination finding in the assessment of patients with AHF
JVP
A low pulse pressure is a marker of a _____ and confers an increased risk in patients admitted with AHF.
Low cardiac output
The accurate assessment of the JVP is highly dependent on examiner skill.The JVP reflects the _____, which typically (although not always) is an indirect measure of LV filling pressures.
RAP
_____ are the most common physical examination finding and have been noted in 66% to 87% of patients admitted for AHF
Rales or inspiratory crackles
JVP may not reflect LV filling pressures in _____ can complicate the assessment of the JVP because the large “CV wave” of tricuspid regurgitation can lead to its overestimation.
Isolated RV failure (e.g., from pulmonary hypertension or RV infarct)
Significant tricuspid regurgitation
However, rales are often not heard in patients with a background of chronic heart failure and pulmonary venous hypertension, due to _____, reinforcing the important clinical pearl that the absence of rales does not necessarily imply normal LV filling pressures
Increased lymphatic drainage
Cool extremities with palpable peripheral pulses suggest _____ consistent with a marginal cardiac index, marked vasoconstriction, or both
Decreased peripheral perfusion
Symptoms related to fluid overload
Dyspnea (exertional, paroxysmal nocturnal dyspnea, orthopnea, or at rest); cough; wheezing
Foot and leg discomfort
Abdominal discomfort/bloating; early satiety or anorexia
Signs related to fluid overload
Rales, pleural effusion
Peripheral edema (legs, sacral)
Ascites/increased abdominal girth; right upper quadrant pain or discomfort; hepatomegaly/ splenomegaly; scleral icterus
Increased weight
Elevated jugular venous pressure, abdominojugular reflux
Increasing S3, accentuated P2
Symptoms related to Hypoperfusion
Fatigue
Altered mental status, daytime drowsiness, confusion, or difficulty concentrating
Dizziness, pre-syncope, or syncope
Signs related to Hypoperfusion
Cool extremities
Pallor, dusky skin discoloration, Hypotension
Pulse pressure (narrow)/proportional pulse pressure (low)
Pulsus alternans
Peripheral edema is present in up to ___% of patients admitted with AHF and is less common in patients presenting with predominantly low-output heart failure or cardiogenic shock
65%
As with rales, the presence of _____ has a reasonable positive predictive value for AHF but a low sensitivity, so its absence does not exclude that diagnosis
Edema
Edema due to AHF is usually dependent, symmetric, and pitting. It is estimated that a minimum of _____ liters of extracellular fluid is accumulated to produce clinically detectable edema.
4L
In diagnostic testing, natriuretic peptides have greater _____ predictive value (i.e., the ability to rule out heart failure as a cause of dyspnea) than _____ predictive value (i.e.,the ability to definitively identify a diagnosis of heart failure as the cause of dyspnea)
Negative
Positive
Assessment of cardiac troponin in patients with AHF is now a Class I recommendation in clinical guidelines and serves to both establish prognosis as well as inform the likelihood of concurrent ACS. It is important to note that elevation of troponin in the context of a typical AHF hospitalization without clinical evidence of ACS is NOT synonymous with a Type ____ MI based on the updated fourth universal MI definition.
Type II MI
_____ is more directly related to the severity of AHF than creatinine, as it integrates both renal function and neurohormonal activation in AHF.
Blood urea nitrogen (BUN)
In the ADHERE registry, 90% of patients underwent chest radiography during hospitalization and there was evidence of congestion in over __% of these patients.
80%
Arrhythmias are also a common trigger for AHF, and atrial fibrillation is present in _____%.
20-30%
An _____ is generally the single most useful test in evaluating the cause in the patient with AHF.
Echocardiogram
The tissue Doppler ratio of peak early diastolic trans-mitral blood flow velocity (E) to the peak early diastolic mitral annular tissue velocity (Ea) (E:Ea ratio) has been shown to be additive to BNP measures in diagnosing AHF patients presenting with dyspnea. An E:Ea ratio of greater than _____ predicts a pulmonary capillary wedge pressure (PCWP) greater than _____ mm Hg and has been demonstrated to be accurate in the emergency room and intensive care settings.
E:Ea >15 = PCWP 15 mm Hg
The initial goals in the management of a patient presenting with AHF are to _____.
(1) Expeditiously establish the diagnosis
(2) Treat life-threatening abnormalities
(3) Initiate therapies to provide symptom relief
(4) Identify the cause and precipitating triggers for the episode of AHF
In patients with hypoxemia (SaO2 < ___%), oxygen administration is recommended.
<90%
Although oxygen saturation on presentation is inversely
related to short-term mortality, inhaled oxygen (FiO2 >/= ____) may cause detrimental hemodynamic effects (such hyperoxia-induced vasoconstriction) in patients with systolic dysfunction, therefore it is not routinely recommended for patients without hypoxemia
> /= 40%
The _____trial enrolled 1069 patients with pulmonary edema who were randomized to standard oxygen therapy, CPAP, or NIPPV. NIV with CPAP or NIPPV was associated with greater improvement in patient-reported dyspnea, heart rate, acidosis, and hypercapnea after 1 hour of therapy, although it was not associated with a 7-day mortal- ity benefit nor a decreased need for intubation when compared with standard oxygen therapy
Three Interventions in Cardiogenic Pulmonary Oedema (3CPO)
_____ are the most frequently administered pharmacologic therapy for AHF; over 75% of patients in the emergency department receive intravenous diuretics, with a mean door to first intravenous administration time of 2.2 hours in ADHERE.
IV Loop diuretics
Whereas some patients with volume redistribution rather than hypervolemia may derive benefit from vasodilators alone, symptomatic patients with objective evidence of congestion consistent with pulmonary or systemic venous hypertension or edema should generally receive urgent diuretic therapy for relief of symptoms related to congestion. Initial therapy is typically a bolus injection with a dose between _____ times the patient’s oral loop diuretic dose for patients on chronic diuretic therapy
1 and 2.5x
In the absence of hypotension, vasodilators may have a role in the initial therapy of patients with pulmonary edema and poor oxygenation. A treatment strategy of early initiation of _____ therapy in patients with severe cardiogenic pulmonary edema has been shown to reduce the need for mechanical ventilation and the frequency of MI
IV nitrate therapy
In general, hospitalization is recommended for patients with _____.
(1) Evidence of significant decompensated heart failure, including hypotension, worsening renal function, or altered mentation;
(2) Significant hypoxemia
(3) Hemodynamically significant arrhythmia (most commonly atrial fibrillation either with rapid ventricular response or new onset)
(4) ACS
Hospitalization should be considered in patients with worsened congestion, even in the absence of dyspnea and often reflected by _____.
(1) Significant weight gain (5 kg)
(2) Other signs or symptoms of pulmonary or systemic congestion
(3) Newly diagnosed heart failure
(4) Complications of heart failure therapy (such as electrolyte disturbances
(5) Frequent implantable cardioverter-defibrillator [ICD] firings)
(6) Other associated comorbid condition
_____ is the most common tachyarrhythmia requiring treatment in patients with AHF.
Atrial fibrillation with rapid ventricular response
In patients with AF with RVR and systolic dysfunction, _____ may be used. _____ and other agents that suppress ventricular function should be avoided in patients with significant systolic dysfunction but may be effective in patients with preserved function.
Intravenous digoxin (in the absence of an accessory pathway), cautious use of beta blocker therapy, or amiodarone
Diltiazem