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RC Test 2 > B4.028 Heart Failure: Clinical Manifestations and Treatment > Flashcards

B4.028 Heart Failure: Clinical Manifestations and Treatment Flashcards

1
Q

why is the HF population growing?

A

improved management of chronic cardiac disease

MI/HF/arrhythmia management

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2
Q

what is the definition of heart failure?

A

structural or functional cardiac abnormality

inability to adequately supple blood to metabolizing body tissues (inability to meet the body’s metabolic needs)

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3
Q

systolic cardiac dysfunction

A

impaired ability (usually LV) to eject blood

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4
Q

diastolic cardiac dysfunction

A

impaired ability of the LV to fill with blood

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5
Q

why is the diagnosis of HFpEF challenging?

A

largely a diagnosis of exclusion of other potential noncardiac causes of symptoms suggestive of HF

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6
Q

what are the 3 classes of causes of heart failure?

A 
underlying causes (diseases)
fundamental causes (pathophysiologic mechanisms)
precipitating causes (stimuli for deterioration)
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7
Q

HF underlying causes (diseases)

A 
CAD
hypertension
myocardial disease
valvular disease
pericardial disease
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8
Q

examples of myocardial disease that can cause HF

A 
dilated
infiltrative
inflammatory
hypertrophic
stress cardiomyopathy (Takotsubo)
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9
Q

examples of valvular diseases that can cause HF

A 
usually left sides
aortic stenosis
aortic regurg
mitral stenosis
mitral regurg
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10
Q

examples of pericardial disease that can cause HF

A

tamponade

constrictive pericarditis

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11
Q

what are the fundamental causes of HF?

A

increased hemodynamic burden or impaired myocardial O2 delivery triggers mechanisms that

  • impact contractility (inotropic state)
  • may promote increased TPR (increased afterload)
  • promote sodium and fluid retention (increased preload)
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12
Q

which systems are activated in HF

A

renin-angiotensin
SYM nervous system
remodeling-structural myocardial changes

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13
Q

precipitating causes of HF

A 
inappropriate reduction of therapy
arrhythmias
MI 
infection
PE
unrelated illness
drug side effects (NSAIDs)
cardiac toxins
severe stress
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14
Q

what factors need to be addressed to treat HF?

A

underlying etiologies
precipitating causes
deleterious reflex responses

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15
Q

what is LV dysfunction?

A

a pathophysiologic condition that can lead to the clinical syndrome of HF (5x more likely)
early recognition and treatment can limit progression

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16
Q

how do HF patients present?

A

decreased exercise tolerance
fluid retention
discomfort at rest (SOB, orthopnea)
increased TPR/ peripheral vasoconstriction

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17
Q

HF risk factors

A 
hypertension
CAD
older age
diabetes
obesity
smoking
valvular heart disease
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18
Q

diastolic dysfunction risk factors

A

older age
female gender
hypertension

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19
Q

what % of people have systolic vs diastolic HF

A

2/3 systolic

1/2 diastolic

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20
Q

what is a physical exam finding of peripheral vasoconstriction?

A

cool skin

cyanosis

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21
Q

ancillary tests for the diagnosis of HF

A 
EKG
CXR
echo
CMR
blood chemistry (BNP)
22
Q

what is BNP

A

brain natriuretic peptide
increased hormone level with increase ventricular wall stress due to PV overload
BNP < 100 acute HF not likely
BNP >500 acute HF likely
can’t distinguish systolic from diastolic

23
Q

EKG findings typical of HF

A 
prior MI
ventricular hypertrophy
arrhythmias
conduction abnormalities
low voltage
24
Q

CXR findings typical of HF

A

pulmonary edema/ vascular congestion

cardiomegaly (LV-LA-right heart)

25
Q

things to check on and echocardiogram for HF

A 
EF (norm 50-70%)
chamber sizes
wall thickness
regional wall motion abnormalities
valve abnormalities
doppler assessment of diastolic function
26
Q

ACCF/AHA stages of HF

A

A: at high risk, but without structural disease or symptoms
B: structural heart disease but without signs or symptoms of HF
C: structural heart disease with prior or current symptoms of HF
D: refractory HF requiring specialized interventions

27
Q

NYHA functional classes of HF

A

I. no limitation of physical activity, ordinary physical activity does not cause symptoms
II. slight limitation of physical activity, comfy at rest but ordinary physical activity results in symptoms
III. marked limitations of physical activity, comfy at rest, but less than ordinary activity causes symptoms
IV. unable to carry on any physical activity without symptoms, symptoms at rest

28
Q

evidence based treatments for systolic HF

A

vasodilators (nitrates, apresoline)
b-blockers (carvedilol, bisoprolol, metoprolol)
ACE inhibitors, angiotensin receptor blockers (ARB), aldosterone antagonists

29
Q

new meds for systolic HF

A

LCZ696: entresto (sacubitril/valsartan)

corlanor (ivabradine)

30
Q

agents for symptom management in systolic HF

A 
diuretics- reduce preload
inotropic agents (dobutamine, milrinone, digoxin) - augment contractility
31
Q

how does digoxin augment contractility

A

inhibits Na/K ATPase to decrease extrusion of Na+ and increase it intracellularly
increased intracellular Na+ inhibits the Na+/Ca2+ exchanger to decrease extrusion of Ca2+ and increase it intracellularly

32
Q

stage A treatment options

A

risk factor reduction
patient and family education
treat HTM, diabetes, dyslipidemia

33
Q

stage B treatment options

A

ACE inhibitors of ARBs in all patients

B-blockers in some patients

34
Q

stage C treatment options

A

ACE inhibitors and B-blockers in all patients
dietary sodium restriction, diuretics, digoxin
cardiac resynchronization if bundle block present
revascularization, mitral valve surgery
consider multidisciplinary team
aldosterone antagonist

35
Q

stage D treatment options

A

inotropes
VAD, transplantation
hospice

36
Q

primary goals of advanced HF management

A

improved survival and reduced readmissions

37
Q

how are recommendations classified?

A 
class I-III
class I benefit >>>risk
class IIA benefit >>risk
class IIb benefit > risk
class III no benefit or harmful
38
Q

how are levels of evidence classified?

A

level A: multiple populations evaluated (multiple random clinical trials or meta analysis)
level B: limited populations evaluated (single trial or nonrandomized studies)
level C: very limited populations evaluated (consensus opinion)

39
Q

nonpharmacological interventions for stage C HF

A 
I-B specific education
I-A exercise training
IIa-C sodium restriction
IIa-B CPAP for sleep apnea
IIa-B cardiac rehab
40
Q

class I treatment protocol for HFpEF

A

BP control

diuretics for symptom relief

41
Q

when do you use diuretics in stage C HFrEF?

A

whenever someone has fluid retention, class I rec

42
Q

when do you use ACE inhibs in stage C HFrEF?

A

all patients, class I rec

43
Q

when do you use ARBs in stage C HFrEF?

A

patients where ACE inhibs don’t work, class I rec

44
Q

when do you use b-blockers in stage C HFrEF?

A

all stable patients, class I rec

45
Q

when do you use aldosterone antagonists in stage C HFrEF?

A 
NYHA class II-IV HF with LVEF <35%
patients following acute MI with LVEF <40%
46
Q

when do you use hydralazine/isosorbide dinitrate in stage C HFrEF?

A

African americans with NYHA class III-IV HF

47
Q

when do you use anticoagulation in stage C HFrEF?

A

chronic HF with AF and additional risk factors for cardioembolic stroke
selection of anticoagulant should be individualized

48
Q

what is an ICD?

A

implantable cardioverter defibrillator
small device in chest/abdomen with leads in heart
uses electrical pulses to help control life threatening arrhythmias

49
Q

what is CRT?

A

cardiac resynchronization therapy

sequentially paces cardiac ventricles in a more synchronized and physiologic pattern

50
Q

what are the recs for stage D HF?

A 
water restriction
inotropic support
mechanical circulatory support
LVAD (left ventricular assist device)
cardiac transplantation
51
Q

surgical/ percutaneous/ transcatheter interventional treatments of HF

A

CABG
PCI (percutaneous coronary artery intervention)
aortic or mitral valve surgery
resection of ventricular aneurysm

RC Test 2 (17 decks)

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