B4.028 Heart Failure: Clinical Manifestations and Treatment Flashcards
why is the HF population growing?
improved management of chronic cardiac disease
MI/HF/arrhythmia management
what is the definition of heart failure?
structural or functional cardiac abnormality
inability to adequately supple blood to metabolizing body tissues (inability to meet the body’s metabolic needs)
systolic cardiac dysfunction
impaired ability (usually LV) to eject blood
diastolic cardiac dysfunction
impaired ability of the LV to fill with blood
why is the diagnosis of HFpEF challenging?
largely a diagnosis of exclusion of other potential noncardiac causes of symptoms suggestive of HF
what are the 3 classes of causes of heart failure?
underlying causes (diseases) fundamental causes (pathophysiologic mechanisms) precipitating causes (stimuli for deterioration)
HF underlying causes (diseases)
CAD hypertension myocardial disease valvular disease pericardial disease
examples of myocardial disease that can cause HF
dilated infiltrative inflammatory hypertrophic stress cardiomyopathy (Takotsubo)
examples of valvular diseases that can cause HF
usually left sides aortic stenosis aortic regurg mitral stenosis mitral regurg
examples of pericardial disease that can cause HF
tamponade
constrictive pericarditis
what are the fundamental causes of HF?
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)
which systems are activated in HF
renin-angiotensin
SYM nervous system
remodeling-structural myocardial changes
precipitating causes of HF
inappropriate reduction of therapy arrhythmias MI infection PE unrelated illness drug side effects (NSAIDs) cardiac toxins severe stress
what factors need to be addressed to treat HF?
underlying etiologies
precipitating causes
deleterious reflex responses
what is LV dysfunction?
a pathophysiologic condition that can lead to the clinical syndrome of HF (5x more likely)
early recognition and treatment can limit progression
how do HF patients present?
decreased exercise tolerance
fluid retention
discomfort at rest (SOB, orthopnea)
increased TPR/ peripheral vasoconstriction
HF risk factors
hypertension CAD older age diabetes obesity smoking valvular heart disease
diastolic dysfunction risk factors
older age
female gender
hypertension
what % of people have systolic vs diastolic HF
2/3 systolic
1/2 diastolic
what is a physical exam finding of peripheral vasoconstriction?
cool skin
cyanosis
ancillary tests for the diagnosis of HF
EKG CXR echo CMR blood chemistry (BNP)
what is BNP
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
EKG findings typical of HF
prior MI ventricular hypertrophy arrhythmias conduction abnormalities low voltage
CXR findings typical of HF
pulmonary edema/ vascular congestion
cardiomegaly (LV-LA-right heart)
things to check on and echocardiogram for HF
EF (norm 50-70%) chamber sizes wall thickness regional wall motion abnormalities valve abnormalities doppler assessment of diastolic function
ACCF/AHA stages of HF
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
NYHA functional classes of HF
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
evidence based treatments for systolic HF
vasodilators (nitrates, apresoline)
b-blockers (carvedilol, bisoprolol, metoprolol)
ACE inhibitors, angiotensin receptor blockers (ARB), aldosterone antagonists
new meds for systolic HF
LCZ696: entresto (sacubitril/valsartan)
corlanor (ivabradine)
agents for symptom management in systolic HF
diuretics- reduce preload inotropic agents (dobutamine, milrinone, digoxin) - augment contractility
how does digoxin augment contractility
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
stage A treatment options
risk factor reduction
patient and family education
treat HTM, diabetes, dyslipidemia
stage B treatment options
ACE inhibitors of ARBs in all patients
B-blockers in some patients
stage C treatment options
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
stage D treatment options
inotropes
VAD, transplantation
hospice
primary goals of advanced HF management
improved survival and reduced readmissions
how are recommendations classified?
class I-III class I benefit >>>risk class IIA benefit >>risk class IIb benefit > risk class III no benefit or harmful
how are levels of evidence classified?
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)
nonpharmacological interventions for stage C HF
I-B specific education I-A exercise training IIa-C sodium restriction IIa-B CPAP for sleep apnea IIa-B cardiac rehab
class I treatment protocol for HFpEF
BP control
diuretics for symptom relief
when do you use diuretics in stage C HFrEF?
whenever someone has fluid retention, class I rec
when do you use ACE inhibs in stage C HFrEF?
all patients, class I rec
when do you use ARBs in stage C HFrEF?
patients where ACE inhibs don’t work, class I rec
when do you use b-blockers in stage C HFrEF?
all stable patients, class I rec
when do you use aldosterone antagonists in stage C HFrEF?
NYHA class II-IV HF with LVEF <35% patients following acute MI with LVEF <40%
when do you use hydralazine/isosorbide dinitrate in stage C HFrEF?
African americans with NYHA class III-IV HF
when do you use anticoagulation in stage C HFrEF?
chronic HF with AF and additional risk factors for cardioembolic stroke
selection of anticoagulant should be individualized
what is an ICD?
implantable cardioverter defibrillator
small device in chest/abdomen with leads in heart
uses electrical pulses to help control life threatening arrhythmias
what is CRT?
cardiac resynchronization therapy
sequentially paces cardiac ventricles in a more synchronized and physiologic pattern
what are the recs for stage D HF?
water restriction inotropic support mechanical circulatory support LVAD (left ventricular assist device) cardiac transplantation
surgical/ percutaneous/ transcatheter interventional treatments of HF
CABG
PCI (percutaneous coronary artery intervention)
aortic or mitral valve surgery
resection of ventricular aneurysm
