Cardiac - Heart failure, Pulmonary edema Flashcards
Heart failure
Definition
NYHA Classification
Differentiate low vs high output heart failure
Differentiate left vs right heart failure S/S
Differentiate HFrEF and HFpEF
Demographics
Risk factors
Difference in CXR
Systolic HF/ HFrEF
Causes
+ Myocarditis
+ Immune disorders: RA, SLE, Chagas
Diastolic HF/ HFpEF
Causes
High output heart failure
Causes
Heart failure
Pathophysiology
Heart failure
Mechanism of compensation and decompensation
Heart failure
Pathophysiology of pressure overload
Evidence of pressure overload
Heart failure
Pathophysiology of volume overload
Evidence of volume overload
Heart failure
Symptoms
Heart failure
Precipitating factors
Heart failure
Diagnostic criteria
Heart failure
History taking questions
Symptoms of HF: Dyspnea, orthopnea, edema, PND…
Past history of CAD, PVD, Stroke
Etiologies:
* Risk factors of CVS: Smoking, Metabolic syndrome (HT, DM,HL)
* Valvular diseases: CTD, Rheumatic fever…etc
* Systemic diseases: Thyroid storm, Pheochromocytoma …etc
* Cardiotoxic drugs: Chemo/RT, Substance abuse
Family history:
Sudden death at young age, FHx of myopathies, arrhythmias, premature CVD
Heart failure
P/E
Heart failure
Biochemical Ix
Heart failure
Radiological Ix
+ CXR
+ Coronary angiography
+ Cardiac MRI
Heart failure
CXR findings
Heart failure
Indications of coronary angiography and cardiac MRI
Heart failure
Acute HF causes
treatment principles
Respiratory causes:
* Acute respiratory failure
* Pulmonary embolism
Circulation emergency:
* Cardiogenic shock
* Hypertension emergency/ Malignant hypertension
Cardiac causes:
* Acute Coronary syndrome/ MI
* Arrhythmia
* Acute mechanical cause e.g. VHD, LVOTO
Systemic:
* Anemia
* Endocrine: e.g. thyroid storm, pheochromocytoma
* Adverse drug effects
Heart failure
General management
General:
* Bed rest
* O2 supplementation: NIV, NI-cPAP, Intubation, Mech. ventilation
* Low salt diet
* Fluid restriction
Monitor:
* Vitals: Orthostatic BP, O2 saturation, HR
* Fluid I/O, Weight
* Clinical: signs of peripheral congestion, symptoms of HF
* Electrolytes and renal function
Acute heart failure
Morphine MoA
Acute heart failure
Loop diuretics
- Indication
- MoA
- Drug choice
- S/E
Acute heart failure
Nitrates
- Indications
- Contraindications
- MoA
- Forms
- S/E
Acute heart failure
Inotropes
- Indications
- Contraindications
- MoA
- Forms
Summary of inotrope effects on heart rate and contractility
Chronic HFrEF
Treatment options
4 main pillars:
* ACEi/ ARB + Beta Blocker
* Mineralocorticoid receptor antagonist
* Angiotensin receptor neprilysin inhibitor (ARNI), Ivabradine
* Surgical: e.g. Cardiac resynchronization therapy (CRT)
Additional:
* Nitrate + Hydralazine if cannot tolerant ACEi and ARB
* Diuretics for volume overload
* Anti-coagulants, Digoxin, PCI for A-fib
* CABG/ PCI for CAD
Lifestyle modification
Salt restriction (< 2 g/day)
Fluid restriction (1.5 – 2 L/day)
Avoid smoking and alcohol
Weight monitoring and exercise training in ambulatory patients
Chronic HFrEF
ACEI/ ARB
- Indication
- MoA
- Drug choices
Chronic HFrEF
B-blockers
- Timing of initiation
- Indications
- MoA
- Drug choices
Chronic HFrEF
Diuretics
- Indication
- MoA
- Monitoring
- Drug choices
Chronic HFrEF additional therapy
ARNi
- Timing
- Indication
- MoA
- Drug choices
Chronic HFrEF additional therapy
MRA
- Prerequisite
- Indications
- MoA
- Drug choices
Chronic HFrEF additional therapy
Ivabradine
- Prerequisite
- Indications
- MoA
Chronic HFrEF additional therapy
Hydralazine + Nitrate
Indication
MoA
Chronic HFrEF additional therapy
Digoxin
Indication
HFrEF additional therapy options
Angiotensin receptor neprilysin inhibitors (ARNi)
Mineralocorticoid receptor antagonist (MRA)
Ivabradine
Hydralazine + Nitrates (Isosorbide dinitrate)
Digoxin
Sodium glucose transporter protein (SGLT-2) inhibitor (Empagliflozin)
No effect:
Statins have NO benefit in patients with HFrEF with or without coronary artery disease
CCBs have NO benefit in patients with HFrEF
Criteria for severity of LV dysfunction
Biomarker for heart failure
Brain Natriuretic Peptide (BNP) and NT-proBNP
Endogenous function: BNP from cardiomyocytes to resist fibrosis and myocardial hypertrophy by decreasing BP, sympathetic tone, RAAS activation
Cardiac causes of high BNP
Confounding non-cardiac causes of high BNP
Surgical Treatment options for HF
Devices:
* Cardiac Resynchronization therapy (CRT) (biventricular pacing)
* Cardiac assist devices: Pacemaker
* Implantable Cardioverter Defibrillator (ICD)
Revascularization:
* Cardiac Transplant
* CABG for ischemic cardiomyopathy
* Valvular surgery
* Left ventricular assist device (LVAD)
Clinical course of HF
Treatment of different hemodynamic profiles of heart failure
Congestion (both left or right heart) (Yes or No)»_space; S3, peripheral edema, orthopnea and PND, high JVP, Pulmonary edema
Perfusion (Adequate or poor)»_space; low peripheral temp and pulse
HF with congestion (Wet profile)
* Adequate peripheral perfusion - Wet and Warm - Treat hypertension and congestion with Vasodilators, Diuretics
* Poor peripheral perfusion - Wet and Cold - Inotropes, Vasopressors, Diuretics for low SBP; Vasodilators, Diuretics for normal SBP
HF without congestion (Dry profile)
* Adequate peripheral perfusion - Dry and warm - Compensated HF, adjust medication
* Poor peripheral perfusion - Dry and cold - treat hypoperfusion with Fluid Challenge, Inotropic agent
Chronic HFpEF
Treatment options
SGLT-2 inhibitor + ACEi/ ARB = major drugs
Additional:
* Slow HR, BP control: BB, CCB
* Diuretics for volume overload
* CAD - coronary revascularization
Pulmonary edema
Types
Pathophysiology
Cardiogenic pulmonary edema
Risk factors
Cardiogenic pulmonary edema
Precipitating factors
Non-cardiogenic pulmonary edema
Causes
Pulmonary edema
Ix, Dx
Acute pulmonary edema
Treatment flowchart
