Cardiology: Congestive Heart Failure Flashcards
Define congestive heart failure
clinical condition caused by ability of the heart to pump enough blood to maintain fluid and metabolic homeostasis
Name 5 risk factors for CHF?
CAD HTN cardiomyopathy valvular heart disease DM
how is CHF classified? 4
American Heart Association/American College of Cardiology-based on clinical syndromes
New York Heart Association (NYHA)-functional severity
left sided vs right-sided failure
systolic vs nonsystolic failure
how is systolic dysfunction defined? 2
EF< 50%
Increased left ventricular end diastolic volume
how is systolic dysfunction caused?
inadequate left ventricular contractility or increased afterload
how does the heart compensate for decreased EF and increased preload? what law is this? what happens when compensation fails? 2
hypertrophy
ventricular dilation
Frank-Starling Law
compensation fails causing increased myocardial work and worsening systolic function
A man was admitted for a CHF exacerbation with low EF. The patient is now ready for discharge, and his medications include furosemide, and metoprolol. What is the nxt step in management?
Add and ACEI to this pts current regimen ACEI have been shown to have a + mortality benefit when used with beta-blockers in NYHA class II-IV heat failure patients
Name some signs and symptoms of systolic heart failure?
mc=extertional dyspnea
progresses to orthopnea, paroxysmal nocturnal dyspnea (PND), and rest dyspnea
chronic cough, fatigue, peripheral edema, nocturia, and/or abdominal fullness
name 5 findings on PE for systolic heart failure?
parasternal lift an elevated and sustained left ventricular impulse S3/S4 gallop JVD peripheral edema
what will a CXR show in systolic heart failure?
cardiomegaly, cephalization of pulmonary vessels, pleural effusions, vascular congestion, interstitial edema, and prominent hila. figure 2.1-7
what will ECHO show in systolic heart failure?
will show EF and ventricular dilation
what lab abnormalities will show in systolic heart failure?
BNP>500pg/mL
increased creatinine (sometimes)
decreased Na in later stages
what will ECG show in systolic heart failure?
usually non diagnostic
can help show underlying causes-AF, and old MI, or LVH
What two CHF medications provide symptomatic relief for systolic HF and confer no mortality benefit?
diuretics and digoxin
What is treatment for acute pulmonary congestions in pt with systolic HF management? use LMNOP mnemonic
Lasix Morphine Nitrates Oxygen Position (upright)
What underlying causes can be corrected in treating systolic HF?
arrhythmias
MI
drugs (CCBs, antiarrhythmics, NSAIDs, alcohol, thyroid and valvular disease, high-output states)
what drugs do you give to aggressively diuresis someone with acute systolic HF?
loop and thiazide diuretics
what should be given to treat all patients with acute systolic HF? What do you give if they can’t tolerate it? what should be avoided?
ACEIs
ARBs
Beta-blockers should be avoided if pt is decompensated but can be started once euvolemic
Describe NYHA functional classification of CHF?
Class I- no limitation of activity, no symptoms with normal activity
Class II- slights limitation of activity, comfortable at rest or with mild exertion
Class III- marked limitation of activity, comfortable only at rest
Class IV- any physical activity brings on discomfort, symptoms present at rest
left sided, right sided, or both?
- dyspnea predominates
- fluid retention predominates
- S3/S4 gallop
- bilateral basilar rales
- JVD
- hepatojugular reflex
- pleural effusions
- pulmonary edema
- hepatomegaly,ascites
- orthopnea, paroxysmal nocturnal dyspnea
- dyspnea predominates=left
- fluid retention predominates=right
- S3/S4 gallop=both
- bilateral basilar rales=left
- JVD=right
- hepatojugular reflex=right
- pleural effusions=left
- pulmonary edema=left
- hepatomegaly,ascites=right
- orthopnea, paroxysmal nocturnal dyspnea=left
What lifestyles changes are used to treat chronic systolic HF?
limit salt intake
limite fluid intake
treat co-morbid conditions
what medications are used to prevent remodeling of the heat and decrease mortality for NYHA class II-IV pts? 2 what should be avoided?
long term beta blockers
ACEIs/ARBs
avoid CCBs
what 2 medications are recommended for chronic systolic HF if underlying cause is prior MI?
daily ASA
statin
what medication combination can prevent fluid overload in pt with chronic systolic HF?
loop diuretics +/- thiazide
when should pts with chronic systolic HF be anticoagulated?
previous embolic events, AF, or mobile left ventricular thrombus
Which medication is shown to decreased mortality in pts with NYHA class III-IV HF?
low dose spironolactone
what should be considered in pts with EF<35% in chronic systolic HF?
biventricular cardiac defibrillator (ICD)
what 2 things can be considered in CHF that is unresponsive to maximal medical therapy?
mechanical left ventricular assist device or cardiac transplantation
how is calcium levels affected with loop vs thiazide diuretics?
loops lose calcium
thiazides take it in
define non systolic dysfunction
decreased ventricular compliance with normal systolic function
what are two etiologies of non systolic dysfunction?
impaired active relaxation (ischemia, aging, hypertrophy)
impaired passive filling (scarring from prior MI, restrictive cardiomyopathy)
In nonsystolic dysfunction what happens to LVEDP, CO, and EF?
LVEDP increased
CO remains normal
EF normal or increased
what is pt’s age in systolic vs nonsystolic dysfunction?
systolic=65 yrs
what cormorbidities in systolic vs nonsystolic dysfunction?
systolic=dilated cardiomyopathy, valvular heat disease
nonsystolic=restrictive or hypertrophic cardiomyopathy’ renal disease or HTN
what PE findings in systolic vs nonsystolic dysfunction?
systolic=displaced PMI, S3 gallop
nonsystolic= sustained PMI, S4 gallop
what findings on CXR in systolic vs nonsystolic dysfunction?
systolic=pulmonary congestion, cardiomegaly
nonsystolic=pulmonary congestion,normal heart size
what ECG/ECHO findings in systolic vs nonsystolic dysfunction?
systolic=Q waves, decreased EF (55%)
name signs/symptoms of nonsystolic HF? 8
stable and unstable angina
SOB, dyspnea on exertion, arrhythmias, MI, HF, and sudden death
name treatment for nonsystolic HF? first line, BP controlled how, what isn’t useful?
diuretics are first line therapy
maintain rate and BP control via beta-blockers, ACEIs, ARBs, or CCBs
digoxin is not useful in these pts
