Chapter 81 - Heart failure

Question 1

Define Heart failure

Answer 1

state where heart is incapable to pump adequate blood supply to meet the metabolic demands of the body OR requires elevated filling pressures to meet these demands

Cardiac index: a measurement that relates cardiac output from the LV to the body surface area. Determined by CRAP: (contractility, rate-heart, afterload and preload)

Question 2

List the 5 most common disease processes resulting in HF

Answer 2

1) Coronary artery disease
2) cardiomyopathy/myocarditis
3) Valvular heart disease
mitral or aortic valve regurg
4) pericardial disease
pericardial effusion
5) pulmonary disease
COPD
PE

Question 3

Describe the different classifications of heart failure

Answer 3

a) acute vs. chronic
in ER, mostly see acutely decompensated HF ( i..e due to a large MI leading to acute pulmonary edema)

b) systolic vs. diastolic function
- systolic dysfunction in HF: LVEF<40% (stroke output reduced, less forward flow)

-diastolic dysfunction: failure of ventricles to relax, leading to high filling pressure.
these people can have HF with a normal EF>
commonly asymptomatic, especially in hypertrophic and restrictive cardiomyopathy, hypertension, AS
very hard to treat

c) Right vs. Left sided HF
Right HF: HSM, edema, systemic venous congestion, JVP elevated

d) High output vs low output HF:

Question 4

Describe the NYHA function HF classes and the killip classification

Answer 4

I. asymptomatic on ordinary physical activity
II.symptomatic on ordinary physical activity
III. Symptomatic on less than ordinary physical activity
IV: symptomatic at rest

Killip classes:
Class I: no clinical signs of HF
II: rales or crakles in the lungs, an S3, elevated JVP
III. frank pulmonary edema
IV: cardiogenic shock or hypotension and evidence or peripheral vasoconstriction (oliguria, cyanosis or sweating)

killip classes is used to predict mortality post- acute MI

Question 5

What are 10 common precipitants of acute HF

Answer 5

1) sodium and volume excess
i. e. patient that missed dialysis
2. systemic hypertension
3. MI or ischemia
4. systemic infection
5. dysrhythmia
6. acute hypoxia or respiratory distress
7. anemia
8. pregnancy
9. thyroid disorders
10. acute myocarditis
11. acute valvular dysfunction
12. PE
13. excess exertion or trauma
14. pharmacological complications

Cardiac 
- rate, rhythm, muscle 
Pulmonary: 
-PE, COPD, untreated OSA
Pharmacological: 
-cocaine
-corticosteroids, NSAIDS, and vasodilator medications leading to sodium retention and volume expansion 
-NSAIDS are bad for people with CHF 
-metabolic/systemic: missed dialysis, anemia, thyroid, sepsis, acute stress states

Question 6

List 6 predictors of acute HF

Answer 6

Hx: 
past history of CHF
PND
SOBOE
orthopnea
nocturia
Hx of any type of heart disease

PE: 
HTN
Diaphoretic 
pulmonary crackless 
pulmonary wheezes (due to peribronchial edema)
JVD
edema
S3

Question 7

List 5 CXR and 5 ECG findings of HF

Answer 7

CXR: 
pleural effusions
cardiomegaly 
Kerly B lines 
upper lobe pulmonary venous congestion (bat wing appearance) 
Interstitial edeam 

ECG:
LVH
LAE - p mitrale (p>120msec, notched in II)
RAE - p pulmonale (>2.5mm in height in II, III, aVF)
RV strain:
Fascicular blocks and bundle branch blocks

Question 8

What is the role of BNP in HF?

Answer 8

sensitive, not specific

In ER, it likely won’t change management

Question 9

Describe the primary management goals in acute HF?

Answer 9

aim to maximize CI/ aka CRAP - contractility, NSR, reduce afterload, preload

understand physiology: systolic vs. diastolic function
find the preceipitans
resuscitate maximing CRAP

Question 10

mechanism of action of NIPPV in HF?

Answer 10

NIPPV: giving patient PEEP - will drop pre-load , will also increase functional reserve capacity (improve V-Q mismatch), decrease work of breathing (improve oxygen delivery by decreasing HR and BP), decrease afterload (therefore improve cardiac output)

If patient looks unwell, tired fo breathing, increased work of breathing, cyanotic — consider NIPPV

NIPPV Contraindicated in patients: 
vomiting, 
not protecting airwaya
facial trauma
agitated patient
apneic
major altered LOC

Question 11

Pharmacological treatment for HF with good perfusion and poor perfusion

Answer 11

1) Acute HF- with adequate perfusion
- PONND: position, O2, NIPPV, nitrates, diuretics
- nitrates can be given 0.4mg SL q 5 min while setting up IV nitrates starting at 5-15 mcg/min IV and up-titrating accordingly

oxygen needs to be adequate in order to help
O2 target is 94-96% (100% only if pre-oxygenating before intubation)

2) acute pulmonary edema(acute HF) + hypotension
-POND plus vasopressors/inotropes
position, O2, NIPPV, diuretics.
Nitrates won’t work because they are already hypotension
-bolus with fluid with small 250 cc
-vasopressors with norepinephrine
-can add inotropic agents like epinephrine
-correct underlying cause

Question 12

List 10 treatment options for chronic HF

Answer 12

1) cardiovascular exercise and strength training
2) obesity reducteion
3) healthy diet
4) beta blockers
5) ace-i
6) ARBs
7) diuretics
8) spironolactone
9) digoxin
10) cardiac re-synchro therapy

Question 13

How do nitrates work in acute pulmonary edema?

doses?

Answer 13

nitrates cause both vasodilation and arterial dilation
- therefore drops pre-load (vasodilation) and afterload - thereby improving filling pressure and dropping SVR

Nitroglycerin: 0.4mg Sl q 5min
Nitroglycerin infusion: 5-10 microgram/min and rapidly titrating