CHF Flashcards
What are the 5 types of CHF?
HFrEF, HFpEF, LHF, RHF, and global HF
What is HFrEF also known as?
-What’s it’s affect on stroke volume?
- What is the criteria for it?
Systolic Heart failure
Reduced stroke volume
LVEF < or = to 35-40%
What is HFpEF also known as?
- What’s it’s effect on stroke volume, end diastolic volume, and EF?
- what’s it’s criteria?
Diastolic HF
Reduced SV, normal/reduced diastolic volume, and preserved EF
LVEF > or = to 40-50%
What are the general causes of systolic and diastolic dysfunction?
CAD, MI, HTN, diabetes, renal disease, and infiltrative diseases (hemochromatosis and amyloidosis)
What are some specific causes of systolic dysfunction?
Dilated Cardiomyopathy, arrhythmias, and myocarditis
What are some specific causes of diastolic dysfunction?
Restrictive cardiomyopathy, Hypertrophic Cardiomyopathy, pericardial Tamponade, constrictive pericarditis
How many stages of CHF are there?
4 stages
What is stage A CHF?
-Corresponding NYHA class
High risk of developing HF, no structural changes or symptoms
- No corresponding class
What is Stage B CHF?
-NYHA class
Structural damage to heart, no sign or symptoms
- NYHA 1 class
What is stage C CHF
- NYHA class
Structural damage to heart, sign and symptoms of HF
- NYHA 1-4
What is stage D HF?
-NYHA class
Terminal stage HF
- NYHA 4 class
How many NYHA classes are there?
4
What is class 1 NYHA criteria?
No limitations of physical activity, no symptoms of CHF
What is class 2 NYHA criteria?
Slight limitations of moderate or prolonged physical activity, comfortable at rest
What is class 3 NYHA criteria?
Marked limitations of physical activity, comfortable only at rest
What is class 4 NYHA criteria?
Confined to bed, symptoms at rest
What diagnostic tests are done for all patients if suspicion of CHF?
Routine Lab studies, cardiac biomarkers, ECG, CXR, and Echo
If CHF is confirmed from diagnostic tests, what should you investigate?
Underlying causes and modifiable risk factors
Apart of routine lab studies, a CBC is to screen for?
Anemia and infection
Routine lab studies:
What three things are looked at during a BMP?
- what would creatinine determine?
- If creatinine is High, what could this indicate?
Creatinine, sodium, and glucose
- What drugs to prescribe
- indicated CKD or cardiorenal syndrome
Routine Lab Studied:
Liver chemistries are looked at for what reasons?
To see if there’s any elevations, particularly of the cholestatic enzymes
Routine Lab Studies:
Increased C reactive protein can indicate?
Acute infection or inflammation
Routine lab studies:
Fasting Lipid Studies has one common factor found for CHF individuals, what is it?
Elevated cholesterol
Routine lab studies:
Lowered TSH is a sign of?
Hyperthyroidism
Routine Lab Studies:
What cardiac biomarkers are looked at?
Natriuretic peptides and troponin
Which Natriuretic Peptides are primarily used to determine HF?
-what other one can be used?
BNP or NT-proBNP
- midregional proatrial natriuretic peptide
BNP levels of HF:
-What levels are unlikely of HF? (In pg/mL)
-Wha levels are like of HF? (In pg/mL)
<100 = unlikely
>500 = likely
NT-proBNP levels of HF:
- HF unlikely (in pg/mL)
- HF likely (in pg/mL)
<300 = unlikely
>1000 = likely
What are the clinical features of CHF?
Nocturia, fatigue, tachycardia or various arrhythmias, S3/S4 gallop, and pulsus alternans
What are some clinical features of LHF?
Pulmonary congestion: dyspnea, orthopnea, pulmonary edema, paroxysmal nocturnal dyspnea, and cardiac asthma
What are some physical examination findings of LHF?
Bilateral basilar rales, laterally displaced apical heart beat, coolness and pallor of lower extremities
What are some clinical features of RHF?
Peripheral pitting edema, abdominal pain and jaundice
What are some physical examination findings of RHF?
JVD, kussmaul sign, hepatosplenomegaly, hepatojugular reflux
What is kussmaul sign?
What is hepatojugular reflux?
- JVD on inspiration
- JVD after pressure applied on the liver
What is hepatojugular reflux?
JVD after physically applying pressure on the liver
What’re some lifestyle modifications used for treatment of CHF?
Smoking cessation, alcohol cessation, recreational drug cessation, exercise, and weight loss
What are some salt restrictions put in place for those with class A&B CHF?
- C&D?
< or = to 1.5g/d in A&B
< or = to 3 g/d in C&D
What should be avoided while on aldosterone agonists?
Potassium rich foods
If your patient has stage D HF and they’re exhibiting signs of edema and hyponatremia, what fluid restriction limit would you put them on?
1.5-2 L/d
Treatment:
How would you treat these underlying comorbidities in HF?
- HTN
- Dyslipidemia
- Diabetes
- HTN: treat with target BP <130
-DLM: Start statins to keep lipids in normal range
-DBT: Screen for hyperglycemia, consider starting SGLT-2 inhibitor (sodium glucose transporter inhibitor)
What drugs should be avoided in CHF?
Class 1 and 3 anti-arrhythmic drugs, CCB’s (except amlodipine), NSAIDS, thiazolidinediones, inhalation anesthetics
What two drugs should not be used in conjunction with each other in CHF?
-what can it cause?
Nondihydropyrimidine CCB’s and beta blockers
-Third degree HB
Treatment:
What is the initial therapy of stage A HF?
- are meds recommended?
Treat underlying disease.
- No.
Treatment:
What is initial treatment of class B HF?
-Any avoidances?
ACEI’s in all with HFrEF
ARB’s in those who can’t tolerate ACEI’s
B-Blockers once pt is stable on ACEI’s (Avoid in pt with decomp. HF until stable)
Treatment:
What ACEI’s would you put the patient on?
-Dose?
-Monitor for?
Enalapril: 2.5mg PO x2/d, titrate up to 10-20mg x2/d
Ramipril: 1.25-2.5mg PO 1/d, titrate up to 10mg 1/d
Lisinopril: 2.5-5mg PO 1/d, titrate up to 20-40mg 1/d
Monitor: BP, renal Fx, and potassium
Treatment:
What ARBS are recommended?
- Dose?
-Monitor for?
Condesartan: 4-8 mg PO 1/d, titrate up to 32mg
Losartan: 25-50mg PO 1/d, titrate up to 150mg
Valsartan: 20-40mg PO 2/d, titrate up to 160mg
Monitor: Same as ACEI’s
Treatment:
What are B-Blocker recommendations?
-Dose?
-Monitor for?
Bisoprolol: 1.25mg PO 1/d, titrate up to 10mg
Carvedilol: 3.125mg PO 2/d, titrate up to 25mg in pt in pt <85kg, 50mg in >85kg
Metoprolol: 12.5-25mg PO 1/d, titrate up to 200mg
Monitor: Titrate slowly to target dose, consider reducing ACEI if hypotension occurs
What is the initial treatment of Stage C HF?
Aldosterone agonists, loop/Thiazide diuretics, Isosorbide dinitrate and hydralazine, angiotensin receptor-neprilysin inhibitors (ARNI’s) and SGLT-2 inhibitors
Treatment:
What are the recommended aldosterone agonists?
-Doses?
-Monitor for?
Spironolactone: 12.5-25mg PO x1/d or x2/d
Eplerenone: 25-50mg PO 1/d
Monitor regularly for hyperkalemia
Treatment:
What are the recommended Loop diuretics?
-Doses?
Torsemide: 10-200mg PO 1/d
Furosemide: 20-300mg x1 or x2/d
Bumetanide: .5-5mg PO x1 or x2/d
Treatment:
What thiazide loop diuretics are recommended?
-Doses?
Chlorthalidone: 12.5-100mg PO 1/d
Hydrochlorothiazide: 25-100mg PO x1 or x2/d
Metolazone: 2.5-20mg PO 1/d
Treatment:
What should you monitor for in loop diuretics? (thiazides are loop diuretics too)
Titrate the dose according to weight and volume status, regularly check electrolytes.
Treatment:
What fixed dose of Isosorbide and Hydralazine is recommended?
ISDN: 20-40mg
And
Hydralazine: 37.5-75mg
PO 3/d, titrate as needed.
Treatment:
What ARNI’s are recommended?
-Dose?
-Initiation?
Monitor for?
Sacubitril: 24-97mg
And
Valsartan: 26-103mg
PO 2/d
Initiation: Stop ACEI’s and administer ARNI no earlier than 36hrs from last ACEI dose
Monitor for hypotension, dizziness, cough and hyperkalemia
Treatment:
For those in Stage D HF, what two drugs can improve symptoms and reduce hospitalizations?
Diuretics and digoxin
What is this sound? link
S3 gallop
What is this sound? link
S4 gallop
What factors are associated with a worsened prognosis?
Elevated BNP, diabetes, anemia, S3 Heart sound, hypotension and hyponatremia
What is the physiology of cardiorenal syndrome?
Renal function progressively declines as a result of sever cardiac dysfunction
How many types are there of cardiorenal syndrome?
-most common type?
Five types
-Type 1
What is Type 1 Cardiorenal syndrome?
-How does it happen?
Acute cardiorenal syndrome
- HF leading to acute kidney injury
What is Type 2 CRS?
-How caused?
Chronic cardiorenal syndrome
- Chronic HF leading to CKD
What is Type 3 CRS?
-Caused by?
Acute Renocardiac syndrome
- Acute kidney injury leading to acute HF
What is Type 4 CRS?
-Caused by?
Chronic renocardiac syndrome
-CKD leading to CHF
What is type 5 CRS?
-Caused by?
Secondary CRS
-Systemic disease leading to kidney and heart failure
Diagnostics of CRS?
Decreased GFR, increased creatinine that can’t be explained by underlying kidney disease
Treatment of CRS?
Heart failure and Renal failure management
ACS and/or acute HF causing acute kidney injury is an example of what type CRS?
Type 1
Chronic HF resulting in a new onset or progression of CKD is an example of what type of CRS?
Type 2
HF resulting from acute kidney injury due to volume overload is an example of what type of CRS?
Type 3
LVH resulting from CKD-associated cardiomyopathy is an example of what type CRS?
Type 4
Cirrhosis and amyloidosis is an example of what type CRS?
Type 5 OR secondary CRS
