CHF Flashcards
what is the MC cause of CHF
coronary artery disease
left-sided failure
increased pulmonary venous pressure from fluid backing up into lungs
sx for left-sided failure
pulmonary sx - progressive dyspnea MC, cough, rales, pink frothy sputum (surfactant), wheezing, pleural effusion, Cheyne’s stokes breathing
Think L for left sided and lungs
what is cheyne stoke’s breathing
deeper faster breathing w gradual decrease and periods of apnea
right-sided failure
due to increased systemic venous pressure –> signs of systemic fluid retention; causes systemic vascular congestion
sx right-sided failure
peripheral edema
JVD
GI/hepatic congestion
anorexia
N/V due to GI
hepatosplenomegaly
hepatojugular reflex
systolic HF
decreased EF associated w S3 (filling of dilated ventricles)
diastolic HF
normal/increased EF associated w S4 (atrial contraction into stiff ventricle)
Class 1 HF
no limitation to physical activity
ordinary physical activity does not cause undue fatigue, dyspnea, or anginal pain
class 2 HF
slight limitation of physical activity, ordinary physical activity results in symptoms
class 3 HF
marked limitation of physical activity
comfortable at rest
less than ordinary activity causes sx
Class 4 HF
unable to engage in any physical activity without discomfort
sx may be present even at rest
what will you see on CXR for CHF
Kerley b lines
butterfly/bat wing appearance - bilateral perihilar alveolar edema
cephalization of vessels
cardiomegaly
pleural effusions
pulmonary edema (bilateral interstitial markings)
what is the most useful imaging to assess size and function in heart failure
echocardiography
what will echo show for systolic HF
decreased EF
thin ventricular walls
dilated LV chamber
S3
what will echo show for diastolic HF
normal/increased HF
thick ventricular walls
small LV chamber
S4
BNP and N-terminal proBNP levels that indicate HF is likely
BNP > 100
N-terminal proBNP > 125
BNP levels increase with
age
renal insufficiency
may be decreased on chronic tx
what is indicated if atherosclerosis is suspected in the presence of HF
cardiac cath
what are the cornerstone agents in treating coronary disease
Anti-platelet agents (Aspirin)
what valve is MC affected in endocarditis
Mitral valve (M > A > T > P)
what valve is most commonly affected in endocarditis in IV drug users
tricuspid valve
RF for endocarditis
increased age (> 60)
rheumatic heart disease
IV drug use
immunosuppression
prosthetic heart valves
congenital heart disease
sx endocarditis
fever
EKG conduction abnormalities
anorexia
wt loss
Janeway lesions
roth spots
osler nodes
splinter hemorrhages of proximal nail bed
clubbing
hepatosplenomegaly
petechiae
septic emboli: CNS, kidneys, spleen, joints
what are Janeway lesions
painless erythematous macules on palms/soles
what are Roth spots
retinal hemorrhage w pale center
osler nodes
tender nodules on pads of digits
staphylococcus aureus and endocarditis
MC cause, including ACUTE infective endocarditis, prosthetic valve infective endocarditis, and IVDA infective endocarditis (especially MRSA)
what valves are usually affected in staphylococcus aureus in infective endocarditis
normal valves
streptococcus viridans in infective endocarditis
MC cause of SUBACUTE infective endocarditis
part of the oral flora; associated w endocarditis from transient bacteremia secondary to gingivitis, poor dentition, dental procedures
what valves are usually affected by streptococcus viridans in infective endocarditis
damaged valve
staphylococcus epidermis in infective endocarditis
early prosthetic valve endocarditis (especially within 60 days of the procedure) is usually caused by S. aureus or S. epidermidis
enterococcus in infective endocarditis
seen especially in men > 50 w a recent history of GI or GU procedure
HACEK organisms
haemophilus aphrophilus
Actinobacillus
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
gram-negative organisms that are hard to culture
when should you suspect HACEK organisms in infective endocarditis
endocarditis + negative blood cultures
streptococcus gallolyticus and bovis in infective endocarditis
commensal bacteria of the gut seen w increased incidence in patients w colorectal CA and UC
colonoscopy should be performed in these patients to rule out both
two most important tests for suspected endocarditis
blood cultures
echocardiography
blood cultures in infective endocarditis
before antibiotic initiation
3 sets at least 1 hour apart if patient is stable
what echocardiogram should be obtained first in infective endocarditis
TTE first
TEE if TTE is nondiagnostic
TEE is much more sensitive than TTE
clinical criteria for infective endocarditis
2 major OR 1 major + 3 minor OR 5 minor
major Duke criteria
sustained bacteremia (2 positive blood cultures by organism known to cause endocarditis)
endocardial involvement documented by either positive echocardiogram (vegetation, abscess, valve perforation, prosthetic dehiscence) OR clearly established new valvular regurgitation (aortic or mitral regurgitation)
minor Duke criteria
predisposing condition (abnormal valves, IVDA, indwelling catheter)
fever > 38C/100.4F
vascular and embolic phenomena (Janeway lesions, septic arterial or pulmonary emboli, ICH)
immunologic phenomena: Osler’s nodes, Roth spots, positive rheumatoid factor, acute glomerulonephritis
positive blood culture not meeting major criteria
echocardiogram not meeting major criteria (worsening of existing murmur)
endocarditis prophylaxis indications for cardiac conditions
prosthetic heart valves
heart repairs using prosthetic material (not including stents)
prior history of endocarditis
congenital heart disease
cardiac valvulopathy in a transplanted heart
what procedures require prophylaxis for infective endocarditis
dental - involving manipulation of gums, roots of teeth, oral mucosa perforation
respiratory - surgery on respiratory mucosa, rigid bronchoscopy
procedures involving infected skin/MSK tissues (including abscess incision and drainage)
prophylactic tx for indicated conditions and procedures
amoxicillin 2g 30-60 main before
Clindamycin 600mg if pcn allergy
Macrolide or Cephalexin are other options
tx for native valve (MSSA) IE
anti-staphylococcal PCN (nafcillin, oxacillin) + either Ceftriaxone of Gentamicin
if PCN allergy - Cefazolin; Vancomycin or Daptomycin
tx for native valve (MRSA) or unknown IE
Vancomycin plus either Ceftriaxone or Gentamicin
Daptomycin if unable to tolerate Vancomycin
tx for fungal IE
parenteral antifungal (Amphotericin containing product) with or without combo (Flucytosine)
how long is therapy for fungal IE
6 weeks or more
how long is therapy for non-fungal IE
4-6 weeks
indications for surgery for IE
refractory CHF
persistent or refractory infection
invasive infection
prosthetic valve
recurrent systemic emboli
fungal infxn
acute bacterial endocarditis
infection of normal vales with virulent organism (s aureus)
subacute bacterial endocarditis
indolent infection of abnormal valves w less virulent organism (S viridian’s)
endocarditis w IVDA
MRSA (s aures)
pseudomonas
candida - esp in HIV patients
prosthetic valve endocarditis
early (after 60 days) - staph epidermis = MC
initial pharm therapy for reduced ejection fraction HF
ACEI, ARB, or ARNI
Diuretic
BB
BB that have proven beneficial in HF
Carvedilol
Metoprolol
Bisoprolol
