CHF Flashcards
NYHA classes
1 = asymptomatic, no limit on physical activity
2 = symptoms w/ ordinary activity, slight limits
3 = symptoms w/ < ordinary activity, moderate limits
4 = symptoms at rest, severe limits
Types of HF
HFpEF = LVEF >50%
HFmEF = LVEF 41-49%
HFrEF = LVEF <40%
Causes of HF
Cardiac: tachycardia, valve disease, CAD, LVH
Toxins: alcohol, amphetamines, cocaine, steroids, radiation
Pregnancy: cardiomyopathy, pre-e, GDM
Inflammation/ infections: myocarditis, sarcoidosis
Metabolic: DM, thyroid, pheochromocytoma, Cushings
Nutritional: low thiamine, malnutrition, obesity, anemia
RF
Older age
Fam hx
Smoking
Alcohol
Chemotherapy
Obesity
HTN
High lipids
IHD/ CAD
DM
Precipitating factors
Forgetting meds
Arrhythmia
Anemia
Ischemia
Infection
Pregnancy
Hyperthyroidism
Renal failure
PE
Prevention
Exercise
Treat dyslipidemia, HTN, DM
Smoking cessation
Screening
BNP for at risk pts - identifies those that need an echo
Sx
Fatigue, wt gain, weakness
Orthopnea, PND
Cough, SOBOE
Nocturia, edema, abdo distension
Signs
Hypotension
Tachycardia
Hypoxia
Weight gain
Raised JVP
Displaced apex
S3 murmur
+AJR
Edema
Ix + results
CBC, lytes, lipids, TSH, urinalysis, trop, BNP
CXR
Interstitial Edema
Kerley B Lines
Pleural Effusions
Cardiomegaly
Echo
Reduced LVEF
Increased LV end-systolic + diastolic dysfunction
LVH
Wall motion abnormalities
Valve dysfunction
ECG
Exercise stress test to assess functional capacity
Management HFrEF
BB (bisoprolol)
Spironolactone (mineralcorticoid receptor antagonist)
ACEi (ramipril)
SGLT2i (empagliflozin)
If not working, switch ACEi for ARNI (scubitril)
If still symptomatic, consider
Ivabradine
ICD/ CRT
Heart transplant
Nitrates for SOB/ angina PRN
Loop diuretic for sx control
Omega 3 polyunsaturated fatty acids 1g daily
Management HFpEF
ACEi/ ARB + BB
Consider spironolactone
Monitoring
Weight, HR, orthostatic vitals, JVP, edema
Check lytes 1 week after adjusting diuretic, ACEi or ARB
Digoxin trough 12hrs post dose
Repeat echo 3 months after titrating meds + q1-3 yrs if stable
Check BNP after titrating triple therapy
Patient education + self monitoring
Self-weighing
Monitoring sx: worsening cough, SOB at rest, edema, wt gain, diiziness
Healthy diet - restrict salt + fluids (<1.5L/d)
Flu shot + pneumococcal vaccine annually
Sleep in upright position
Medication adherence
Smoking cessation
Exercise that does not induce sx
Supervised cardiac rehab for NYHA 1-2
Supervised mod aerobic + resistance training for NYHA 2-3
Assess for cognitive impairment, dementia and depression
Acute HF management
ECG, CXR, lytes, Cr, CBC, trop, BNP
Admit if NYHA 3-4, hypoxia, new dx, worsening renal function
BIPAP: 14/8 or 10/5
IV Lasix 20-80mg
If hypotensive, give inotropes like dobutamine milrinone
When to refer
Initial HF dx
After hospitalisation
HF w/ ischemia, HTN, valve disease, syncope, renal dysfunction
CHF acute management
oxygen, BiPAP, lasix, nitro if hypertensive
CHF + hypotension = what? What do you do about it?
cardiogenic shock, urgent cardio referral, arrange transfer, norepi
Steps prior to case turning up in ED
don PPE, call for help, call lab + XR in, assign roles
Most common cause of CHF
ischemic cardiomyopathy
When to refer pts for heart transplant or ICD?
NYHA class 3, 4, advanced HF, high risk
When to refer pts for CRT or ICD?
LVEF <35%
HFpEF rx
SGLT2i
HFrEF rx
BB, ACEi, spironolactone, SGLT2i
HFrEF triple therapy x3mo, no improvement, what to offer?
Entresto (Sacubitril / Valsartan i.e. angiotensin receptor-neprilysin inhibitor), vericiguat, digoxin, ICD/ CRT, transplant
What to add in CHF w/ HR >75?
Ivabradine (HCN channel blocker)
Indicators of advanced CHF
recurrent hospitalisations, cardiac cachexia, intolerance of BB, inability to walk 1 block on level ground, maximal diuretic therapy, frequent ICD shocks, progressive decline in renal function
Physical exam in CHF
weight, volume status, peripheral vascular exam, leg edema, lung sounds, JVP, S3
What score do you use to dx HFpEF + what are the components?
H2FPEF = heavy (BMI >35), hypertensive, aFib, pulmonary HTN, Elder >80, filling pressure
What can you consider switching black pts or pts that are intolerant of ACEi/ ARBs to?
consider H-ISDN (hydralazine/ isosorbide dinitrate)
What could you add for pts that have had a recent hospitalisation?
Vericiguat
