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CHF Flashcards

1
Q

What is heart failure?

A

A syndrome resulting from a structural or functional issue of ventricular filling or ejection of blood

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2
Q

5- year survival rate of CHF

A

~50%

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3
Q

CHF Risk Factors

A

HTN
CVD
DM
Obesity
Cardiotoxic agent exposure
Genetic variant
Family hx

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4
Q

How to classify acute vs chronic Heart Failure

A

Acute- sx days to weeks
-SOB, Paroxysmal Nocturnal Dyspnea, orthopnea, RUQ pain

Chronic- sx for months
-Fatigue, anorexia, Abd distension, edema

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5
Q

Describe High vs Low output Heart Failure

A

High= heart unable to meet peripheral needs
-Thyrotoxicosis, severe anemia, sepsis

Low=Insufficient forward output
-Low Ejection Fracture

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6
Q

Describe Reduced EF vs Preserved EF Heart Failure

A

Reduced Ejection Fracture= Reduced systolic, EF <= 40%

Preserved Ejection Fracture= EF >=50%

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7
Q

Which is MC Heart Failure- Left or Right?

A

Left HF

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8
Q

First symptoms from Left sided HF are from the _______

A

Lungs
-Orthopnea, DOE

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9
Q

First symptoms from Right sided HF are from the _______

A

Body
JVD, Hepatic congestion, ascites, anorexia, LE edema

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10
Q

Image of Left HF Sx

A
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11
Q

Image of Right HF Sx

A
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12
Q

What method do we use to classify severity of HF? What does it assess?

A

NYHA- New York Heart Association
(assesses effort needed to elicit symptoms)

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13
Q

Describe NYHA Classification of Severity levels 1-4

A

1) NO limitation of physical activity
2) Slight limitation of physical activity, no symptoms at rest
3) Marked limitation of physical activity, no symptoms at rest
4) Uncomfortable during all physical activity, symptoms at rest

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14
Q

What do we use to stage HF? What does it assess?

A

ACCF/AHA
(American College of Cardiology Foundation/American Heart Association)

Assesses evolution of heart failure

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15
Q

What determines the therapeutic approach and prognosis?

A

Stage of Heart Failure A-D

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16
Q

Describe the 4 Stages of Heart Failure A-D

A

A) NO structural heart dx or sx of HF
B) Structural heart dx WITHOUT sx of HF
C) Structural heart dx WITH prior or current sx of HF
D) Refractory HF= usually Transplant candidates

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17
Q

Image of HF Pathophysiology

A
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18
Q

What compensatory mechanisms occur that leads to heart failure?

A

The body adjusts, for the reduced Cardiac Output and Sys/Dia Dysfunction, the changes are called “Neurohumoral Adaptations”
-Vasoconstriction will maintain pressure
-Myocardial contractility and heart rate is increased to restore the cardiac output

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19
Q

Small changes in afterload in HF can lead to HUGE changes in ____

A

Stroke Volume

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20
Q

With systolic dysfunction, there is a reduction in _____________ which is associated with a reduction in _______ &_________

A

Myocardial contractility
SV & CO

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21
Q

Systolic dysfunction promotes _____ &_____ retention which raises end-diastolic pressure and volume

A

Salt & water

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22
Q

Activation of what nervous system when there is low Cardiac Output? Why?

A

SNS is activated because it will:
-Increase Norepi= increases contractility and heart rate
-Constricts vessels and enhances venous tone to increase preload
-Stimulates sodium reabsorption which worsens the fluid overload

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23
Q

What stimulates RAAS

A

Decreased glomerular filtration and increased Beta-1 adrenergic activity

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24
Q

What does RAAS stimulate?

A

Increases Sodium reabsorption
Induces systemic and renal vasoconstriction
Can promote myocyte remodeling which increases AT2 receptors

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25
ADH is released when?
Carotid sinus and aortic arch baroreceptors detecting low cardiac output
26
What does ADH do?
Stimulates thirst Increase systemic vasc resistance Promotes water retention Can cause fluid overload
27
Hypo_____ (electrolyte) can occur with ADH stimulation
Hyponatremia because it is diluted by all the excess fluid
28
What is Atrial Natriuretic Peptides (ANP)? When does it present in HF?
Atria releases ANP to expand volume ANP rises in early HF
29
What is Brain Natriuretic Peptide (BNP)? When does it present in HF?
Ventricles releases BNP to reduce vascular resistance, increase natriuresis and reduces afterload BNP present in chronic or advanced HF; it responds to high ventricular filling pressures
30
HF Compensation complications
Pulm Vascular congestion & peripheral edema (due to elevation in diastolic pressures) Cardiac function depression (due to increased afterload which enhances deterioration) Worsening Ischemia (due to increased heart rate) Cardiac remodeling (due to myocyte loss bc catecholamines and angiotensin II)
31
Cardinal Symptoms of HF
Dyspnea Fatigue Fluid retention
32
What can help identify source of HF?
Detailed History
33
Vitals with Heart Failure
Resting Sinus Tachycardia Narrow Pulse pressure Diaphoresis Peripheral Vasoconstriction evidence
34
How might volume overload present in HF?
Inspiratory rales or dull breath sounds= Pulmonary Congestion Scrotal and LE edema, Ascites= Peripheral Edema Elevated JVP= edema due to HF
35
Pulsus alternans is a huge sign for _________
Severe LV failure
36
What is Pulsus Alternans?
Evenly spaced strong and weak peripheral pulses
37
Laterally displaced apical impulse indicates _______
LV enlargement
38
S3 gallop is associated with ______ HF
Systolic HF
39
S4 is MC with ______ HF
Diastolic HF
40
Imagining Diagnostics for HF
EKG CXR
41
What is this?
Cardiac Enlargement
42
What is this?
Pulmonary Vascular Congestion
43
Serum tests to diagnose HF
BNP Troponin I & T CBC CMP (need to check liver) Mg Coag studies Fasting BG Lipid panel
44
If BNP is normal, is someone in heart failure?
Nope, swelling is coming from somewhere else
45
Normal value for BNP
<100 pg/mL
46
Which half-life is longer: BNP or NT-proBNP
NT-pro-BNP
47
T/F: Patient with severe chronic HF can have persistently HIGH levels of BNP
TRUE
48
Significant elevation of Troponin I or T most likely indicates what source for HF?
Ischemic source (But if not, could indicate an ongoing myocardial injury or necrosis)
49
T/F: You do not need to get an Echo with new onset HF
False! Need to check heart size, functions and abnormalities
50
What test is useful in checking for CAD in HF?
Stress Testing or Coronary Angiography (Can also do MRI, CTA if can't do stress test, Bx)
51
T/F: Denying CP is enough reason to exclude CAD possibility with HF
FALSE, need to work up
52
How to diagnose HF? Flowchart
53
Gold Standard for diagnosing HF
Right heart catheterization
54
Right heart catheterization needs to show what in order to diagnose HF?
Elevated Pulmonary Capillary Wedge Pressure (PCWP), specifically: HF sx AND PCWP >=15 mmHg OR PCWP>=25 mmHg during exercise
55
How to treat HF
Manage symptoms and try to improve functional status
56
Should we always do a Right heart cath for all patients we sus HF?
Nope, only if we are on the fence of diagnosing them
57
AHA/ACC Diagnostic Eval Chart
58
T/F: There is strong evidence for pharmacologic therapy and diet reducing mortality for Diastolic HF
False
59
Treatment plan for Diastolic HF (HFpEF)
First-Line= Diuretics PRN +/-SGLT2 AND Manage BP
60
T/F: There is strong evidence that Systolic HF Treatment can reduce mortality
True
61
If LVEF is still <=40% in HFrEF after trying first line treatment, what treatment do we do?
KEEP ALL #1 MEDS + Black, NYHA3-4= Hydral-nitrates LVEF<=35% with >1year survival, NYHA 1-3=Implantable defibrillator LVEF<=35% NSR and QRS >=150ms with LBB, NYHA 2-3= Cardio resynchronization with defibrillator
61
First-Line treatment plan for Systolic HF (HFrEF)
ALL OF THESE: ARNI if NYHA 2-3 ACEI/ARB if NYHA 2-4 Beta Blocker MRA SGLT2I Diuretics PRN
62
What medication is most effective for providing sx relief for HF?
Diuretics
63
If patient has MILD fluid retention, what diuretic do we use?
Thiazide (Monitor Renal Funx & K)
64
If patient has SEVERE fluid retention, what diuretic do we use?
Loop (Monitor Renal Funx & K)
65
Can someone be on both Thiazide AND Loop?
Yes, combo therapy can be used if continued fluid retention
66
Oral Potassium should be prescribed to every patient that takes _______
Loop diuretics
67
For every ____mEq of Lasix, we also need _____mEq of Potassium
20 mEq, 10mEq
68
How to monitor Diuretic therapy
Daily weight check BMP within one week of tx initiation or dose change
69
ARNI stands for what?
Angiotensin Receptor Neprilysin Inhibitor
70
What medication is indicated MORE than ACEI/ARBs for HFrEF
ARNI
71
Patient needs to be off ACEI for _____ hours before starting ARNI
36 hours
72
What is the generic name for ARNI? Brand name?
Sacubitril/Valsartan Entresto
73
Sacubitril is a _______ inhibitor It limits the breakdown of __________
Neprilysin Natriuretic peptides (ANP, BNP)
74
CI of Entresto
Hx of angioedema with ACEI
75
ACEI MOA
Blocks angiotensin converting enzyme which stops neurohumoral response to RAAS
76
How to monitor ACEI
BMP at baseline then again in 1-2 weeks
77
ARB MOA
Blocks Angiotensin 2 which stops neurohumoral response to RAAS
78
Why are Beta Blockers added on for HFrEF?
Proven to improve survival
79
Aldosterone Antagonist MOA
Blocks effect of aldosterone (sodium and water retention)
80
CI Aldosterone Antagonist
Potassium >5 eGFR <30
81
How does SGLT2 help HFrEF?
Mechanism unknown, possibly due to decreasing arterial pressure and reducing preload and afterload
82
If someone is NOT diabetic, should we add SGLT2 if HFrEF?
Yes, regardless of DM status, it is proven to reduce mortality
83
What kind of HF pt should get SGLT2?
Symptomatic chronic HFrEF Also may help any HFpEF
84
When to use Hydralazine/Nitrates?
Black pt already trying ACEI and Beta Blocker Non-Black if ACEI/ARB intolerant OR renal failure
85
MOA of Ivabradine
Inhibits channel in sinus node= slows HR
86
What presentation must a patient have in order to use Ivabradine?
HR>= 70 In sinus rhythm Already tried max dose beta blockers
87
T/F: Ivabradine is shown to reduce mortality
True
88
Digoxin can control what in Afib?
Ventricular rate
89
How often to monitor Digoxin?
Check levels 1 week after initiation and if symptoms present
90
MOA of Digoxin
Blocks Na-pump which increases intracellular Na and increases Ca in Myocardium, which causes INCREASED contractile force of heart
91
What CCB are HARMFUL to HF
Verapamil Diltiazem
92
T/F: CCB are shown to be beneficial for HF
False, but they are safe to use with HF
93
What 3 meds should we avoid in HF?
All Antiarrhythmics EXCEPT Amiodarone and Dofetilide NSAIDS Thiazolidinediones (pioglitazone, rosiglitazone)
94
What is the only true #1 treatment for HFpEF?
Diuretics PRN
95
What are the "Rules of 2"?
Na <2000 mg/day Fluid <2L/day Gain >2lb in 24 hours = call office or extra diuretic dose
96
Does Fluid restriction include fluid in food?
Yes!
97
What NYHA class is recommended to get Cardiac rehab?
NYHA 2-3
98
Who should get Cardiac Resynchronization Therapy?
LVEF <= 35% QRS >120ms NYHA 3-4
99
Primary Prevention of Cardiac Arrest using Implanted Defibrillator is indicated for who?
LVEF <=35% with Class 2-3 HF sx AND >40 days post-MI LVEF <=35% with NYHA 2-3 AND >90 days post dx and >1yr life expectancy
100
What can we use as a bridge to Implantable Defibrillator?
Wearable Cardiac Defibrillator
101
When in a waiting period for Implantable Defibrillator, when do we repeat an echo?
Repeat an echo at 90 days
102
Secondary prevention of Cardiac Arrest is indicated for who?
Have survived SCD OR Have sustained VTach without obvious reversible causes
103
What prevention is recommended for patient with LVEF <=30% and unexplained syncope
Implanted Defibrillator
104
Acute Decompensated HF will present with
Acute dyspnea Rapid fluid accumulation Pulm Edema Pink Frothy Sputum Inspiratory rales
105
How to treat Acute Decompensated HF
Airway, Vitals Monitor Cardio and Urine output IV Diuretics +/- Vasodilator
106
What causes cardiorenal syndrome
Elevated venous pressure and low Cardiac Output causes renal hypoperfusion
107
What to do if diuretics arent working for Acute Decompensated HF?
Na restriction Water restriction if hyponatremia Add second diuretic Check albumin- if low, diuretics won't work as well
108
What is the only situation we could give vasodilator to Acute Decompensated HF?
If they do NOT have HoTN or severe symptomatic fluid overload
109
What IV vasodilators would we use for Acute Decompensated HF?
Nitroglycerin, Nitroprusside, Morphine
110
When to use Nitroprusside?
Afterload reduction is needed in emergency
111
Nitroprusside metabolizes into _________
Cyanide, risk of toxicity
112
Nitroprusside should only be used for ______ hours
24-48 hours
113
What vasodilator can be used if Pulm. Edema is present with Acute Decompensated HF?
Morphine
114
T/F: We can initiate Beta Blockers with Acute Decompensated HF
FALSE! Will kill the patient If they are ALREADY on it, HOLD it if severely decompensated or in shock
115
What inotropic agents are used with Acute Decompensated HF? What is it inidicated?
Milirinone and Dobutamine Indicated for severe LV systolic dysfunction
116
Milirinone MOA
PDE3 Inhibitor with mainly inotropic effects and vasodilation
117
Dobutamine MOA
Stimulates B1 to increase BP, HR and vasodilation
118
What medications are used for Venous Thromboembolism Prophylaxis?
Heparin LMWH
119
T/F: Acute Decompensated HF can use Continuous Renal Replacement Therapy to remove excess fluid
True
120
Durable Mechanical Circulatory Support is considered with Acute Decompensated HF if they are in ____________
Cardiogenic Shock Cardiac Index <2L/min Systolic Pressure <90 mmHg Pulm wedge pressure >18 mmHg
121
What devices can be used for Durable Mechanical Circulatory Support?
Intraaoritc Balloon counterpulsation Implanted LV Assist Device (mainly for End Stage HF) ECMO(takes blood out, oxygenates it, and replaces it) Impella (Heart pump)
122
How to calculate Cardiac Index
Cardiac Output/Body Surface Area
123
Cardiogenic Shock has _____% survival rate
50%
124
Characteristics of Cardiogenic shock
Hypotension with end-organ hypoperfusion Usually has peripheral vasoconstriction (cool, moist skin) and tachycardia
125
What Lab findings might we see with Cardiogenic shock?
Due to hypoperfusion; High: SCr, AST, ALT, Lactate Anion gap acidosis
126
What treatments to avoid with cardiogenic shock?
Beta Blocker Agressive Fluid resuscitation
127
What should we add if in Cardiogenic shock with severe HoTN and using inotropic agents?
Hemodynamic support
128
T/F: We should use ASA with Cardiogenic shock
True
129
What vasopressors are used for Cardiogenic Shock?
Norepi and Dopamine
130
What inotropic agents are used for Cardiogenic Shock?
Milirinone or Dobutamine

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