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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
Q

ADH is released when?

A

Carotid sinus and aortic arch baroreceptors detecting low cardiac output

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26
Q

What does ADH do?

A

Stimulates thirst
Increase systemic vasc resistance
Promotes water retention

Can cause fluid overload

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27
Q

Hypo_____ (electrolyte) can occur with ADH stimulation

A

Hyponatremia because it is diluted by all the excess fluid

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28
Q

What is Atrial Natriuretic Peptides (ANP)? When does it present in HF?

A

Atria releases ANP to expand volume
ANP rises in early HF

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29
Q

What is Brain Natriuretic Peptide (BNP)? When does it present in HF?

A

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

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30
Q

HF Compensation complications

A

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)

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31
Q

Cardinal Symptoms of HF

A

Dyspnea
Fatigue
Fluid retention

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32
Q

What can help identify source of HF?

A

Detailed History

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33
Q

Vitals with Heart Failure

A

Resting Sinus Tachycardia
Narrow Pulse pressure
Diaphoresis
Peripheral Vasoconstriction evidence

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34
Q

How might volume overload present in HF?

A

Inspiratory rales or dull breath sounds= Pulmonary Congestion

Scrotal and LE edema, Ascites= Peripheral Edema

Elevated JVP= edema due to HF

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35
Q

Pulsus alternans is a huge sign for _________

A

Severe LV failure

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36
Q

What is Pulsus Alternans?

A

Evenly spaced strong and weak peripheral pulses

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37
Q

Laterally displaced apical impulse indicates _______

A

LV enlargement

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38
Q

S3 gallop is associated with ______ HF

A

Systolic HF

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39
Q

S4 is MC with ______ HF

A

Diastolic HF

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40
Q

Imagining Diagnostics for HF

A

EKG
CXR

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41
Q

What is this?

A

Cardiac Enlargement

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42
Q

What is this?

A

Pulmonary Vascular Congestion

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43
Q

Serum tests to diagnose HF

A

BNP
Troponin I & T
CBC
CMP (need to check liver)
Mg
Coag studies
Fasting BG
Lipid panel

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44
Q

If BNP is normal, is someone in heart failure?

A

Nope, swelling is coming from somewhere else

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45
Q

Normal value for BNP

A

<100 pg/mL

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46
Q

Which half-life is longer:
BNP or NT-proBNP

A

NT-pro-BNP

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47
Q

T/F: Patient with severe chronic HF can have persistently HIGH levels of BNP

A

TRUE

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48
Q

Significant elevation of Troponin I or T most likely indicates what source for HF?

A

Ischemic source

(But if not, could indicate an ongoing myocardial injury or necrosis)

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49
Q

T/F: You do not need to get an Echo with new onset HF

A

False!
Need to check heart size, functions and abnormalities

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50
Q

What test is useful in checking for CAD in HF?

A

Stress Testing or Coronary Angiography

(Can also do MRI, CTA if can’t do stress test, Bx)

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51
Q

T/F: Denying CP is enough reason to exclude CAD possibility with HF

A

FALSE, need to work up

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52
Q

How to diagnose HF? Flowchart

A
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53
Q

Gold Standard for diagnosing HF

A

Right heart catheterization

54
Q

Right heart catheterization needs to show what in order to diagnose HF?

A

Elevated Pulmonary Capillary Wedge Pressure (PCWP), specifically:

HF sx AND PCWP >=15 mmHg
OR
PCWP>=25 mmHg during exercise

55
Q

How to treat HF

A

Manage symptoms and try to improve functional status

56
Q

Should we always do a Right heart cath for all patients we sus HF?

A

Nope, only if we are on the fence of diagnosing them

57
Q

AHA/ACC Diagnostic Eval Chart

A
58
Q

T/F: There is strong evidence for pharmacologic therapy and diet reducing mortality for Diastolic HF

A

False

59
Q

Treatment plan for Diastolic HF (HFpEF)

A

First-Line= Diuretics PRN
+/-SGLT2
AND
Manage BP

60
Q

T/F: There is strong evidence that Systolic HF Treatment can reduce mortality

A

True

61
Q

If LVEF is still <=40% in HFrEF after trying first line treatment, what treatment do we do?

A

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
Q

First-Line treatment plan for Systolic HF (HFrEF)

A

ALL OF THESE:
ARNI if NYHA 2-3
ACEI/ARB if NYHA 2-4
Beta Blocker
MRA
SGLT2I
Diuretics PRN

62
Q

What medication is most effective for providing sx relief for HF?

A

Diuretics

63
Q

If patient has MILD fluid retention, what diuretic do we use?

A

Thiazide

(Monitor Renal Funx & K)

64
Q

If patient has SEVERE fluid retention, what diuretic do we use?

A

Loop

(Monitor Renal Funx & K)

65
Q

Can someone be on both Thiazide AND Loop?

A

Yes, combo therapy can be used if continued fluid retention

66
Q

Oral Potassium should be prescribed to every patient that takes _______

A

Loop diuretics

67
Q

For every ____mEq of Lasix, we also need _____mEq of Potassium

A

20 mEq, 10mEq

68
Q

How to monitor Diuretic therapy

A

Daily weight check
BMP within one week of tx initiation or dose change

69
Q

ARNI stands for what?

A

Angiotensin Receptor Neprilysin Inhibitor

70
Q

What medication is indicated MORE than ACEI/ARBs for HFrEF

A

ARNI

71
Q

Patient needs to be off ACEI for _____ hours before starting ARNI

A

36 hours

72
Q

What is the generic name for ARNI? Brand name?

A

Sacubitril/Valsartan
Entresto

73
Q

Sacubitril is a _______ inhibitor
It limits the breakdown of __________

A

Neprilysin

Natriuretic peptides (ANP, BNP)

74
Q

CI of Entresto

A

Hx of angioedema with ACEI

75
Q

ACEI MOA

A

Blocks angiotensin converting enzyme which stops neurohumoral response to RAAS

76
Q

How to monitor ACEI

A

BMP at baseline then again in 1-2 weeks

77
Q

ARB MOA

A

Blocks Angiotensin 2 which stops neurohumoral response to RAAS

78
Q

Why are Beta Blockers added on for HFrEF?

A

Proven to improve survival

79
Q

Aldosterone Antagonist MOA

A

Blocks effect of aldosterone (sodium and water retention)

80
Q

CI Aldosterone Antagonist

A

Potassium >5
eGFR <30

81
Q

How does SGLT2 help HFrEF?

A

Mechanism unknown, possibly due to decreasing arterial pressure and reducing preload and afterload

82
Q

If someone is NOT diabetic, should we add SGLT2 if HFrEF?

A

Yes, regardless of DM status, it is proven to reduce mortality

83
Q

What kind of HF pt should get SGLT2?

A

Symptomatic chronic HFrEF

Also may help any HFpEF

84
Q

When to use Hydralazine/Nitrates?

A

Black pt already trying ACEI and Beta Blocker

Non-Black if ACEI/ARB intolerant OR renal failure

85
Q

MOA of Ivabradine

A

Inhibits channel in sinus node= slows HR

86
Q

What presentation must a patient have in order to use Ivabradine?

A

HR>= 70
In sinus rhythm
Already tried max dose beta blockers

87
Q

T/F: Ivabradine is shown to reduce mortality

A

True

88
Q

Digoxin can control what in Afib?

A

Ventricular rate

89
Q

How often to monitor Digoxin?

A

Check levels 1 week after initiation and if symptoms present

90
Q

MOA of Digoxin

A

Blocks Na-pump which increases intracellular Na and increases Ca in Myocardium, which causes INCREASED contractile force of heart

91
Q

What CCB are HARMFUL to HF

A

Verapamil
Diltiazem

92
Q

T/F: CCB are shown to be beneficial for HF

A

False, but they are safe to use with HF

93
Q

What 3 meds should we avoid in HF?

A

All Antiarrhythmics EXCEPT Amiodarone and Dofetilide

NSAIDS
Thiazolidinediones (pioglitazone, rosiglitazone)

94
Q

What is the only true #1 treatment for HFpEF?

A

Diuretics PRN

95
Q

What are the “Rules of 2”?

A

Na <2000 mg/day
Fluid <2L/day
Gain >2lb in 24 hours = call office or extra diuretic dose

96
Q

Does Fluid restriction include fluid in food?

A

Yes!

97
Q

What NYHA class is recommended to get Cardiac rehab?

A

NYHA 2-3

98
Q

Who should get Cardiac Resynchronization Therapy?

A

LVEF <= 35%
QRS >120ms
NYHA 3-4

99
Q

Primary Prevention of Cardiac Arrest using Implanted Defibrillator is indicated for who?

A

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
Q

What can we use as a bridge to Implantable Defibrillator?

A

Wearable Cardiac Defibrillator

101
Q

When in a waiting period for Implantable Defibrillator, when do we repeat an echo?

A

Repeat an echo at 90 days

102
Q

Secondary prevention of Cardiac Arrest is indicated for who?

A

Have survived SCD
OR
Have sustained VTach without obvious reversible causes

103
Q

What prevention is recommended for patient with LVEF <=30% and unexplained syncope

A

Implanted Defibrillator

104
Q

Acute Decompensated HF will present with

A

Acute dyspnea
Rapid fluid accumulation
Pulm Edema
Pink Frothy Sputum
Inspiratory rales

105
Q

How to treat Acute Decompensated HF

A

Airway, Vitals
Monitor Cardio and Urine output
IV Diuretics +/- Vasodilator

106
Q

What causes cardiorenal syndrome

A

Elevated venous pressure and low Cardiac Output causes renal hypoperfusion

107
Q

What to do if diuretics arent working for Acute Decompensated HF?

A

Na restriction
Water restriction if hyponatremia
Add second diuretic
Check albumin- if low, diuretics won’t work as well

108
Q

What is the only situation we could give vasodilator to Acute Decompensated HF?

A

If they do NOT have HoTN or severe symptomatic fluid overload

109
Q

What IV vasodilators would we use for Acute Decompensated HF?

A

Nitroglycerin, Nitroprusside, Morphine

110
Q

When to use Nitroprusside?

A

Afterload reduction is needed in emergency

111
Q

Nitroprusside metabolizes into _________

A

Cyanide, risk of toxicity

112
Q

Nitroprusside should only be used for ______ hours

A

24-48 hours

113
Q

What vasodilator can be used if Pulm. Edema is present with Acute Decompensated HF?

A

Morphine

114
Q

T/F: We can initiate Beta Blockers with Acute Decompensated HF

A

FALSE! Will kill the patient

If they are ALREADY on it, HOLD it if severely decompensated or in shock

115
Q

What inotropic agents are used with Acute Decompensated HF? What is it inidicated?

A

Milirinone and Dobutamine

Indicated for severe LV systolic dysfunction

116
Q

Milirinone MOA

A

PDE3 Inhibitor with mainly inotropic effects and vasodilation

117
Q

Dobutamine MOA

A

Stimulates B1 to increase BP, HR and vasodilation

118
Q

What medications are used for Venous Thromboembolism Prophylaxis?

A

Heparin
LMWH

119
Q

T/F: Acute Decompensated HF can use Continuous Renal Replacement Therapy to remove excess fluid

A

True

120
Q

Durable Mechanical Circulatory Support is considered with Acute Decompensated HF if they are in ____________

A

Cardiogenic Shock
Cardiac Index <2L/min
Systolic Pressure <90 mmHg
Pulm wedge pressure >18 mmHg

121
Q

What devices can be used for Durable Mechanical Circulatory Support?

A

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
Q

How to calculate Cardiac Index

A

Cardiac Output/Body Surface Area

123
Q

Cardiogenic Shock has _____% survival rate

A

50%

124
Q

Characteristics of Cardiogenic shock

A

Hypotension with end-organ hypoperfusion

Usually has peripheral vasoconstriction (cool, moist skin) and tachycardia

125
Q

What Lab findings might we see with Cardiogenic shock?

A

Due to hypoperfusion;
High: SCr, AST, ALT, Lactate
Anion gap acidosis

126
Q

What treatments to avoid with cardiogenic shock?

A

Beta Blocker
Agressive Fluid resuscitation

127
Q

What should we add if in Cardiogenic shock with severe HoTN and using inotropic agents?

A

Hemodynamic support

128
Q

T/F: We should use ASA with Cardiogenic shock

A

True

129
Q

What vasopressors are used for Cardiogenic Shock?

A

Norepi and Dopamine

130
Q

What inotropic agents are used for Cardiogenic Shock?

A

Milirinone or Dobutamine

CV (6 decks)

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