CHF 2 Flashcards
What are the major s/s of HF?
dyspnea, orthopnea, nocturnal dyspnea, cachexia, tachycardia, + hepato-jugular reflex, S3/S4, ascites
What are the minor s/s of HF?
depression, MR, afib, peripheral edema
Can a pt w HF be asx?
Yes, it depends on the severity of the dz
What are the s/s of L sided HF?
exertional dyspnea, non-productive cough, fatigue, orthopnea, paroxysmal nocturnal dypsnea, basilar rales, gallops, exercise intolerance
What are the s/s of R sided HF?
distended neck veins, tender or non-tender hepatic congestion, nausea, dependent pitting edema, often caused by L sided HF
What are the NYHAF classes of HF?
Class 1 = sx only at activity levels that would limit normal ppl
Class 2 = sx w ordinary exertion
Class 3 = sx w less than ordinary exertion
Class 4 = sx at rest
What are the ACC/AHA stages of development of HF?
Stage A = high risk w/o structural heart dz or sx
Stage B = heart dz w asx LV dysfunction
Stage C = prior or current sx
Stage D = refractory end stage
What is the pathophys of HF?
LV has decreased CO, pulmonary back up, RV congestion which leads to pedal edema and increased JVD
In order to dx HF what does everyone get in terms of imaging?
EKG
CXR
Echo
What would you be able to see on an EKG to dx HF?
signs of ischemia, LVH, heart block, tachycardia (a fib w RVR)
What would you be able to see on a CXR to dx HF?
cardiomegaly, pulm edema (fluffy infiltrates), Kerley B lines, pleural fluid, redistribution, boot shaped heart
What are Kerley B lines?
They are seen on a CXR of some pts w HF when fluid leaks into the peripheral interlobular septa, it is seen as septal lines or Kerley B lines. They are peripheral, short 1-2 cm horizontal lines near the costophrenic angles that run perpendicular to pleura
What would you be able to see on an echo to dx HF?
ventricle size & shape, LV EF%, valves (structure and function), wall motion, synchronicity of ventricular contraction, LV remodeling, LVH or RVH, pressure gradient, valve inflow/outflow properties, output state
What cardiac specific labs would you order for a pt w HF?
Creatine Kinase & CKMB
Troponins
BNP
Lipids (TC, HDL, LDL, triglycerides)
What are you looking for when assessing CK levels?
They will be elevated in 4-8 hrs after the event and peak after 24 hrs, then decline in 2-3 days
Trend the peak
Ratio of CK to CKMB of >2.5 is indicative of an MI
Skeletal injury would make results invalid
What are you looking for when assessing Troponin levels?
They will be released/elevated after 3 hrs post event and persist for 7-10 days. Troponin I (binds actin & inhibits actin-myosin interactions)
What are you looking for when assessing BNP levels?
400 has high predictive value for CHF (find underlying cause if there is one), compare levels to baseline.
Remember there will be lower levels in obese pts and higher levels in pts with renal failure & sepsis
Which routine labs are important to order when assessing a pt with HF?
CBC, BMP, LFTs, TSH, UA
What are the treatment goals in HF?
Remove fluid (loops, spironolactone)
Work directly on Ca++ movement in and out of SR (digitalis & CCB)
Decrease cardiac work, after load (ACEi)
Increase contractility (inotropic support - dobutamine, milrnone)
Who gets hospitalized for AHF?
hypotension, acute kidney injury, altered MS (any new organ dz)
dyspnea at rest
dangerous arrhythmias
ACS
wt gain >/= 5 Kg (pulm/systemic congestion)
electrolyte disturbances
PNA, PE, DKA, TIA/CVA
ICD fires
previous undo HF w s/s of systemic/pulmonary congestion
What are the goals for AHF treatment for hospitalized pts?
improved sx optimize volume status id etiology id precipitating factors optimize chronic oral therapy minimize SEs id pts whom may benefit from revascularization EDUCATE pts initiate a dz mgmt program
What should the hemodynamic monitoring of a hospitalized pt with AHF entail?
vitals
possible swan, arterial/central line
echo
ekg
What can be done to assess and stabilize systolic & diastolic dysfunction?
ABCs ( is bipap or cpap needed) IV access upright position (tripod) O2 (only when needed) diuresis (lasix) vasodilator therapy (NTG) morphine (MONA) monitor UOP
What is the mainstay treatment for AHF?
diuretics
caution if pt is hypotensive & LVOT obstruction should be diuresed w caution bc they are preload dependent
What are some other treatments for AHF besides diuretics?
Sodium & fluid restricton
vasodilators (NTG)
ACEi/ARB (for systolic dysfunc - start once pt is stable)
Inotropic agents (for severe systolic dysfunction – dobutamine, milrinone)
BB
Morphine (decrease anxiety & WOB)
mechanical cardiac assistance (balloon pump, VAD)
Ultrafiltration
Vasopressin receptor antagonists
What is important to do when discharging a pt that was treated for AHF?
Address exacerbating factors, achieve near optimal volume status & pharm therapies (goal doses), will need f/u!!
What are the goals for treatment of Chronic HF?
Improve sx, slow or reverse deterioration & reduce mortality in addition to treating underlying systemic effects of HF
What are some echo findings for Systolic dysfunction?
decreased EF (<45%) enlarged LV w thin wall eccentric LV remodeling Mitral regurg pulm HTN decreased mitral filling increased filling pressure
What are some echo findings for diastolic dysfunction?
Normal EF > 45% normal LV size thick LV wall dilated atria concentric LV remodeling pulm HTN abnl mitral filling increased filling pressure
What are the treatments for systolic dysfunction - CHF? Which NYHA class should they be started at?
ACEi/ARB (mainstay for chronic HF) Class 1-4
BB Class 1-4
Loop diuretics Class 3-4
Hydralazine & nitrates (ISDN/mononitrates, better in AA) Class 3-4
Aldosterone Antagonist (spironolactone Class 3-4, eplerenone Class 2)
Digoxin Class 3-4 esp if pt has a fib
Inotropic agents - severe
fish oil, statins, exercise
NO CCB
AICD - post cardiac arrest
What are the treatments for diastolic dysfunction - CHF?
Tx underlying cause: HTN
anti-htn (regression of LVH) ARBs/CCB/ACEi
control afib (preload dependent)
anti-ischemic tx (BB, nitrates, PCI & CABG)
aldosterone antagonists
statins
exercise
slightly better prognosis than systolic dysfunction
What drug should not be used in diastolic dysfunction?
digoxin bc contractility is intact
What should you keep in mind when treating diastolic dysfunction?
There is a decrease LV volume & therefore must be cautious as not to decrease preload much - don’t overload too much
What is the prevention recommendation of HF?
early detection and removal of reversible predisposing conditions, prevention is aimed to Class A & B HF
