CHF

Question 1

Main abnormality behind systolic HF

Answer 1

decreased EF from impaired contractility

Question 2

Name some causes of systolic HF

Answer 2

• ischemic heart disease/recent MI -> cardiac muscle cannot pump effectively -> decreased EF
• HTN resulting in cardiomyopathy
• valvular heart disease
• myocarditis
• EtOH abuse, radiation, hemochromatosis, thyroid dx

Question 3

Main abnormality seen in diastolic HF

Answer 3

impaired ventricular filling during diastole (usu. from impaired relaxation or increased stiffness of ventricle or both)

Question 4

What does echocardiogram show in diastolic HF?

Answer 4

impaired relaxation of left ventricle

Question 5

Name some causes of diastolic HF

Answer 5

• HTN leading to myocardial hypertrophy
• valvular disease (ex: AS, MS, AI)
• restrictive cardiomyopathy (amyloidosis, sarcoidosis, hemochromatosis)

Question 6

Symptoms of left sided heart failure

Answer 6

• dyspnea from pulmonary congestion/edema
• orthopnea with nocturnal cough, worse lying down
• paroxysmal nocturnal dyspnea
• critically ill: confusion/memory problems with less brain perfusion and diaphoresis/cool extremities at rest

Question 7

Physical exam findings in left sided heart failure

Answer 7

THINK PULM CONGESTION

• displaced PMI
• pathologic S3 gallop (may be normal in children) best heard at apex
• S4 gallop (stiff left ventricle)
• crackles/rales at lung bases (pulm edema)
• dullness to percussion and tactile fremitus on left lower lng fileds from pleural effusion

Question 8

Symptoms/signs of right sided heart failure

Answer 8

THINK VOLUME OVERLOAD IN REST OF BODY

• peripheral edema (non specific)
• nocturia (increased venous return when legs elevated)
• JVD
• hepatomegaly/hepatougular reflux
• ascites
• right ventricular heave (from enlarged right ventricle)

Question 9

Given enough time, left sided heart failure will always lead to……….

Answer 9

RIGHT SIDED HEART FAILURE and vice versa

Question 10

Modalities to diagnose CHF

Answer 10

chest xray
transthroracic echo
ECG (look for signs of ischemia, previous MI, or ventricle enlargement)
stress test
cardiac cath is diagnostic and therapeutic
radionuclide ventriculography with tech99

Question 11

Findings of heart failure on chest xray

Answer 11

cardiomegaly
kerley B lines (horizontal lines near periphery indicated dilated pulmonary lymphatics
pleural effusion
prominent interstitial markings

Question 12

What is initial test of choice when you suspect CHF and what useful things can it show you?

Answer 12

TTE (trans thoracic echo)
EF (if less than 40% = systolic HF!)
chamber dilations, muscle hypertrophy
helps determine whether cause of CHF is due to pericardial, myocardial, or valvular process

Question 13

What lifestyle modifications to treat systolic HF

Answer 13

• Na restriction
• fluid restriction (1-2 L per day)
• weight loss, smoking cessation, exercise, weight monitoring yadadadada

Question 14

Medical therapy for systolic CHF?

Answer 14

diuretics, spironolactone (aldosterone antagonist), ACEIs, ARBs, B blockers, digitalis, hydralazine

Question 15

What is the most effective way to treat SYMPTOMS (but not necessarily cure systolic CHF)

Answer 15

diuretics (usually Lasix, most potent

Question 16

How to classify HF?

Answer 16

NYHA Classifications

class 1 - symptoms only with vigorous activity, nearly asymptomatic
class 2 - symptoms with prolonged/moderate exertion like climbing stairs or lifting, slight limitation
class 3 - symptoms occur with usual ADLs like getting dressed
class 4 - symptoms at rest; incapacitating

Question 17

When is spironolactone (aldosterone antagonist) effective in treating HF?

Answer 17

only in class 3 or 4; contraindicated in renal failure (may cause hyperkalemia)

Question 18

Benefit of using ACEIs in heart failure

Answer 18

• cause venous and arterial dilation which decreases preload and afterload, use when LVEF<40%
• REDUCES MORTALITY, prolongs survival, and alleviates symptoms in all classes of heart failure

Question 19

What is the initial treatment in most symptomatic patients?

Answer 19

diuretic and ACEI combo

Question 20

What to use of patient cannot tolerate ACEI (i.e. due to cough?)

Answer 20

ARB or hydralazine/isosorbide dinatrates

but really really try to do ACEI if you can

Question 21

When and how are B blockers beneficial in treating heart failure

Answer 21

• decrease mortality in patients with post MI heart failure
• antiarrhythmic and anti-ischemic efect
• metoprolol, bisoprolol, and carvedilol

Question 22

Who should get B blockers for HF?

Answer 22

STAAAAAABLE patients with mild-moderate CHF (class 1-3)

Question 23

Who should get digitalis?

Answer 23

patients with EF<40% who continue to have symptoms despite optimal therapy with ACEI, Bblcoker, aldosterone antag, and diuretic
CHECK SERUM DIGOXIN

Question 24

Disadvantages to digitalis

Answer 24

only provides symptomatic relief, ha snot been shown to improve mortality

Question 25

What common meds are contraindicated in CHF and why?

Answer 25

metformin - can induce lactic acidosis
thiazolidinediones - cause fluid retention
NSAIDS - may increase risk of CHF exacerbation

Question 26

Most common cause of death from CHF

Answer 26

ventricular arrythmia

Question 27

What devices have been shown to reduce mortality in some CHF patients

Answer 27

ICD - prevents suden cardiac death - use in post MI patients with Class 2-3 HF, EF<35%
CRT (cardiac resynchronization therapy) - biventricular pacemaker - prolonged QRS

Question 28

Treatment options for diastolic HF

Answer 28

FEW THERAPEUTIC OPTIONS…just treat symptoms

- Bblockers, diuretics

Question 29

Meds that have been shown to lower mortality rate in systolic heart failure

Answer 29

ACEI and ARBs
aldosterone antagonists (spirinolactone)
beta blockers
hydralazine plus nitrate (used in patients who can’t tolerate ACEIs)

DIGOXIN AND LOOP DIURETICS HAVE NOT! ->ONLY FOR SYMPTOMATIC TREATMENT

Question 30

Signs of digoxin toxicity (GI, Cardiac, CNS)

Answer 30

GI - n/v/anorexia
Cardiac - ectopic (ventricular beats), AV block, Afib
CNS - visual disturbances, disorientation