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N810 > CHF > Flashcards

CHF Flashcards

1
Q

Heart Failure Definition

A
  • Syndrome caused by cardiac dysfunction, due to myocardial dysfunction or loss and characterized by either LV dysfunction, hypertrophy, or both
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2
Q

Heart failure secondary effects

A
  • Leads to neurohormonal and circulatory abnormalities
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3
Q

CHF Facts

A
  • Without therapy, is progressive
  • Severity of s/s varies; doesn’t always correlate with underlying dysfunction
  • Has either (or both) pulmonary and systemic venous congestion &/or inadequate peripheral O2 delivery, at rest or with stress
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4
Q

CHF Patho review

A
  • Systolic: LV pump failure (impaired emptying); EF Low
  • Diastolic: Problem with LV relaxing (impaired filling); EF normal
  • Mized: Usually co-exist
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5
Q

CHF Causes: Common

A
  • CAD
  • HTN
  • Idiopathic
  • Valvular heart disease
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6
Q

CHF Causes: Less common

A
  • Endocrine
  • Cardiotoxic substances
  • Dysrhythmias
  • Viral infections
  • Restrictive CM
  • Severe anemia
  • Peripartum CM
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7
Q

How do CHF patients present?

A
  • Symptom: decreased exercise tolerance
  • Sign: Fluid retention
  • Asymptomatic: Incidentally discovered LV dysfunction
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8
Q

Symptoms to alert a HCP to likelihood of CHF

A
  • Fatigue*
  • Decreased exercise tolerance*
  • Dyspnea on exertion*
  • Orthopnea
  • PND
  • Chest pain
  • Cough
  • Hemoptysis
  • Palpitations/syncope
  • N/V/ABD fullness
  • Nocturia
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9
Q

Signs to alert a HCP to likelihood of CHF

A
  • VS: Orthostasis, tachypnea, tacycardia
  • Pallor
  • Unexplained weight gain
  • JVD
  • Laterally displaced PMI
  • RV heave
  • Extra heart sounds/murmur
  • Rles
  • RUQ tenderness
  • Ascites
  • Peripheral edema
  • decreased pulses
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10
Q

NYHA Classification

A
  • Class I: No limitations in activity (only at levels of exertion do symptoms arise)
  • Class II: Slight limitation in activity (s/s with ordinary exertion)
  • Class III: Marked limitation in activity (s/s with less than ordinary exertion)
  • Class IV: Unable to carry out any activity w/out s/s (s/s at rest)
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11
Q

New “Stages” of CHF

A
  • Stage A: High risk for developing HF
  • Stage B: Asymptomatic with LV dysfunction
  • Stace C: Past or current s/s of HF
  • Stage D: ESHF
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12
Q

Stage A: High risk

A
  • PREVENTION is key
  • BNP NOT recommended
  • ACE-I: Hx of CAD, PVD, CVA, DM, smokers
  • BB: Hx of MI
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13
Q

Initial Labs: CHF

A
  • Electrolytes
  • CBC
  • FSBS
  • LFTs/Lipids
  • TSH
  • Uric acid
  • UA
  • Others: sleep-disturbed breathing, rheumatologic tests, HIV, amyloidosis, pheochromocytosis
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14
Q

Measurement of BNP

A
  • BNP or Pro-BNP should be assessed in ALL patients suspected of having HF when Dx is uncertain
  • BNP and NT-proBNP can be helpful with risk stratification
  • Determination of BNP or NT-proBNP is NOT recommended as a routine part of evaluation for structural heart disease in patients at risk without s/s of CHF
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15
Q

Established CHF patient: Important facts

A
  • Cause of HF (ischemic or not)
  • Systolic or Diastolic dysfunction
  • Current meds and doses
  • Current NYHA class
  • Volume status, weight, diet, and Na intake
  • current use of substances, alternative therapies, chemotherpiy meds, OTC meds
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16
Q

Routine Labs for CHF

A
  • Electrolytes: q6mo if stable; more frequent if therapy/volume changes, severe HF, receiving diuretics, clinically unstable
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17
Q

Reevaluation of EF

A
  • Reassess if:
  • change in status, recovered from clinical event, received Tx that may have significant effect on heart functions
  • Considering ICD, transplantation, or other serious Tx
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18
Q

Major goals for therapy: CHF

A
  • Identify and treat correctable etiologies
  • Control or reduce s/s
  • Impede the natural disease progression (even if asymptomatic)
  • Improve survival
  • Reduce need for hospitalization
19
Q

Dietary Na and fluid restriction

A
  • 2-3g Na daily for sys and dia dysfunction

- <130) and if fluid retention despite high doses of diuretic and sodium restriction

20
Q

Body weight and nutrient supplements: CHF

A
  • Avoid unintentional weight loss and cardiac cachexia
  • BMI should be <30
  • Daily multivitamin
  • Nutraceutical use not recommended
  • Avoid ephedra or ephedrine
21
Q

Misc. Recommendations: CHF

A
  • ETOH cessation (if Hx of abuse)
  • PNA and Flu vaccines
  • SSRI if antidepressant indicated
  • PD5-I may be used for ED if stable HF and no nitrates
  • CPAP if OSA
  • NSAIDs and Cox-2 inhibitors NOT recommended
  • Endocarditis prophylaxis only if concurrent valve disease
  • Supplemental O2 NOT recommended
22
Q

Exercise Indications

A
  • Exercise safe & recommended if no arrhtyhmias or ischemia per exercise testing
23
Q

ACE-I: CHF

A
  • 1st-line for ALL pts with systolic dysfunction with current or past symptoms
  • No particular choice of which ACE to use
  • Important to titrate to target doses
  • If intolerant, ARB—> then combo hydralazine/oral nitrate
24
Q

Beta-Blockers: CHF

A
  • Recommended for all stable patients with current or past s/s of HF and reduced LVEF, unless contraindicated
  • Benefit (w/ ACE and diuretic): Improved survival, reduced hospitalizations
  • Contraindications: Asthma, symptomatic bradycardia (<80)
25
Q

Beta-Blockers approved for CHF

A
  • Carvedilol (Coreg): 3.125mg BID (T 25-50mg BID)
  • ** Must take with food to prevent HoTN
  • Metoprolol XL 12.5mg qd (T 200mg qd)
  • Bisoprolol 1.25mg qd (T 10mg qd)
26
Q

Beta-Blocker: Pearls

A
  • Patient educations (may feel worse at start)
  • May need to start low dose diuretic if not already on one
  • Titration schedule
  • Know “when to hold ‘em, know when to fold ‘em”
  • More is better (survival benefit)
  • Avoid abrupt discontinuation
  • Temporary dose reduction for acute decompensation
  • Do not use in patients with known cocaine abuse
27
Q

Aldosterone Antagonists: CHF

A
  • Indications: LVEF 2.5 for men, >2 for women; K >5; With other K-sparing diuretics
28
Q

Diuretics: CHF

A
  • Indications: Fluid overload; use in combo w/ACE for sys dysfunction
  • Benefits: Rapid improvement of s/s
  • Contraindications: Orthostasis; worsening renal insufficiency
  • Pearls: Loops preferred; divide daily doses; Avoid daily thiazides to prevent electrolyte imbalances
29
Q

Hydralazine and Oral Nitrates

A
  • Indication: for self-identified Afr-Amer w/sys dysfunction already on ACE and beta but still symptomatic
  • NYHA class II-IV (stronger data for class III-IV)
  • Hydralazine 20mg/isosorbide 37.5mg combo: up to TID; titrate up to 2tab TID
30
Q

Digoxin: CHF

A
  • can be beneficial for those with current or prior s/s of HF and reduced LVEF to decrease hospitalizations for HF
  • do NOT give to patients with preserved LVEF
  • Dose based on lean BMI, renal Fx, and other meds
  • Dose should be 0.125 mg/d in most
  • NEW goal: 0.7-0.9ng/mL
31
Q

Antiarrhythmics: CHF

A
  • In general not recommended
  • Not recommended as 1-line prevention of sudden death
  • Amiodarone for ICD pts who have repetitive shocks
  • Monitor amiodarone levels closely (esp. if on dig or warfarin)
32
Q

Polypharmacy

A
  • Combined use of ACE, ARB, & BB not recommended
  • If intolerant to BB therapy, triple combo of ACE, ARB, & Aldosterone antagonist NOT recommened due to hyperkalemia
  • Use of CCBs NOT recommended
33
Q

Anticoagulant & Antiplatelet Agents

A
  • Warfarin: A-fib; Hx of emboli; 1st3mo after MI; Recent MI w/LV thrombus; May be considered for dilated Ischemic CM; INR goal 2-3
  • ASA: recommended for HF w/CAD; not recommended for non-ischemic HF; lower dose better
34
Q

Prophylactic ICD Placement

A
  • Indication:
  • Primary prevention of sudden cardiac death
  • LVEF 1yr
35
Q

Chronic Resynchronization Therapy (CRT)

A
  • Bi-Ventricular pacing (w/ or w/o ICD)
  • QRS >0.12 while in NSR and LVEF 36%
  • Symptomatic despite stable, optimal medical therapy (for 3-6mo ideally)
  • Mod-to-sev HF, NYHA III and ambulatory IV
  • Also now indicated for: QRS >0.15 with NYHA class I or II and symptomatic; Chronically V paced and reduced LVEF may be considered
36
Q

End of Life care: Device Inactivation

A
  • Importance of discussion in advance:
  • About specific plans to allow for a natural death should be based on individual’s risks and preferences
  • This should be rediscussed at any turning points in patient’s care
37
Q

Patient Education: CHF

A
  • indiv./Group counseling, telemonitoring
  • Team approach
  • Consider literacy, cognitive status, psychological state, culture, access to social/financial resources
  • Educate at each visit
38
Q

Preserved LVEF

A
  • Definition varies: LVEF >40,45, or 50%
  • Terms used: Diastolic failure, HF w/NL LVEF, HF w/preserved LVEF
  • Evaluate for ischemic HD and inducible myocardial ischemia
  • Aggressive BP control
  • Low sodium diet
  • For A-fib: 1st goal - restore, maintain SR, otherwise control rate
39
Q

Tx of DHF

A
  • Consider diuretics to control pulm. congestion & Peripheral edema; thiazide or loop
  • BB if prior MI, HTN, or AF
  • Use of BB, ACE, ARB, or CCB might be effective in minimizing symptoms
  • Usefulness of digitalis to minimize symptoms is NOT well established
40
Q

DHF: Special populations

A
  • The elderly: same standard meds; pay attention to ability to metabolize and tolerate; many elderly have DHF
  • Women: increased incidence of ACE cough; pay attention to dosing and renal Fx with Dig
  • African-Americans: May need combo of isosorbide dinitrate+hydralazine rather than ACE+BB
41
Q

Signs that Tx needs to be readjusted: DHF

A
  • Worsened renal function
  • Hypo/hyperkalemia
  • Fluid overload
  • symptomatic hypotension
  • Marked bradycardia or advanced heart block
42
Q

Hospitalization Guidelines: 2010 HFSA

A
  • Evidence of severe ADHF: HoTN, worsened renal insufficiency, AMS
  • Dyspnea at rest: resting tachypnea, SpO2
  • Hemodynamically significant arrhythmias: New onset AF
  • Acute coronary syndrome
43
Q

Hospitalization should be considered: HF

A
  • Worsened congestion (even w/out dyspnea)
  • S/S of pulmonary or systemic congestion (even if no weight gain)
  • Major electrolyte disturbance
  • Associated comorbid conditions: PNA, PE, DKA, TIA/CVA
  • Repeated ICD firings
  • Previously undx’d HF w/ S/S of systemic or pulmonary congestion

N810 (18 decks)

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