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
2
Q
Heart failure secondary effects
A
- Leads to neurohormonal and circulatory abnormalities
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
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
5
Q
CHF Causes: Common
A
- CAD
- HTN
- Idiopathic
- Valvular heart disease
6
Q
CHF Causes: Less common
A
- Endocrine
- Cardiotoxic substances
- Dysrhythmias
- Viral infections
- Restrictive CM
- Severe anemia
- Peripartum CM
7
Q
How do CHF patients present?
A
- Symptom: decreased exercise tolerance
- Sign: Fluid retention
- Asymptomatic: Incidentally discovered LV dysfunction
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
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
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)
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
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
13
Q
Initial Labs: CHF
A
- Electrolytes
- CBC
- FSBS
- LFTs/Lipids
- TSH
- Uric acid
- UA
- Others: sleep-disturbed breathing, rheumatologic tests, HIV, amyloidosis, pheochromocytosis
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
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
16
Q
Routine Labs for CHF
A
- Electrolytes: q6mo if stable; more frequent if therapy/volume changes, severe HF, receiving diuretics, clinically unstable
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
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
Beta-Blockers approved for CHF
- 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
Beta-Blocker: Pearls
- 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
Aldosterone Antagonists: CHF
- Indications: LVEF 2.5 for men, >2 for women; K >5; With other K-sparing diuretics
28
Diuretics: CHF
- 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
Hydralazine and Oral Nitrates
- 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
Digoxin: CHF
- 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
Antiarrhythmics: CHF
- 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
Polypharmacy
- 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
Anticoagulant & Antiplatelet Agents
- 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
Prophylactic ICD Placement
- Indication:
* Primary prevention of sudden cardiac death
* LVEF 1yr
35
Chronic Resynchronization Therapy (CRT)
- 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
End of Life care: Device Inactivation
- 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
Patient Education: CHF
- indiv./Group counseling, telemonitoring
- Team approach
- Consider literacy, cognitive status, psychological state, culture, access to social/financial resources
- Educate at each visit
38
Preserved LVEF
- 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
Tx of DHF
- 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
DHF: Special populations
- 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
Signs that Tx needs to be readjusted: DHF
- Worsened renal function
- Hypo/hyperkalemia
- Fluid overload
- symptomatic hypotension
- Marked bradycardia or advanced heart block
42
Hospitalization Guidelines: 2010 HFSA
- 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
Hospitalization should be considered: HF
- 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
