CHF Flashcards
What is heart failure?
Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
A chronic, progressive condition in which the heart muscle is unable to pump enough blood through the heart to meet the body’s needs for blood and oxygen
What factors contribute to cardiac output?
contractility
afterload
preload
What is contractility, and what could cause it to be impaired?
Actual measurement of the hearts ability to squeeze – the “force of contraction”
When inadequate this is also called “systolic failure”
Reasons the heart is not able to contract effectively:
Dead tissue doesn’t move – heart attack, cardiotoxic drugs (Adriamycin)
Abnormal heart cells (muscular dystrophy)
Excessive wall stress (dilation of the ventricle, neurohormonal activation
What is preload?
The amount of blood filling the ventricle
What is afterload?
The resistance the heart must pump against to empty the ventricle
Examples of elevated afterload include hypertension or aortic stenosis
Why do people get heart failure?
Impaired contractility (systolic failure) Increased afterload Impaired filling (diastolic failure)
What causes HFrEF
"Systolic Failure" Impaired contractility Myocardial infarction Chronic volume overload Mitral regurgitation Aortic regurgitation Dilated Cardiomyopathy
Increased Afterload
Aortic Stenosis
Hypertension
What causes HfpEF
"diastolic failure" Impaired Relaxation Left Ventricular Hypertrophy Hypertrophic Cardiomyopathy Restrictive Cardiomyopathy Myocardial Ischemia
Insufficient Preload
Mitral stenosis
Pericardial constriction
What are symptoms of heart failure?
Dyspnea Ankle edema Pulmonary edema Fatigue Exercise intolerance Orthopnea Paroxysmal Nocturnal Dyspnea Weight loss Cough Nocturia Palpitations Depression Cachexia
What are signs of heart failure?
Tachycardia Elevated venous pressure Positive hepatojugular reflux Pulmonary rales Tachypnea Third/fourth heart sound Hepatomegaly Ankle edema Cardiomegaly Splenomegaly Hypotension Pulsus alternans Extrasystoles Atrial fibrillation Weight loss Ascites Pleural effusion
right sided heart failure s/s
Peripheral edema Hepatomegaly (pain?) Jugular venous distention (with hepatojugular reflux) Fatigue/Decreased exercise tolerance S3/S4 Gallop
left sided heart failure s/s
Dyspnea Orthopnea Paroxysmal nocturnal dyspnea (PND) Fatigue/Decreased exercise tolerance Tachycardia/tachypnea Pulmonary rales S3/S4 Gallop
when does the S4 occur?
S4 occurs during the active filling of the ventricle (atrial contraction)
“Tennessee”
when does S3 occur?
S3 occurs during the passive filling of the ventricle
“Kentucky”
Describe NYHA Class I
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).
Describe NYHA Class II
Class II (Mild) – Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
Describe NYHA Class III
Class III (Moderate) – Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.
Describe NYHA Class IV
Class IV (Severe) – Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Describe 2013 HF Stage A
Goals: heart healthy lifestyle, prevent vascular/CAD, prevent LV structural abnormalities
Drugs: ACE-I or ARB appropriate for patients with vasc disease, statins as appropriate
Describe 2013 HF Stage B
NYHA Class I
Goals: prevent HF symptoms, prevent further cardiac remodeling
drugs: ACE-I or ARB as appropriate, Beta blockers as appropriate
In selected patients: ICD, revascularization or valvular surgery as appropriate
Describe 2013 HF Stage C
NYHA Class II-III
HFpEF
Goals: control symptoms, improve HRQOL, prevent hospitalization, prevent mortality
strategies: ID comorbidities
Treatments: diuresis to relieve symptoms of congestion, follow guidelines driven indications for comorbidities like HTN/AF/CAD/DM
HFrEF
Goals: control symptoms, improve HRQOL, prevent hospitalization, prevent mortality
Drugs for routine use: diuretics, ACE-I or ARB, BB, aldosterone antagonists
Drugs for use in selected patients: hydralazine, ACEI/ARB, digitalis
In selected patients: CRT, ICD, revascularization surgery as appropriate
Describe 2013 HF Stage D
Goals: control symptoms, improve HRQOL, reduce hospital readmissions, establish patients end of life goals
options: advanced care measures, heart transplant, chronic inotropes, temp/permanent MCS, experimental surgery or drugs, palliative care and hospice, ICD deactivation.
What are compensatory mechanisms seen in HF?
Frank-Starling mechanism
Neurohormonal alterations
Ventricular hypertrophy and remodeling
what are neurohormonal alterations
Adrenergic Nervous System
Baroreceptors cause an increase in heart rate, augment contractility, and vasoconstrict through α-receptors
Renin-Angiotensin-Aldoserone System (RAAS)
Renin release causes vasoconstriction, increased thirst, and augments sodium reabsorption
Increased Antiduretic Hormone (ADH)
Natriuretic Peptides
Released when ventricular myocardium is subjected to hemodynamic stress – cause excretion of sodium and water, vasodilatation, and inhibit the above hormones
What are some reversible/precipitating causes of hypertrophy
Increased metabolic demands (infection, anemia, hyperthyroid, etc.)
Increased preload (excessive sodium, excessive fluid intake/administration, renal failure)
Increased afterload (pneumonia, uncontrolled hypertension, PE)
Impaired contractility (negative inotropic medications, myocardial ischemia, ethanol)
Medication non-adherence
What are diagnostic studies to consider
Chest x-ray CBC, CMP, BNP TSH, urinalysis EKG Echocardiogram
What is BNP?
n-terminal-pro-BNP (nt-pro-BNP)
synthesized and secreted by the ventricular myocardium in response to increases in volume or pressure
Renally excreted
Okay for use in evaluation of dyspnea, but in general not recommended for serial measurement
What is start for treatment of HF?
Good primary care – HTN and Hyperlipidemia
Treat underlying condition – valve repair/replacement, coronary artery revascularization, antihypertensives, alcohol cessation, rhythm reestablishment
Eliminate acute precipitating cause – infection, arrhythmia, salt intake, medication changes, thyroid, etc.
Treatment of heart failure symptoms
Diuretics
Vasodilators and positive inotropic drugs
Modulation of the neurohormonal response
What should patients be educated on with new diagnosis of HF?
Dietary – sodium restriction, alcohol cessation, caffeine avoidance
Smoking Cessation
Exercise – may be monitored (cardiac rehab), mild-moderate intensity ~ about 60% of maximal heart rate. Should try to get within 10% of ideal body weight if obese
Daily Weights – same scale, first thing in the morning after initial urination. Need to contact provider with 2 lb weight gain in one day, or 5 lbs in one week. Can often be given a “sliding scale” to titrate their diuretic dosing.
Medications – do not miss doses or prescriptions and avoid NSAIDs, Calcium Channel Blockers, and thiazolidinediones
Vaccines
What does diuretic do to help HF? How does it affect cardiac output? What are the most effective in treating HF?
With the use of diuretics it is possible to decrease the preload so that the hydrostatic pressure no longer causes pulmonary/venous congestion
Should not effect cardiac output since the Frank Starling curve has “flattened”
Most effective diuretics are the loop diuretics (furosemide, bumetanide, torsemide, ethacrinic acid)
Possible side-effects of hypokalemia, hypomagnesia, orthostatic hypotension, lethargy/drowsiness
Monitor kidney function and electrolytes
What are vasodilators used in treating HF?
Venous vasodilators – nitrates
Arteriole vasodilators – hydralizine
“Balanced” vasodilators – ACE-I, ARB, hydralizine+isosorbide dinatrate
Nesiritide – recombinant BNP (intravenous drip)
Benefits of ACEs
Help to break the cycle of the RAAS
Antihypertensive (afterload)
Renal protective
Indicated post myocardial infarction
SE of ACEs
Hypotension Acute Renal Failure Hyperkalemia Cough Angioedema
Benefits of ARBs
Help to break the cycle of the RAAS
Antihypertensive (afterload)
Renal protective
Indicated post myocardial infarction
SE of ARBS
Cough (3 versus 9%)
Angioedema
Hypotension
what are aldosterone antagonists and what should you monitor?
Spironolactone and Epleronone
Monitor kidney function and potassium for risk of hyperkalemia
talk about BB and HF
Initially contraindicated
Only carvedilol (β1 and β2 as well as weak α1), bisoprolol (β1), and sustained release metoprolol (β1) have been studied and approved for heart failure
Improves indices of LV function, delays progression of myocardial dysfunction, and improves survival (MERIT-HF 1999)
Monitor blood pressure and heart rate (sympathetic nervous system blockade)
When should you consider using hydralazine and isosorbide dinitrite?
Recommended for patients self-described as African Americans with NYHA class III–IV receiving optimal therapy with ACE inhibitors and beta blockers. It can be useful in those who cannot be given an ACE or ARB because of drug intolerance, hypotension, or renal insufficiency.
can you give nepolysin to someone on ACEI?
no!! not for 36+ hours, also it costs $$$$$$$$
who should get dig?
positive inotrope
Digitalis – must monitor blood level (goal between 0.5 and 0.8 ng/mL )
Class II-IV despite optimal therapy should get Digoxin
Symptomatic relief, but no morbidity/mortality benefit
Indicated for atrial fibrillation
additional treatment options
Iron therapy, Sleep study, Cardiac Resynchronization Therapy (CRT) Internal Cardiac Defibrillator (ICD) Anticoagulation Cardiac Assist Device Cardiac Transplant
major framingham criteria for HF
need 2 for diagnosis
Paroxysmal nocturnal dyspnea Orthopnea Elevated jugular venous pressure Pulmonary rales Third heart sound Cardiomegaly on chest x-ray Pulmonary edema on chest x-ray Weight loss ≥4.5 kg in five days in response to treatment of presumed heart failure
Minor criteria framingham
1 major plus 2 of these = dx
Bilateral leg edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion Tachycardia (heart rate ≥120 beats/min) Weight loss ≥4.5 kg in five days
evaluation initial for HF
Complete history and physical examination
History of alcohol, illicit drugs, standard or “alternative” therapies, and chemotherapy drugs
Ability to perform routine and desired activities of daily living
Assessment of volume status, orthostatic blood pressure changes, height and weight, and calculation of body mass index
CBC, urinalysis, CMP, glucose (A1C?), lipid profile, and thyroid panel
EKG and CXR
Echocardiogram
Cardiac cath if concern for ischemia
