CHF (EXAM 4) Flashcards
CHF is the most common __________ diagnosis in the U.S. in those > 65
- inpatient
What are the important epidemiology factors for CHF?
- very common!
- incidence increases with age (75% of cases are in those > 65)
- M > F
- 25% higher incidence in African American patients
- some forms of cardiomyopathy are genetic
Who is the most at risk for developing CHF?
Those with:
- Coronary heart disease
- Smokers
- HTN
- Obesity (huge risk factor!)
- Diabetes
- Valvular heart disease
Heart function and cardiac output depend on these 4 thing:
- contractility of myocardium
- preload of the ventricle
- afterload applied to ventricles
- heart rate
(issues with any of these 4 factors can result in CHF)
What is this the definition of?
- the pressure in the ventricle at the end of diastole
PRELOAD
AFTERLOAD: They systemic ________ ________ (pressure) that the heart works ______ to pump blood (pressure in the ventricle wall during ejection)
- vascular resistance
- against
Describe the Frank-Starling Law
- Stroke Volume (SV) of the heart increases in response to increase in the volume of blood filling the heart (end diastolic volume)
aka - increase in the volume of blood going into the ventricle during diastole = more stretch of ventricle = increased force of contraction and quantity of blood pumped during systole
What is the #1 and #2 most common causes of CHF in the U.S?
1 –> MI
#2 --> Untreated/inadequately treated HTN
- remember: HTN increases the LV afterload -->
longterm this can result in LV hypertrophy
What type of dysfunction is this describing?
- ventricular filling is abnormal
- mycocardial relaxation is impaired or chamber is noncompliant (stiff)
DIASTOLIC DYSFUNCTION
- Slowed, delayed, and incomplete myocardial relaxation
- Increased dependence on LV filling from atrial contraction
- Increased passive stiffness and decreased distensibility of the LV
- Shift of filling from early to late diastole
- stiffness comes from excess hypertrophy/compositional changes of myocardium
_________ dysfunction - is an abnormality of diastolic relaxation, filling, or distensibility of the LV, regardless of symptoms of EF
Diastolic
HFpEF is? Describe it
Heart Failure Preserved Ejection Fraction
- clinical signs and symptoms of heart failure, LV diastolic dysfunction, and a normal LVEF
What is generally considered a normal EF%?
> 50% (varies slightly by clinic)
_________ is the most common mechanism of SYSTOLIC DYSFUNCTION
Ischemia
Another important mechanism:
- decreased LV ejection fraction (EF) < 40-50%
Other causes:
- idiopathic dilated cardiomyopathy
- inflammation (ex: myocarditis)
- infiltration (ex: amyloidosis)
- toxin-induced cardiomyopathies (ex: cocaine, ethanol)
- valvular heart disease
Adaptations to heart failure Part I:
- if SV is ________ by high afterload or ________ contractility, pressure and EDV ________.
- if SV is DECREASED by high afterload or DECREASED contractility, pressure and EDV INCREASE.
- leads to dilated ventricles if chronic
Adaptations to heart failure Part II:
Reduced CO causes:
- ________ sympathetic activity leads to: ________ myocardial contractility, ________ HR, and __________ venous tone.
- _________ of renal blood flow and GFR.
- INCREASED sympathetic activity leads to: INCREASED myocardial contractility, INCREASED HR, and INCREASED venous tone.
- leads to ventricular modeling and progressive
ventricular dysfunction - REDUCTION of renal blood flow and GFR.
- leads to RAAS system activation
Which side of heart failure is this?
- Impairment in adequate circulation of blood into systemic circulation –> blood backs-up into the pulmonary vasculature causing pulmonary edema and dyspnea
LEFT
(Left sided = think Lungs!)
- may hear crackles
- can be systolic or diastolic
And what about this side for heart failure?
- Unable to adequately pump venous blood into the pulmonary circulation –> fluid backs up into the body leading to peripheral edema, increased JVP, and ascites
RIGHT
**often caused by left heart failure
What body system is very connected to the heart other than pulmonary?
RENAL!
Cardio______ Syndrome
- acute or chronic dysfunction of the heart or kidneys can induce acute or chronic dysfunction in the other organ system
**Remember - heart, lungs, and kidneys are all very connected!
What can trigger decompensated HF?
Hint: think about blood volume, issues with rhythm, blood flow, etc
- uncontrolled HTN
- Increased salt & water intake (or noncompliance with
diuretics) - tachyarrhythmias (esp. new onset afib)
- ischemia
- worsening renal failure
- anemia
- chronic lung disease
- infection
What is the prominent symptom of LEFT sided heart failure?
Name 3 other symptoms along with the above.
- DYSPNEA
(Progression: DOE –> orthopnea, PND –> dyspnea at rest) - chronic non-productive cough
- fatigue
- exercise intolerance
________ retention is the prominent symptom of RIGHT sided heart failure.
What is the other symptom you can see on inspection of the patient?
- FLUID retention
- edema is also seen
How many classes of heart failure does the NYHA classify? Describe them! (I know I am annoyed by this one too!)
*Paulson said to know these well!
- FOUR
I –> No limitation of physical activity. Asymptomatic.
II –> Slight limitation of physical activity. Comfortable at
rest. Ordinary physical activity results in fatigue,
palpitation, dyspnea, or angina.
II –> Marked limitation of physical activity. Comfortable
at rest. Less than ordinary activity leads to fatigue,
palpitations, dyspnea, or angina.
IV –> Unable to cary out ANY physical activity without
discomfort. Symptoms of heart failure at rest. If any
physical activity is undertaken, discomfort worsens.
PE:
What might you see on a patient’s vital signs when they present with CHF?
- Tachycardia
- Hypotension OR Hypertension
- Hypoxia
PE:
What might a respiratory exam show?
(4 things)
- dyspnea during activity or conversation
- cyanotic
- crackles on auscultation (wheeze/ronchi also possible)
- dullness to percussion
PE:
What might the cardiovascular exam show?
(7 things)
- parasternal lift
- laterally displaced PMI
- elevated JVP
- peripheral edema (legs, ascites, scrotum, sacral)
- pulse alternans (alternating strong & weak pulses)
- S3 OR S4 gallop
- cool extremities
**NOTE OTHER SIGNS: You may also see HSM and hepatojugular reflux.
What labs do you want to get on this patient?
5 potentials
- BNP
- CBC
- BMP
- Troponin (caution here - only order if you suspect CHF
caused by ACS; otherwise you may have opened
pandora’s box) - TSH
BNP FACTS:
- hormone released from the ________.
- plasma concentrations are increased in patients with
___ _________. - Helpful if diagnosis is uncertain:
- < 100: high ________ predictive value.
- 100-400: not particularly useful.
- > 400: most _______ patients w/ heart failure. - has ________ significance
- multiple limitations
- hormone released from the HEART.
- plasma concentrations are increased in patients with
LV DSYFUNCTION. - Helpful if diagnosis is uncertain:
- < 100: high NEGATIVE predictive value.
- 100-400: not particularly useful.
- > 400: most DYSPNEIC patients w/ heart failure. - has PROGNOSTIC significance
- multiple limitations
What are the limitations of BNP?
5 of them
- elevated in renal dysfunction and afib
- lower in obesity
- chronically elevated in some
- high levels do not exclude other diseases
- normal values increase with age
True or false - the below is the comprehensive list of imaging you would want to get on this patient.
- EKG
- CXR
FALSE!
- ECHO - always get the ECHO!
- can differentiate b/t HFrEF and HFpEF
- EKG
- CXR
List the lifestyle modifications you would educate this patient on
(7 items)
- smoking cessation
- restrict/abstain from alcohol
- abstain from drug use
- restrict sodium intake
- may need to fluid restrict (for refractory patients esp.
with hyponatremia) - avoid obesity
- daily wt monitoring
How are we going to treat our patient with HFpEF?
5 treatments
- control the HTN
- diuretics to take off excess volume
- manage comorbidities (esp. cardiovascular)
- cardiac rehab (only intervention shown to improve
QoL/exercise capacity) - Meds: None proven to be effective
Furosemide (Lasix) is a _____ diuretic. What does it do, and what do we need to watch out for?
- LOOP diuretic
- relieves sign & symptoms of volume overload (edema,
dyspnea)
- IV more potent than PO
- must maintain long-term to prevent recurrence of
volume overload - WATCH OUT FOR: hypokalemia, increased BUN/Cr, hypomagnesemia, dizziness, hypotension, hypo OR hypernatremia, ototoxicity
What are the other Loop Diuretics?
- Bumetanide (Bumex)
- Torsemide (Demedex)
- Ethacrynic Acid (Edecrin)
*BID works best for Lasix
What are the two main Thiazide Diuretics? What do we need to watch-out for with these guys?
- Metolazone (Zaroxolyn)
- HCTZ
- BE CAREFUL! --> watch for: electrolyte disturbances, massive diuresis (these guys are potent AF)
** can combine with a loop diuretic for refractory edema
What about HFrEF; how are we going to treat this?
6 treatments
- treat contributing factors/assoc. diseases
- improve the symptoms (diuretics, ARB, digoxin, and the
below) - Meds: Improve morbidity & mortality
- Beta-Blockers
- ACEI
- ARNI
- Aldosterone agonists
- Hydralazine + nitrate - device therapy (if indicated)
- cardiac rehab (class II-III pts)
- serial assessment/close follow-up
_____ is considered first line and should be given to ALL patients with HFrEF as it improves survival/symptoms, and reduces hospitalizations. ______ is a common patient complaint with these meds.
ACEI; COUGH
- ARB is alternative if not tolerated
- also watch out for: dizziness, hyperkalemia, angioedema, ARF
Name the 3 most common ACEI inhibitors for CHF
- Lisinopril
- most commonly used - start with 5mg
- Enalapril
- Captopril
Beta-Blockers ________ the LV size, _______ the EF over time, and ________ the ventricular contraction rate.
- Beta-Blockers REDUCE the LV size, INCREASE the EF over time, and DECREASE the ventricular contraction rate.
The 3 most commonly used Beta-Blockers for CHF are?
** the ‘lols’
- Carvedilol (Coreg)
- Metoprolol succinate (Toprol XL)
- Bisoprolol (Zebeta)
- watch out for: dizziness, edema, hypotension
Who is recommended to receive an Aldosterone Receptor Blocker?
(3 groups)
- those with NYHA class II AND LVEF ≤ 30%
OR - those with NYHA class III-IV AND LVEF ≤ 35%
- post-STEMI pts already on ACEI with LVEF ≤ 40% with
either symptomatic heart failure OR diabetes
What are the two most common Aldosterone Receptor Blockers, and why do we use them in CHF?
- Spironolactone (Aldactone)
- Eplerenone (Inspra)
- reduces CV death and hospitalization
- watch for: hyperkalemia, creatinine
Hydralazine + Nitrate (Isosorbide dinitrate) act by: venous & arterial ___________ to _______ cardiac preload and afterload.
- Hydralazine + Nitrate (Isosorbide dinitrite) act by:
venous & arterial VASODILATION to DECREASE cardiac
preload and afterload.
What two groups of patients is Hydralazine + Nitrate (Isosorbide dinitrate) recommended for?
- best mortality benefit seen in black patients when
added to optimal therapy- NYHA class III-IV with LVEF < 40%
- patients who are unable to tolerate ACEI/ARB
- watch for: symptomatic hypotension, HA, dizziness
compliance
What is an alternative medication class for patients with NYHA Class II-IV with LVEF ≤ 40% given in place of ACEI/ARB?
- ARNI’s!
- newer drug class, but $$$
- some recommend as initial therapy
- lots of good data coming out on these guys
What do ARNI’s do? Name one example of an ARNI used in CHF.
- reduce CV mortality, all-cause mortality, and
hospitalizations - Sacubitril-Valsartan (Entresto)
_______ is a positive inotrope that is used to ________ heart contractility.
- DIGOXIN is a positive inotrope that is used to
INCREASE heart contractility.
When do we give Digoxin to CHF patients and how do we monitor its levels?
- given for symptom control in patients already on
appropriate therapy - levels are monitored by SERUM DIGOXIN
CONCENTRATION
What do we need to keep in mind when prescribing Digoxin to CHF patients?
(4 things)
- Narrow therapeutic window –> 0.7 - 1.2 serum
concentration is optimal - Must use RENAL DOSING
- Levels can be increased by: Amiodarone, Quinidine,
and Verapamil - watch out for: cardiac arrhythmias, visual disturbances,
N/V, anorexia
**remember you cannot dialyze Digoxin out! Must
use Digibind to clear
What are the indications for device Therapy in CHF?
- ICD for primary or secondary prevention of sudden
cardiac death
-vtach/vfib = mcc of sudden cardiac death - cardiac resynchronization therapy (CRT) with
biventricular pacing
- improves symptoms for patients reduced EF and
prolonged QRS
What is the initial treatment for someone with Acute Decompensated CHF?
(sorry this one is a bit rough)
INITIALLY:
- supplemental O2
- assisted ventilation (if needed)
- IV loop diuretic
- if loop naive: if no response to initial dose,
DOUBLE the dose Q2hrs (likely need to increase
starting point for renal insufficiency or severe HF)
- if chronically take loops: initial IV dose needs to be
≥ their maintenance total daily PO dose
MONITOR:
- electrolytes and renal function closely
What can patients do to prevent CHF?
6 things
- smoking cessation
- avoid excessive alcohol use/cocaine use
- regular exercise
- low fat diet to prevent CAD
- control their HTN
- prevent readmission (home wt monitoring, salt
restriction, pt diuretic adjustment, case management)
What are some things to remember about prognosis with CHF?
6 items
- hospitalization is a marker for poor prognosis
- survival of HF patients worsens with age
- better survival for women over men
- HFpEF has a better prognosis
- 30-50% will be readmitted w/in 3-6 months
- main cause of death: sudden or arrhythmic death,
progressive pump failure
