Chronic Heart Failure, E, S, D

Question 1

CHF, what is it, how would you confirm a chronic HF

Answer 1

• a heart failure that developed over time, allowing for adaption and compensatory mechanisms within the cardiovascular system to occur.
• a CHF can be comfirm based on:
  .confirmed cardiac dysfunctions
  .neuro-hormonal activation confirmed
  .Response to HF treatment

Question 2

CHF, etiology

Answer 2

• most commonly results from coronary artery diseases (IHD)
• non ischemic etiologies include: myocarditis, HTN, valvular disorders, genetic cardiomyopathies, drugs and toxins

Etiology can be sub classified based on the ones resulting with High or low CO:

• with high CO: anemia, thyrotoxicosis, AV-fistula, Liver cirrhosis, Paget disease, beriberi
• With low CO: CAD, HTN, valvular disease, cardiomyopathy, arrhyhtmia pericardium disease, toxins, RV failure

Question 3

CHF: pathomechanism

Answer 3

• there’s a decreased in supply and an increased in demand of the body tissues -> decreased CO -> peripheral vasoconstriction -> pulmonary and venous congestion -> hypovolemia -> tissue hypoxia -> hypertrophy, weakness and failure of the heart

Question 4

CHF: Symptoms

Answer 4

Patients with CHF can present in various ways:

• no symptoms at all, but only presents evidence based on screening study (ex: echocardiography)
• mild symptoms of exacerbated by conditions of increased myocardial demand: dyspnea with exertion, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, and fatigue
• or patients will present in an acutely decompensated state, with or without hemodynamic stability, due to volume overload and/or low cardiac output.

Question 5

CHF: complications

Answer 5

• acute worsening of CHF causes the heart to be unable to adapt, and results in an acute decompensated HF

Question 6

CHF: Diagnosis

Answer 6

• a systematic evaluation using history, physical examination
• studies will help to discern the etiology of their chronic heart failure
• transthoracic echocardiography - this will confirm the presence of systolic dysfunction, will allow determination of an ejection fraction, and will help rule out evidence of other structural heart disease (e.g., valve stenosis or regurgitation, atrial or ventricular septal defect, congenital anomalies, etc.)
• When an etiology cannot be determined, and particularly when ischemic disease is a possibility, cardiac catheterization (or alternative diagnostic modality) should be considered to define the coronary artery anatomy and evaluate for the presence of obstructive coronary artery disease.

Question 7

Classification of HF based on the ejection fraction

Answer 7

HFrEF: HF with reduced ejection fraction

• Symptoms +- signs
• LVEF < 40%

HFmrEF: HF with mild range ejection fraction

• Symptoms +- signs
• LVEF: between 40-49%
• elevated levels of natriuretic peptides
• at least one additional criterions: relevant structural heart disease (LVH and/or LAE), diastolic dysfunction

HFpEF: HF with preserved EF

• Symptoms +- signs
• LVEF > 50%
• elevated levels of natriuretic peptides
• at least one additional criterions: relevant structural heart disease (LVH and/or LAE), diastolic dysfunction

Question 8

CHF: lab studies

Answer 8

Laboratory studies should complement the history, physical examination, and diagnostic imaging studies. Abnormalities in serum electrolytes, markers of renal function, and liver function tests can help identify patients who are decompensated and require more optimal pharmacologic therapy, including augmented diuresis.

Biomarkers used for the guiding of chronic HF: creatinine, NT proBNP, bilirubin