Clinical Reasoning-CHF Flashcards
How does heart failure kill you?
Arrhythmia (quick death) or pump failure (slow death)
Why is it important to start treating someone for heart failure even if they are asymptomatic (stage B heart failure)?
Those people are most likely to die of arrhythmias
A 60 year old male comes to see you. He had an MI at age 55 and now his EF is 40%. He experiences dyspnea with severe exertion. He does not have any edema. How does his decreased ejection fraction affect the rest of his CV system?
Forward failure (decreased cardiac output) and backward failure (increased venous congestion)
What is the vicious cycle of neurohormonal activation in CHF?
Decreased CO -> NE, RAAS, ADH release -> Vasoconstriction, Na & H2O retention -> ATII, NE & Aldosterone cause myocyte fibrosis -> LV dysfunction -> Decreased CO and so on…
What is the first line therapy for patients with asymptomatic heart failure?
Moderate to high dose ACE-I. This decreases afterload and fibrosis in cardiac myocytes.
A 44 year old mother with 5 kids comes to see you because of increased dyspnea on exertion. You do an echo and find that her EF is 40% and she has a dilated LV. She wants to live for a long long time and asks what she can do to slow the progression of her heart failure. List 5 things you could recommend.
ACE-I, Reduce BP, Reduce EtOH, Beta-blocker, Sleep apnea study.
A 60 year old male comes to see you. He had an MI at age 55 and now his EF is 40%. He experiences dyspnea with severe exertion. He does not have any edema. 5 years later he comes to see you and his EF has gone from 40% to 30%. He has crackles in his lungs. He also can’t even walk up the stairs without feeling dyspneic. Would you recommend diuretics for this patient?
Loop diuretics have proven effective in relieving patients of their symptoms, but actually increase mortality. You could do it short term.
What combination of diuretics can cause life-threatening massive diuresis?
Loop diuretics with a thiazide, this is because you are blocking a large amount of Na+ channels in the nephron.
How can you help prevent your patient on diuretics from going into shock due to volume depletion?
Have them weigh themselves every day.
What are the only diuretics that have been shown to prolong life in patients with heart failure?
Spironolactone and eplerenone. They reduce the amount of cardiac fibrosis that occurs from aldosterone activity.
In what patients are eplerenone and spironolactone contraindicated in?
Patients w/ [K+] > 5 mEq/L or Cr clearance < 30 mL/min due to risk of hyperkalemia.
A patient comes to you with symptoms of early heart failure. You want to prolong this patient’s life so you start him on a moderate-dose ACE-I, eplerenone and one other medication. What is this other medication and what dose do you start with?
Beta-blockers prolong life in CHF patients; however, you must start at a very low dose otherwise you will kill them because it is a negative inotrope.
What patients would you consider using digoxin therapy for?
Stage 2 CHF and above. It decreases CHF mortality by increasing contractility but increases mortality by increasing arrhythmias…so it’s a wash and you would give it just to help with their symptoms.
A patient comes to you with symptoms of early heart failure. You want to prolong this patient’s life so you start him on a moderate-dose ACE-I, eplerenone and a beta-blocker. The patient’s EF is
ICD (implantable defibrillator)
What EKG findings are increased in patients in CHF with a dilated left atrium and on a K+ channel blocker?
LA = atrial fibrillation. K+=torsades de pointes.
A 65 year old woman comes to see you with exertional dyspnea. She has long-standing, poorly controlled HTN. She has a normal EF, but you note that the left ventricle’s walls are hypertrophied. How do you treat this patient?
This patient has HFPEF (HF w/preserved EF). You treat the symptoms w/beta-blockers, ACE-I and diuretics; however, you DO NOT give digoxin.
