Congestive Heart Failure Flashcards by Cassandra Martinez

What is congestive heart failure?

It is a clinical syndrome characterized by structural or functional impairment of ventricular filling or ejection of blood resulting in insufficient perfusion to meet metabolic demands.

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What are the three most common clinical manifestations of CHF?

Edema, dyspnea, fatigue

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What is the ejection fraction for

Heart failure with a reduced ejection fraction?

Left ventricular fraction of 40% or less

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What is the ejection fraction for a person with heart failure with a preserved ejection fraction?

Left ventricular ejection fraction of 50% or more

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Patients with borderline reduced ejection fraction have an ejection fraction value of what range?

41 to 49%

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What is the predominant cause of heart failure with reduced ejection fraction (systole hf)?

Coronary artery disease

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What is the predominant cause of heart failure with a preserved ejection fraction (diastolic)?

Hypertension

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Which type of heart failure results in left ventricular dilation?

Heart failure with reduced ejection fraction, systolic heart failure

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Which type of heart failure results in left ventricular hypertrophy?

Heart failure with preserved ejection fraction, diastolic heart failure

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For staging by American college of cardiology foundation/American heart association, what stage is this:

Patient is at high risk for heart failure, without structural heart disease or symptoms based on wrist factors of hypertension, diabetes, dyslipidemia, etc.

Stage A

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For staging by American college of cardiology foundation/American heart association, what stage is this:

Patient has structural heart disease with evidence of ventricular modeling, previous MI, without signs or symptoms of heart failure.

Stage B

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For staging by American college of cardiology foundation/American heart association, what stage is this:

Patient has structural heart disease with prior or current symptoms of heart failure

Stage C

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For staging by American college of cardiology foundation/American heart association, what stage is this:

Heart failure that is refractory to optimal goal directed medical therapy

Stage D

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Functional classification by New York heart association (based on symptom severity), what class is this?

Symptoms are experienced at rest, unable to carry on any physical activity without symptoms.

Class IV (4) severe

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Functional classification by New York heart association (based on symptom severity), what class is this?

Heart disease with no symptoms are limitations on physical activity.

Class I (1)

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Functional classification by New York heart association (based on symptom severity), what class is this?

Patient is comfortable at rest, but symptoms heart failure with minimal exertion.

Class III (3) moderate

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Class II (2) mild

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What are the differences between the classifications by the American College of cardiology foundation/American heart Association and the New York heart Association?

The American heart Association/American College of cardiology foundation go based off of structure and progression of disease as evidenced by ECG and echocardiography

New York goes based off symptom severity

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The filling of ventricles is impaired owing to abnormal relaxation or stiffness and decreased diastolic distensibility, which type Heart failure is this?

Diastolic heart failure, heart failure with preserved ejection fraction

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Heart failure with preserved ejection fraction that has been improved or recovered is to have a ejection fraction of what percent?

Ejection fraction has improved more than 40% in a patient previously classified as having heart failure with reduced to ejection fraction

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Left ventricular contractility is impaired and is often dilated, which type of heart failure is this?

Systolic heart failure, heart failure with a reduced ejection fraction

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What is considered chronic heart failure that is stable?

Treated heart failure, signs and symptoms are unchanged from more than one month.

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When conducting a family history in evaluating for heart failure what is important to ask?

If there is a presence of cardiomyopathy, ask about heart failure remembers going back three generations

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Presence of a S3 Gallup is associated with which type of heart failure?

It is associated with systolic heart heart failure

heart failure with reduced ejection fraction

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Presence of S4 Gallop is common in which type of heart failure?

Diastolic heart failure or heart failure with preserved ejection fraction

Which less specific symptoms can be absent in advance chronic heart failure?

Crackles in rails may be absent in advanced chronic heart failure

Risk factors associated with heart failure: Age What race/ethnicity? What sex is more common?

Black Americans have a higher incidence. Males have a higher incidence and women

Diagnosis for heart failure is suspected based off of what?

Through their history and physical exam

When it comes to make an initial diagnosis, using the b-type natriuretic peptide should be used to do what?

To rule out rather than to rule in the diagnosis on initial evaluation. A negative predictive value exceeds positive predictive value in ruling out a diagnosis than a positive value does in ruling in.

For chronic stable heart failure what are the general goals?

Relieve symptoms, prevent hospitalizations, improve quality of life, and functional capacity, and reduce mortality

For pts in stage A, what is the goal?

The goal is risk factor modification to prevent disease

``` For patients and stage B or class one, what is a goal? List 2 ```

The goal is to prevent symptoms and progressive cardiac remodeling

For patients in stage C or class 2 and class 3 , what is the goal? List 4

Control symptoms, improve quality of life, prevent hospitalizations, and prevent mortality

For patients and stage D or class 4, what are the goals?

Control symptoms, improve quality of life, reduce hospital readmission, and explore alternative treatment (such as heart transplant or mechanical circulatory support)

Should patients with heart failure take anti-platelet drugs such as aspirin? When are the exceptions?

There is no evidence of benefit from antiplate lit drugs and patients with chronic stable heart failure unless con committed Coronary artery disease is present or if the patient has atrial fibrillation or known cardiac thrombus present

For stage B what are the recommended medications ?

Ace inhibitor or arb and a beta blocker | Statin too if they have hx of MI or at high risk of CAD

What does an ace inhibitor do?

It reduces mortality by inhibiting the renin angiotensin aldosterone system and decreases cardiac remodeling

What does a beta blocker do?

Prevents symptoms and reduces mortality by blocking catecholamines and slowing the heart rate which allow for improved ventricular filling and improved ejection fraction

What is the recommended pharm therapy for stage C? List 3 med classes

Use ACE inhibitor or ARB or angiotensin receptor—neprilysin inhibitor Use in conjunction with beta blocker and aldosterone antagonist in selected pts

What medications do you not give together?

An ACE inhibitor with an ARB And Angiotensin receptor-neprilysin inhibitor with an ACE inhibitor (severe risk for angioedema)

How long should you wait to give angiotensin receptor-neprilysin inhibitor after the last dose of an ACE inhibitor ?

More than 36 hours

What are the 3 beta blockers to be used in heart failure?

Bisoprolol, carvedilol, long-acting metoprolol (succinate)

What are the requirements to be on an aldosterone antagonists? Focus more on creatinine for men and women and potassium level

Ejection fraction less than 35% History of prior CV hospitalization or elevated BNP After acute MI with ejection fraction less than 40% Creatinine should be 2.5 or less in men and 2 or less in women Potassium level should be less than 5

Eplerenone belongs to what class?

Aldosterone receptor antagonists

Sacubitril-Vallarta belongs to what class?

Angiotensin receptor neprilysin inhibitor

Isosorbide dinitrate belongs to which class of medication?

Vasodilators

Cardioverter defibrillator contraindications, list three

Less than 40 days post MI Less than 90 days post revasculizarization life expectancy is less than 1 yr

What is the preferred beta blocker for patients with heart failure and poor diabetes control?

Carvedilol

What is important to know about Spirinolactone when treating patients with heart failure and diabetes?

Spirinolactone may moderately worsen glycemic control in patients with heart failure and diabetes

What two medications should be used in addition to, or in place of, ACE inhibitor in black patients with congestive heart failure class 2 or higher?

Hydralazine and isosorbide dinitrate

What are some precipitating factors for ventricular arrhythmias?

Electrolyte disturbances, prolonged QT interval, digoxin toxicity, myocardial ischemia

Concurrent heart failure NHL fibrillation place the patient high risk for what type of thromboembolic events?

TIA, stroke, DVT

The best single predictor for mortality in acute decompensated heart failure is a high BUN level admission, followed by low systolic blood pressure, then by high level of serum creatinine. What are the levels/set point for each?

BUN level higher than 43 Low systolic blood pressure less than 115 High level serum creatinine of 2.75mg/dL

What are some cardiotoxic agents/medications that should be avoided in patients that are at high risk for developing heart failure?

Cocaine, antineoplastic drugs, ephedra, cobalt, anabolic steroids, Chloroquine, clozapine, amphetamines, methylphenidate, catecholamines

What two types of diabetes medication classes are preferred for patients with heart failure?

Metformin and sodium glucose cotransporter type 2 inhibitors

Which class of diabetes medication is not recommended for patients with heart failure because it’s associated with fluid retention?

Thiazolidinediones

Are statins used to improve symptoms of heart failure?

No they have not been shown to improve symptoms of heart failure, it is recommended for prevention of ASCVD

Digoxin is associated with an increased risk of death in which sex?

Female

For patients that have congestive heart failure and depression what class of medication is preferred for anti depressants?

SSRIs

What are the initial laboratory evaluation that patients should get when presenting with heart failure?

Complete account, your analysis, serum electrolytes including magnesium and calcium, blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function test, thyroid stimulating hormone.

What 2 lab tests are useful for establishing prognosis or disease severity in acutely decompensated heart failure?

BNP or cardiac troponin

What is useful to support clinical decision making regarding the diagnosis of heart failure in ambulatory patients?

BNP

BNP is good for support in clinical decision making but not as a guide for therapy…true or false

True

If echocardiography are inadequate, what can be useful to assess left ventricular ejection fraction and volume? List 2 alternatives

Radionuclide ventriculography or MRI can be useful

Endomyocardjal biopsy should not be performs for routine evaluation of pts with heart failure True or false

True

Routine combined you an ace inhibitor, an ARB, and an aldosterone antagonist is what?

Potentially harmful

``` Omega 3 polyunsaturated fatty acid supplementation is reasonable to use as adjunctive therapy in pts with what class of heart failure? List New York class ```

Heart failure class 2-4

In what type of patients is natriuretic peptide biomarker based screening followed by TEam based care including cv specialist optimizing guideline management, can be useful to prevent the development of left ventricular dysfunction or new onset heart failure.

For patients AT RISK of developing heart failure At risk patients: hypertension, diabetes, known vascular disease (stage A hf)

During a heart failure hospitalization, a pre-discharge natriuretic peptide level can be useful to establish what?

Post discharge prognosis.

A patient taking angiotensin receptor neprilysin inhibitor can elevate what CHF biomarker?

It increases BNP levels Has no effect on NI-pro BNP levels

In ARNI, an ARB is combined with an inhibitor of neprilysin which does what?

Neprilysin is an enzyme that degrades natriuretic peptides, bradykinin, Arden one Dillon and other vasoactive peptides

What causes a cough in ACE inhibitors?

They inhibit kininase and increase levels of bradykinin which can induce a cough

Ace inhibitors can produce angioedema, should be given with caution to patients with what?

Low systemic blood pressures, Renal insufficiency or elevated serum potassium

In patients with chronic symptomatic heart failure with reduced ejection fraction with a New York Heart Association class of two or three tolerating ace inhibitors or an ARB, replacement by what medication is recommended to further reduce morbidity and mortality?

ARNI | Angiotensin receptor neprilysin inhibitor

Why should ARNI not be administered concomitantly with ace inhibitor or within 36 hours of the last dose of an ace inhibitor?

If used in combination with ace inhibitor, it will cause angioedema

Ivabradine can be beneficial to reduce HF hospitalizations for pts with symptomatic (2-3 Nyah) stable chronic hf (ej less than 35) who are on a beta blocker at max dose and in a sinus rhythm with a heart rate of what?

Greater than 70 at rest

Routine use of nitrates or phosphodiesterase 5 inhibitors To increase activity or quality of life in patients with heart failure with preserved ejection fraction is ineffective. True or false

True

In patients with heart failure and anemia, should erythropoietin stimulating agents be used?

No, there is no benefit

In patients at increase risk, stage A heart failure, the optimal blood pressure and those with hypertension should be less than what?

Less than 130/80

Adaptive servo ventilation for central sleep apnea in pts with heart failure is associated with what?

Harm

In patients with cardiovascular disease and obstructive sleep apnea, CPAP may be reasonable to improve what?

Improve sleep quality and daytime sleepiness No evidence of benefit on cardiovascular events

What is the mechanism of action for ivabradine ?

Selectively Inhibits I channel in the sino atrial node, providing heart rate reduction

Blood that can’t be ejected from the heart or get out of the heart is associated with what type of heart failure?

Heart failure with reduced (systolic) ejection fraction

Blood that can’t get into the heart is associated with what type of heart failure?

Heart failure with preserved (diastolic) heart failure

What is ejection fraction ?

The proportion of blood that the heart can pump out in one contraction.

In the pulmonic circulation the arteries have what type of blood and the veins have what type of blood? Is it oxygenated or deoxygenated

In pulmonic circulation, the arteries have deoxygenated blood and the veins have oxygenated blood

In the systemic circulation, the arteries have what type of blood and the veins have what type of blood ?

In the systemic circulation, all arteries have oxygenated blood and the veins have deoxygenated blood.

Blood coming out of the heart goes out via what?

Arteries

All blood that goes to the heart goes to the Heart Via what?

Veins

NSAIDs, most calcium channel blocked and anti-arrhythmic drugs should be used or avoided in pts with CHF?

Avoided

Forward failure is associated with what type of heart failure?

Systolic dysfunction or heart failure with reduced ejection fraction because the weakened ventricle can’t pump blood into the arterial system which results in decreased cardiac output and hypoperfusion of end organs

With hypoperfusion of the kidneys, what 2 mechanisms are stimulated in response to systolic dysfunction?

Renin system and ADH

Backward failure is associated with what type of heart failure?

Diastolic failure

What causes pulmonary congestion?

Diastolic heart failure, the backward failure caused elevated filling and backward buildup into the pulmonary venous system which results in extravasation of fluid intro the pulmonary interstitium

Left sided heart failure is associated with what—systolic or diastolic hf?

Diastolic hf

Hepatomegaly, Jugular venous distention, venous congestion, splenomegaly, ascites is associated with what kind of heart failure?

Right sided heart failure, systolic hf, reduced ejection fraction

Pulmonary symptoms such as congestion, rales, sob are associated with what hf?

Diastolic heart failure, preserved ejection fraction

What is the preferred 2 dimensional echocardiography with Doppler ?

Transthoracic echocardiography

What kind of patients may have falsely Low natriuretic peptide levels?

Obese patients