Congestive Heart Failure

Question 1

Heart failure
• Heart failure is defined as inability of heart to pump ——- (CO) at a rate commensurate with the requirements of the ————- or is able to do so only with an elevated ————pressure.

Answer 1

Heart failure
• Heart failure is defined as inability of heart to pump blood (CO) at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure.

Question 2

• ——— is major contributor of morbidity and mortality worldwide.

Answer 2

Heart

Question 3

Heart failure
• —— term is used when both ventricular chambers fail resulting into fluid overload.
• There is approximately how many people (— to —% of adult population) suffering for CHF in USA.
• Mortality of advanced disease exceed —%
• In Africa, it affects —to—% of adult population with greater severity.

Answer 3

Heart failure
• BVF term is used when both ventricular chambers fail resulting into fluid overload.
• There is approximately 5 million people (6 -10% of adult population) suffering for CHF in USA.
• Mortality of advanced disease exceed 50%
• In Africa, it affects 3-4% of adult population with greater severity.

Question 4

Heart failure triggers ‘counter-regulatory’ responses which make the situation better. T or F

Answer 4

F

Heart failure triggers ‘counter-regulatory’ responses which make the situation worse, not better.

Question 5

Treatment of heart failure is aimed at reversing these counterregulatory changes, which include:
– ————
– ————
– ————

Answer 5

Treatment of heart failure is aimed at reversing these counterregulatory changes, which include:
– activation of the renin–angiotensin–aldosterone system;
– activation of the sympathetic nervous system;
– release of vasopressin (an antidiuretic hormone,

Question 6

Cardiac performance is determined by ———, ———,——— and ———.
• Treatment targets these aspects, often by blocking one or other of the ———- mechanisms.

Answer 6

Cardiac performance is determined by preload, afterload,myocardial contractility and heart rate.
• Treatment targets these aspects, often by blocking one or other of the counterregulatory mechanisms.

Question 7

Physiology of HF
PRELOAD
• Cardiac preload, the cardiac filling pressure, is determined by ——— which is increased by —— and ——— retention – and ————-, increased by ———— activation.
• Drugs can reduce blood volume (such as——-) and reduce capacitance vessel tone (such as———).
AFTERLOAD
• Afterload is determined by the ————- and by ————-.
• Drugs that relax arterial smooth muscle reduce cardiac ———-.

Answer 7

Physiology of HF
PRELOAD
• Cardiac preload, the cardiac filling pressure, is determined by blood volume – increased by salt and water retention – and capacitance vessel tone, increased by sympathetic nervous system activation.
• Drugs can reduce blood volume (diuretics) and reduce capacitance vessel tone (venodilators).
AFTERLOAD
• Afterload is determined by the systemic vascular resistance and by aortic stiffness.
• Drugs that relax arterial smooth muscle reduce cardiac afterload.

Question 8

Physiology of HF
MYOCARDIAL CONTRACTILITY
• ———— (i.e. drugs that increase the force of contraction of the heart) can improve cardiac performance temporarily by increasing contractility, but at the expense of increased ———— and risk of ————.
HEART RATE
• Cardiac function deteriorates as heart rate increases beyond an optimum, due to insufficient time for ——- during ——-.
• Heart rate can usefully be slowed by ———— (i.e. drugs that slow the heart).

Answer 8

Physiology of HF
MYOCARDIAL CONTRACTILITY
• Positive inotropes (i.e. drugs that increase the force of contraction of the heart) can improve cardiac performance temporarily by increasing contractility, but at the expense of increased oxygen consumption and risk of dysrhythmia.
HEART RATE
• Cardiac function deteriorates as heart rate increases beyond an optimum, due to insufficient time for filling during diastole.
• Heart rate can usefully be slowed by negative chronotropes (i.e. drugs that slow the heart).

Question 9

Causes of heart failure include:

Answer 9

Causes of heart failure
• Myocardial infarction
• Coronary artery disease
• Valve disease
• Idiopathic cardiomyopathy
• Viral or bacterial cardiomyopathy
• Myocarditis
• Pericarditis
• Arrhythmias
• Chronic hypertension
• Thyroid disease
• Pregnancy
• Septic shock

Question 10

Signs and symptoms of heart failure include the following:

Answer 10

Signs and symptoms of heart failure include the following
• Exertional dyspnea and/or dyspnea at rest
• Orthopnea
• Acute pulmonary edema
• Chest pain/pressure and palpitations
• Tachycardia
• Fatigue and weakness
• Nocturia and oliguria
• Anorexia, weight loss, nausea
• Central or peripheral cyanosis, pallor
• Exophthalmos and/or visible pulsation of eyes
• Distention of neck veins
• Weak, rapid, and thready
pulse
• Rales, wheezing
• S 3 gallop a4w338nd/or pulsus alternans
• Increased intensity of P 2 heart sound
• Hepatojugular reflux
• Ascites, hepatomegaly, and/or anasarca

Question 11

The New York Heart Association (NYHA) classification
• Class I: —————
• Class II: —————
• Class III: ————-
• Class IV: —————

Answer 11

The New York Heart Association (NYHA) classification
• Class I: No limitation of physical activity
• Class II: Slight limitation of physical activity
• Class III: Marked limitation of physical activity
• Class IV: Symptoms occur even at rest; discomfort with any physical activity

Question 12

The New York Heart Association (NYHA) classification
• Class —: Slight limitation of physical activity
• Class —: Symptoms occur even at rest; discomfort with any physical activity
• Class —: Marked limitation of physical activity
• Class —: No limitation of physical activity

Answer 12

• Class II: Slight limitation of physical activity
• Class IV: Symptoms occur even at rest; discomfort with any physical activity
• Class III: Marked limitation of physical activity
• Class I: No limitation of physical activity

Question 13

THERAPEUTIC OBJECTIVES AND GENERAL MEASURES FOR CHRONIC HEART FAILURE includes:

Answer 13

• Therapeutic objectives in treating heart failure are
– to improve symptoms and
– to prolong survival.

Question 14

Drug used in heart Failure
• Accordingly, six classes of drugs have been shown to be effective:
• (1)
• (2)
• (3),
• (4)
• (5)
• (6)

Answer 14

Drug used in heart Failure
• Accordingly, six classes of drugs have been shown to be effective:
• (1) inhibitors of the renin-angiotensin system,
• (2) ß-adrenoreceptor blockers,
• (3)diuretics,
• (4) direct vasodilators,
• (5) aldosterone antagonists
• (6) Digitalis e.g digoxin /inotropic agents e.g dobutamin

Question 15

Drug used in heart Failure
• Accordingly, six classes of drugs have been shown to be effective:
• (1)
• (2)
• (3),
• (4)
• (5)
• (6)

Answer 15

Drug used in heart Failure
• Accordingly, six classes of drugs have been shown to be effective:
• (1) inhibitors of the renin-angiotensin system,
• (2) ß-adrenoreceptor blockers,
• (3)diuretics,
• (4) direct vasodilators,
• (5) aldosterone antagonists
• (6) Digitalis e.g digoxin /inotropic agents e.g dobutamin

Question 16

Treatment of Heart Failure
To Improve contractility: Positive———
i)
ii)
iii)

To reduce odema:
————-

To reduce preload & after load: ———-

Answer 16

Treatment of Heart Failure
To Improve contractility: Positive inotropes
i) Cardiac Glycosides
ii) B, agonists-* Dobutamine, Dopamine ii) PDE inhibitors-* Amrinone, Milrinone

To reduce odema:
Diuretics - Thiazide & Frusemide

To reduce preload & after load: ACE inhibitors

Question 17

Drugs used to treat Heart failure
A.) RAAS blockers:
1.) ACE inhibitors:
2.)ARBs:
B.) beta- blockers:
C.) Diuretics:
D.) Directvasodilator:
E.)Inotropic agents:

Answer 17

Drugs used to treat Heart failure
A.) RAAS blockers:
1.) ACE inhibitors: Captopril
Enalapril
Fosinopril
Lisinopril
Quinapril
Ramipril

2.)ARBs: Gandesartan
Telmisartan
Losartan
Valsartan

B.) beta- blockers: carvediol
Atenolol
Metoprolol

C.) Diuretics: Bumetanide
Furosemide
Hydrochlorothiazide
Metolazone

D.) Directvasodilator: Hydralazine
Isosorbide dinitrate
Sodium nitroprusside

E.)Inotropic agents: Amrinone
Digitoxin
Digoxin
Dobutamine
milrinone

Question 18

Drug used in heart Failure

NYHA I.
1.)For survival/morbidity :
2.)for symptoms:

NYHA II.
1.)For survival/morbidity:
2.)for symptoms:

NYHA III.
1.)For survival/morbidity:
2.)for symptoms:

NYHA IV
1.)For survival/morbidity:
2.)for symptoms:

Answer 18

Drug used in heart Failure

NYHA I.
1.)For survival/morbidity : Continue ACE inhibitor/ARB;if ACE inhibitor intolerant, continue aldosterone antagonist if post-MI,add beta-olocker if post-MI
2.)for symptoms: reduce / stop diuretic

NYHA II.
1.)For survival/morbidity: ACE inhibitor as first-line treatment/ARB, if ACE inhibitor intolerant add beta-blocker
and aldosterone antagonist, if post MI
2.)for symptoms: +/- diuretic depending on fluid retention

NYHA III.
1.)For survival/morbidity: ACE inhibitor plus ARB or ARB alone, if ACE intolerant beta- blocker add aldosterone antagonist
2.)for symptoms: + diuretics + digitalis
If still symptomatic

NYHA IV
1.)For survival/morbidity: Continue ACE inhibitor/ARB beta-blocker Aldosterone antagonist
2.)for symptoms: +diuretics + digitalis + consider temporary inotropic support

Question 19

Nonpharmacologic therapy:

Answer 19

Nonpharmacologic therapy:
• Oxygen and noninvasive positive pressure ventilation,
• dietary sodium restriction.
• fluid restriction.
• physical activity as appropriate.
• and attention to weight gain.