CONGESTIVE HEART FAILURE Flashcards
CONGESTIVE HEART FAILURE 2 TYPES MAIN WHAT ARE THEY?
1-HEART FAILURE WITH REDUCED EF:
HFrEF
–DECREASED CONTRACTILITY AND
–SYSTOLIC DYSFUNCTION
2- HEART FAILURE WITH PRESERVED EF:
HFpEF –DECREASED RELAXATION AND
–DIASTOLIC DYSFUNCTION
POOR PROGNOSTIC FACTORS IN CHF
-S3+
-HYPONATREMIA (MANGE WITH FLUID RESTRICTION
-PCWP>12
-PAP>50
-PEAK O2 UPTAKE<14ML/KG
DRUGS THAT IMPROVE MORETALITY IN CHF
-ACEI
-ARBS
-ARNI-VALSARTAN -
SACUBITRIL WHICH IS
ARB+NI (NEPRILYSIN
INHIBITOR)- BETTER
THAN ARBS ALONE
BUT CAN CAUSE HOTN
-SPIRONOLACTONE-
LD- FOR NHY III OR IV
-SGLT2I
-HYDRALAZINE
+NITRATES
-BB
-IVABRADINE
DRUGS THAT DONT IMPROVE SURVIVAL IN CHF OR HAVE NOT SHOWN TO DECREASE MORTALITY IN CHF PATIENTS
-DIGOXIN-IMPROVES
FUNCTIONAL
CAPACITY AND
DECREASES
HOSPITALIZATIONS
-CCBS
-FUROSEMIDE ,
MILRINONE
RX SEQUENCE FOR HFrHF
1-FUROSEMIDE
2- ACEI OR ARNI(IF BP
CAN HANDLE ARNI)
-WHEN TRANSITION
FROM ACEITO ARNI-
MUST WAIT 36
HOURS FOR WASH
OUT PERIOD OF THE
ACEI BEFORE
STARTING ARNI
- IF+COUGH THEN
CHANGE TO ARB
- IF CREAT INCREASES
ON ACEI/ARNI/ARB
THEN SWITCH TO #6
3-ONCE VOL IS
CORRECTED ADD BB
4- ONCE OPTIMIZED
ON THE ABOVE
MEDS CHECK EF-IF
EF STILL LOW THEN
SART LD
SPIRONOLACTONE
5- ADD SGLT2I TO ALL
OF ABOVE EVEN IF
PATIENT DOING
WELL
**VERIGIGUAT- WILL
NOT ASK BUT IT
INCREASES
COLLATERAL
CIRCULATION
6- HYDRALIZINE PLUS
NITRATE ESPECIALLY
IF PATIENT IS AFAM
MALE OR IF CREAT IS
GOING UP ON #2
MEDS
7-IVABRADINE IF
HR>70
8-AFTER 3 MONTHS ON OPTIMIZED MEDICATIONS AND EF<40%
– AND NORMAL QRS
DURATION-PLACE
ICD ONLY
OR
–QRS PROLONGED
+LBBB -PLACE ON
ICD&CRT(ADDING
PACEMAKER)
9- AFTER ON ICD +/-
CRT IF EF STILL <20%
PUT PATIENT ON
TRANSPLANT LIST
AND PLACE LVAD
UNTIL TRANSPLANT
READY
RX FOR HFpEF
NO SEQUENCE
BUT
#1 TOC- DIURETICS
#2 SGLT2I
OTHERS+/- TO ABOVE
-SPIRONOLACTONE
-CANDESARTAN
-ACEI
-BB
CCB-LONG ACTING
-CARDIAC REHAB(BETTERQOL)
WHAT BNP IS SENSITIVE
AND SPECIFIC FOR ACUTE CHF?
SENSITIVE FOR CHF BNP ABOVE 100 (MEANS MIN BNP TO SAW CHF IS 100)
SPECIFIC FOR CHF BNP ABOVE 400
60 F IS EVALUATED FOR 3 MO HX + OF SOB ON EXERTION. NO CP, PMHX IS SIGNIFICANT FOR HTN, T2DM, AND HIGH CHOLESTEROL FOR WHICH SHE TAKES MEDS FOR
NEXT STEP?
TTE- TO DOCUMENT THE EF IN CHF
50M ER WITH INCREASING SOB FOFR PAST 3 DAYS
PMHX+ FOR HTN
BMI 40
JVP ELEVATED AT 14
+BL BASAL CRACKLES
S3+
BL PEDAL EDEMA +
BNP IS 160
MOST APPROPRIATE MNGMT?
IV FUROSEMIDE
BC BNP IS FALSE LOW IN OBESE PATIENTS WHICH IS WHY BNP IS ONLY 160 IN THIS PT
PT PRESENTS WITH EXERCISE INTOLERANCE AND DYSPNEA ON EXERTION
PE+ JVD 10, FEW BASAL RALES+ S3 +
PT IS DXED WITH CHF
CARDIAC ENZ AND TROPS- NORMAL
PT IS TREATED WITH DIURETICS AND GETS BETTER
TTE REVEALS EF OF 22%
WHAT RX IS PRESCRIBED AT D/C?
ACEI OR ARNI OR ARB
PT PRESENTS WITH EXERCISE INTOLERANCE AND DYSPNEA ON EXERTION
PE+ JVD 10, FEW BASAL RALES+ S3 +
PT IS DXED WITH CHF
CARDIAC ENZ AND TROPS- NORMAL
PT IS TREATED WITH DIURETICS AND GETS BETTER
TTE REVEALS EF OF 22% WAS D/CED ON ACEI OR ARNI OR ARB AND CREAT INCREASED FROM 1.1 RO 2 AND POTASSIUM FROM 4 TO 5.6 BEST MNGMT NOW?
DC ACEI AND START HYDRALAZINE PLUS NITRATES
PT WITH CHF ON LISINOPRIL 5 QD AND FUROSMIDE 40 PO OD PRESENTS FOR FU VISIT. STILL HAS FATIGUE WITH JVD 12(INCEASED), +BL SCATTERED RALES, +BL PITTING PEDAL EDEMA WHAT IS NEXT STEP IN MNGMT?
MAXIMIZE LISINOPRIL DOSE AND START IV LOOP DIURETIC -FUROSEMIDE
CANNOT START BB YET, ONCE VOL OD IS CORRECTED THEN CAN START LD BB AND TITRATE DOSE UP.
PT WITH CHF ON LISINOPRIL 5 QD AND FUROSMIDE 40 PO OD PRESENTS FOR FU VISIT. STILL HAS FATIGUE WITH JVD 12, +BL SCATTERED RALES, +BL PITTING PEDAL EDEMA
AFTER RX FOR ACUTE DECOMPENSATED CHF WITH MAX LISINOPRIL AND IV LOOP DIURETICS AND THEN ONCE VOL OD WAS CORRECTED NOW BEING DCED HOME MOST APPORPRIATE MNMGT AT THIS TIME?
CALL 2 DAYS POST DC WITH FU APT IN 1 WEEK- BECAUSE SHOWN THAT EARLY POST DC MONITORING CALL AND FU APT IN 7 DAYS SHOWED TO DECREASE HOSPITALIZATIONS AND ALL CAUSE MORTALITY IN CHF PATIENTS
PT NOW HERE FOR FU CURRENTLY ON LISINOPRIL 10MG WHAT RX START NOW?
CARVEDILOL-BB
2 MONTHS LATER PATIENT ONLISINOPRIL20 AND CARVEDILOL 25 BID, LASIX 40 QD POTASSIUM SUPPLEMEMTNS CLASS III AND EF IS NOW 30% WITH POTASSIUM OF 5.2
NEXT STEP?
DC POTASSIUM SUPPLEMENT AND START LD SPIRONOLACTONE
PT ON SPIRONOLACTONE ARE AT INCREASED RISK FOR?
HYPERKALEMIA
PT ON FUROSEMIDE, SPIRONOLACTONE, CARVEDILOL, LISINOPRIL COMES IN 6 MONTH LATER WITH LEFT BREAST ENLARGMENT
NEXT STEP?
BIOPSY SINCE BREAST ENLARGEMENT IS UL NOT BL
IF BL BREAST ENLARGMENT THEN DUE TO SPIRONOLACTONE AND WILL DC SPIRONOLACTONE AND START EPLERENONE
PT ON LISINO 30MG ATORVA 40 QD CARVEDILOL 25 BID SPIRONOLACTONE 25 QD AND ASA 81 QDLASIX WAS INCREASED TO40 THEN TO 60MG QD XOMES IN 3 WEEKS LATER
JVP 10CM, LUNGS+BIBASILAR CRACKLES S3+
EKG QRS IS 0.15 SEC WITH LBBB+
ECHO -EF IS 35%
BEST MNGMT?
START METOLAZONE 30 MIN PRIOR TO LASIX
TO BLOCK THE DISTAL TUBULE WITH METOLAZONE BEFORE BLOCKING PROXIMAL TUBULE WITH FUROSEMIDE
3 MOTNHS LATER PT ON LISINO 40MG ATORVA 40 QD CARVEDILOL 25 BID SPIRONOLACTONE 25 QD AND ASA 81 QD LASIX 60MG QD WITH METOLAZONE 30 MINS PRIOR TO LASIX
EKG QRS IS 0.15 SEC WITH LBBB+
ECHO - EF IS STILL 35%
BEST MNGMT NOW?
START ICD WITH CRT
MUST OPTIMIZE MEDICAL TREATMENT AT LEAST 3 MONTHS BEFORE ICD PLACEMENT
PT WITH CHF NYHA II EF 40% ON LISINO 30 BID CARVEDILOL 25 BID and spirono
bp is 130/80 AND
PT HAS NO SX NEXT STP?
SWITCH FROM LISINO TO ARNI
BY DC LISINO
WAIT 36 HOURS
THEN START ARNI- DECREASES MORTALITY AND HOSPITALIZATION
ACEI AND ARNI IS CONTRAINDICATED AS COMBO USE
AND CHECK PRO-BNP
PT WITH MILD CHF ON CANDESARTAN AND STABLE NEXT STEP?
SWITCH TO ARNI
PT SWITCHED TO ARNI DVPS COUGH NEXT STEP?
DC SACUBITRIL AND STAY ON ARB
IF PT IS ON ACEI AND DVPS COUGH SWITCH TO ARB
65 F BROUGHT TO ER WITH ONSET OF SEVERE SUBSTERNAL CP SINCE YESTERDAY AND GETS OUT OF BREATH
+MVA OR DIAGNOSED WITH BREAST CC OR LOST JOB OR $$ CATASTROPHE MC SOMETHING UNEXPECTED
JVP NORMAL
FR 120/M
LUNGS CLEAR
SUMMATION GALLOP HEARD ON ASCULTATION
TROP IS 36
EKG+1MM ST SEG ELEVATION IN V1-V4
ECHO -+HYPERCONTRACTILE BASE AND NON-CONTRACTILE APEX WITH EF OF 35% AND APICAL BALLOONING OF THE LV
CORONARY ANGIOGRAM SHOWS NO CORONARY OBSTRUCTION
MOST LIKELY DX?
DX: TAKOTSUBO CARDIOMYOPATHY (BROKEN HEART SYNDROME)
RECOVERS IN 2-3 MOTNHS
DT SUDDEN STRESS- INCREASE CORTISOL WHICH IN TURN INCREASE BP, STRESS ALSOINCREASES EPI AND SUDDEN BP INCREASE WHICH STRANGLES THE LV
SE OF ACEI INCLUDES? AND MNGMT OF SE
**COUGH:DT
INCREASED
BRADYKININ
–MNGMT SWITCH TO
ARB
**FIRST DOSE
SYNCOPE–>
PE - BP& HR -WNL–> –MNGMT CONTINUE
ACEI
**ANGIOEDEMA AND
LARYNG’L EDEMA–> –MNGMT CAN SWITCH
TO ARB
**DECREASED CONSTRICTION OF EFFERENT ARTERIOLES–> RENAL FAILURE IN MARGINAL PTS
OR
** INCREASED VASODILATION OF EFFERENT ARTERIOLES WITH HYPOPERFUSION OF GLEMERULUS
** NEUTROPENIA
WHICH DRUGS ARE NOT TO BE USED IN CHF PATIENTS?
-NSAIDS
-GLITAZONES (INSULIN
SENSITIZING AGENTS)
-CCBS
-CILOSTAZOL
-METFORMIN IN
ADVANCED CHF
WHAT HAS THE COMB USE OF ACEI AND ARBS TOGETHER SHOWN?
-LESS PROTEINURIA
AND
- POORER RENAL
OUTCOMES
65 F (POST MENOPAUSAL FEMALE) PRESENTS WITH NEW ONSET SOB ON MINIMAL EXERTION RELIEVED WITH REST
CHF +
LOUD S4+
SOFT S3+
JVD 12
FEW BASAL RALES+
EKG+BBB
ECHO+EF 25%
PT IS STARTED ON IV FUROSEMIDE AND IV ACEI
AND SXS IMPROVE
WHAT IS THE MOST APPROPRIATE NEXT DXIC TEST?
CORONARY ANGIOGRAM
LOUD S4+—-ISCHEMIA
LEADING CAUSE
OF CHF
SOFT S3+—–CHF
FINDINGD FOUND IN BOTH CONSTRICITVE PERICARDITIS AND RESTRICTIVE CARDIOMYOPATHY
*SX-DYSPNEA,
FATGIUE, HPMGLY
ASCITES, PEDAL
EDEMA
- RIGHT AND LEFT
SIDED PRESSURES -
INCREASED
*SYSTOLIC FUNCTION-
NORMAL
*DIASTOLIC
FUNCTION- YES;
EARLY RESTRICTIVE
FILLING WITH
EQUALIZATION OF
DIASTOLIC
PRESSURES
*JVP BULGE- YES
*SQUARE ROOT/DIP
AND PLATEAUE ON
EKG
ONLY IN CONSTRICTIVE PERICARDITIS
PATHO- RIGID PERICARDIUM AND LV CAN’T STRETCH
ETIOLOGY- POST CARDIOTOMY(#1MCC), POST AV REPLACEMENT, VIRAL(#2MCC), RADIATION TO THE CHEST(#3MCC)
HEART SOUNDS- EARLY DIASTOLIC SOUND OR EARLY 3RD HS
EKG - MOSTLY NORMAL
MURMURS-LESS COMMON
BNP<100
CXR- PERICARDIAL CALCIFICATIONS/DESCRIBED AS HEART BORDER IS CALCIFIED
ATRIAL ENLARGMENT- CARDIOMEGALY WITH BIATRIAL ENLARGMENT LESS COMMON
MRI** MOST SENSITIVE DIAGNOSTIC TEST FOR CONSTRICTIVE PERICARDITIS - THICKENED PERICARDIUM
DOPPLER ECHO-
-BULGING OF SEPTUM
TO THE LEFT
-MITRAL ANNULUS E’
>12 CM/SEC
-RESP VARIATION 10-
40%
RX-CARDIAC STRIPPING
ONLY IN RESTRICITVE CARDIOMYOPATHY
PATHO- RIGID VENTRICLE AND NOT RELAXING
ETIOLOGY-
>60Y/O-AMYLOID, <40Y/O-SARCOIDOSIS,
ENDOMYOCARDIAL FIBROSIS
HEART SOUNDS-
3RD HS LATER IN DZ——->4TH HS EARLY IN DZ
***EKG -
-LOW VOLTAGE EKG, -REPOLARIZATION ABNORMALITIES:
-ST-T WAVE
CHANGES,
-BBBS,
-AV CONDUCTION
DELAYS **
MURMURS-MC
-TR
-MR
BNP>400
CXR- CARDIOMEGALY DUE TO ATRIAL ENLARGEMENT
ATRIAL ENLARGMENT- CARDIOMEGALY WITH BIATRIAL ENLARGMENT MORE COMMON
MRI MOST SENSITIVE DIAGNOSTIC TEST - VENTRICULAR WALL THICKENING, THICKENED SEPTUM OR REFRACTILE **
DOPPLER ECHO-
-MITRAL ANNULUS E’
<8 CM/SEC
-RESP VARIATION< 10%
RX: CARDIAC TRANSPLANT
65 PT PRESENTS WITH DYSPNEA ON EXERTION AND FATIGUE FOR THE PAST COUPLE MONTHS
PMHX+MI 5 YR AGO AND+CABG AT THE SAME TIME,**
PE:
+JVP BULGES ON INSPIRATION
+EARLY DIASTOLIC SOUND ON ASCULTATION**
PEDAL EDEMA 1+ BP130/80
ON INSPIRATION 118/74(PULSUS PARADOXUS)
EKG-WNL
BNP 80**
ECHO- +EARLY RESTRICTIVE FILLING WITH SEPTUM BULGING TO THE LEFT ON INSPIRATION**
DX?
CONSTRICTIVE PERICARDITIS
70 PT PRESENTS WITH DYSPNEA ON EXERTION AND FATIGUE FOR THE PAST COUPLE MONTHS
PMHX+HTN
PE:
+PERIORBITAL ECCHYMOSIS BL*
+JVP BULGES ON INSPIRATION
+S3 ON ASCULTATION
TRACE PEDAL EDEMA AND PETECHIA OVER BL FEET*
LUNGS CLEAR
+PANSYSTOLIC MURMUR AT LEFT LOWER STERNAL BORDER
+TENDER HEPATOMEGALY
BP140/80
EKG-+ST SEG AND T WAVE CHANGES AND 1ST DEGREE AV BLOCK*
CXR+CARDIOMEGALY
DX?
RESTRICTIVE CARDIOMYOPATHY
BUZZ WORDS FOR AMYLOIDOSIS
+PERIORBITAL ECCHYMOSIS BL*
+PETECHIA OVER BL FEET*
HYPERTROPHIC CARDIOMYOPATHY (HCM)
-PATHO
-MC PRESENTATION
-FAMILIAL FORM
-PULSES
-HEART MUMUR
-DX?
-PATHO DYSFUNCTION
IS DIASTOLIC
-MC PRESENTATION: IS DYSPNEA ON EXERTION AND FATIGUE
-SUDDEN SYNCOPE, DEATH AFTER VIGOROUS EXERCISE–SYNCOPE IS POOR PROGNOSTIC FACTOR
-FAMILIAL FORM-SUDDEN DEATH NC IN FAMILIAL FORM IN YOUNG PT
-CP+
-PULSES: CAROTID AND PERIPHERAL PULSES WITH BRISK PSTROKE, BIFID OR TRIFID PULSE( USUALLY NO RADIATION TO CAROTIDS)
-HEART MUMUR: EARLY SYSTOLIC MURMUR AT LEFT LOWER STERNAL BORDER INCREASES WITH DECREASED FLOW(IE STANDING AND VALSALVA)
-DX? ASSYMETRIC HYPERTROPHY OF THE LV ON ECHO=HCM
PT IS DXED WITH HOCM NEXT STEP?
-ECHO FOR 1ST DEGREE RELATIVES TO R/O HOCM–>NEGATIVE ECHO–>NEXT DO GENE TESTING+–>MONITOR WITH ECHO SURVEILLANCE
-ECHO LV WALL >15MM
-RX:
1ST LINE: BB METOPROLOL
–IMPROVES SYMPTOMS GIVEN TO INCREASE DIASTOLIC FILLING TIME
POOR PROGNOSTIC FACTOS IN HOCM?
-VENTRICULAR
TACHYCARDIA
-AGE<30
-SEPTAL THICKNESS
>3CM OR >30MM
-SYNCOPE
-FAILURETO INCREASE
BP BY20MMHG UPON
EXERCISE
-FAMILIAL FORM AND
FAMILY HISTORY OF
SUDDEN DEATH
ASXIC 18 Y/O WANTS TO JOIN SOCCER TEAM AND PRESENTS FOR ROUTINE PHYSICAL WHICH RFEVEALS A
+EJECTION MURMUR AND BRISK CAROTID UPSTROKE
ECHO +16MM THICKENED UPPER PORTION OF THE IV SEPTUM NEXT STEP?
-NO HIGH INTENSITY SPORTS
-CAN DO BOWLING, CRICKET, CURLING
**IF PT HAS VTACHY
OR
HAS 1 RUN OF NSVT(3PVC/24HOURS) ON HOLTER
AND
+FAMILY HISTORY OF SUDDEN CARDIAC DEATH
***—NEXT STEP IS PLACE AN ICD
DDX MURMUR HOCM VS AS
HOCM
**EARLY SM
OR
**HARSH CRESCENDO-DECRESCENDO MURMUR AT LLSB
OR
**MID SM AT APEX RADIATING TO AXILLA(HOCM PLUS MR)
AS
**HARSH CRESCENDO-DECRESCENDO MURMUR AT RIGHT STERNAL BORDER
DDX BTW HOCM VS ATHLETES HEART
ECHO HOCM>15MM LV WALLTHICKENING AND ASSYMETRIC
ECHO ATHLETE HEART<15MM LV WALL SYMMETRIC THICKENING
