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CARDIOLOGY AWR > CONGESTIVE HEART FAILURE > Flashcards

CONGESTIVE HEART FAILURE Flashcards

1
Q

CONGESTIVE HEART FAILURE 2 TYPES MAIN WHAT ARE THEY?

A

1-HEART FAILURE WITH REDUCED EF:
HFrEF
–DECREASED CONTRACTILITY AND
–SYSTOLIC DYSFUNCTION

2- HEART FAILURE WITH PRESERVED EF:
HFpEF –DECREASED RELAXATION AND
–DIASTOLIC DYSFUNCTION

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2
Q

POOR PROGNOSTIC FACTORS IN CHF

A

-S3+
-HYPONATREMIA (MANGE WITH FLUID RESTRICTION
-PCWP>12
-PAP>50
-PEAK O2 UPTAKE<14ML/KG

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3
Q

DRUGS THAT IMPROVE MORETALITY IN CHF

A

-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

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4
Q

DRUGS THAT DONT IMPROVE SURVIVAL IN CHF OR HAVE NOT SHOWN TO DECREASE MORTALITY IN CHF PATIENTS

A

-DIGOXIN-IMPROVES
FUNCTIONAL
CAPACITY AND
DECREASES
HOSPITALIZATIONS
-CCBS
-FUROSEMIDE ,
MILRINONE

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5
Q

RX SEQUENCE FOR HFrHF

A

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

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6
Q

RX FOR HFpEF

A

NO SEQUENCE
BUT
#1 TOC- DIURETICS
#2 SGLT2I
OTHERS+/- TO ABOVE
-SPIRONOLACTONE
-CANDESARTAN
-ACEI
-BB
CCB-LONG ACTING
-CARDIAC REHAB(BETTERQOL)

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7
Q

WHAT BNP IS SENSITIVE
AND SPECIFIC FOR ACUTE CHF?

A

SENSITIVE FOR CHF BNP ABOVE 100 (MEANS MIN BNP TO SAW CHF IS 100)

SPECIFIC FOR CHF BNP ABOVE 400

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8
Q

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?

A

TTE- TO DOCUMENT THE EF IN CHF

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9
Q

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?

A

IV FUROSEMIDE
BC BNP IS FALSE LOW IN OBESE PATIENTS WHICH IS WHY BNP IS ONLY 160 IN THIS PT

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10
Q

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?

A

ACEI OR ARNI OR ARB

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11
Q

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?

A

DC ACEI AND START HYDRALAZINE PLUS NITRATES

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12
Q

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?

A

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.

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13
Q

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?

A

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

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14
Q

PT NOW HERE FOR FU CURRENTLY ON LISINOPRIL 10MG WHAT RX START NOW?

A

CARVEDILOL-BB

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15
Q

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?

A

DC POTASSIUM SUPPLEMENT AND START LD SPIRONOLACTONE

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16
Q

PT ON SPIRONOLACTONE ARE AT INCREASED RISK FOR?

A

HYPERKALEMIA

17
Q

PT ON FUROSEMIDE, SPIRONOLACTONE, CARVEDILOL, LISINOPRIL COMES IN 6 MONTH LATER WITH LEFT BREAST ENLARGMENT
NEXT STEP?

A

BIOPSY SINCE BREAST ENLARGEMENT IS UL NOT BL

IF BL BREAST ENLARGMENT THEN DUE TO SPIRONOLACTONE AND WILL DC SPIRONOLACTONE AND START EPLERENONE

18
Q

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?

A

START METOLAZONE 30 MIN PRIOR TO LASIX
TO BLOCK THE DISTAL TUBULE WITH METOLAZONE BEFORE BLOCKING PROXIMAL TUBULE WITH FUROSEMIDE

19
Q

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?

A

START ICD WITH CRT
MUST OPTIMIZE MEDICAL TREATMENT AT LEAST 3 MONTHS BEFORE ICD PLACEMENT

20
Q

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?

A

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

21
Q

PT WITH MILD CHF ON CANDESARTAN AND STABLE NEXT STEP?

A

SWITCH TO ARNI

22
Q

PT SWITCHED TO ARNI DVPS COUGH NEXT STEP?

A

DC SACUBITRIL AND STAY ON ARB
IF PT IS ON ACEI AND DVPS COUGH SWITCH TO ARB

23
Q

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?

A

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

24
Q

SE OF ACEI INCLUDES? AND MNGMT OF SE

A

**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

25
Q

WHICH DRUGS ARE NOT TO BE USED IN CHF PATIENTS?

A

-NSAIDS
-GLITAZONES (INSULIN
SENSITIZING AGENTS)
-CCBS
-CILOSTAZOL
-METFORMIN IN
ADVANCED CHF

26
Q

WHAT HAS THE COMB USE OF ACEI AND ARBS TOGETHER SHOWN?

A

-LESS PROTEINURIA
AND
- POORER RENAL
OUTCOMES

27
Q

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?

A

CORONARY ANGIOGRAM

LOUD S4+—-ISCHEMIA
LEADING CAUSE
OF CHF
SOFT S3+—–CHF

28
Q

FINDINGD FOUND IN BOTH CONSTRICITVE PERICARDITIS AND RESTRICTIVE CARDIOMYOPATHY

A

*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

29
Q

ONLY IN CONSTRICTIVE PERICARDITIS

A

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

30
Q

ONLY IN RESTRICITVE CARDIOMYOPATHY

A

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

31
Q

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?

A

CONSTRICTIVE PERICARDITIS

32
Q

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?

A

RESTRICTIVE CARDIOMYOPATHY

BUZZ WORDS FOR AMYLOIDOSIS
+PERIORBITAL ECCHYMOSIS BL*
+PETECHIA OVER BL FEET*

33
Q

HYPERTROPHIC CARDIOMYOPATHY (HCM)
-PATHO
-MC PRESENTATION
-FAMILIAL FORM
-PULSES
-HEART MUMUR
-DX?

A

-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

34
Q

PT IS DXED WITH HOCM NEXT STEP?

A

-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

35
Q

POOR PROGNOSTIC FACTOS IN HOCM?

A

-VENTRICULAR
TACHYCARDIA
-AGE<30
-SEPTAL THICKNESS
>3CM OR >30MM
-SYNCOPE
-FAILURETO INCREASE
BP BY20MMHG UPON
EXERCISE
-FAMILIAL FORM AND
FAMILY HISTORY OF
SUDDEN DEATH

36
Q

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?

A

-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

37
Q

DDX MURMUR HOCM VS AS

A

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

37
Q

DDX BTW HOCM VS ATHLETES HEART

A

ECHO HOCM>15MM LV WALLTHICKENING AND ASSYMETRIC

ECHO ATHLETE HEART<15MM LV WALL SYMMETRIC THICKENING

CARDIOLOGY AWR (12 decks)

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