Congestive Heart Failure Flashcards
What is heart failure
A complex clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the heart to fill with or to eject blood
Systolic heart failure
difficulty pumping (depressed EF)
Diastolic heart failure
difficulty filling (preserved EF)
Symptoms of heart failure
Fatigue Poor stamina Dyspnea Paroxysmal nocturnal dyspnea (PND) Nocturnal cough ( Orthopnea) Abdominal fullness, bloating, nausea Edema
Signs of heart failure
Resting tachycardia Low systolic BP and narrow pulse pressure Elevated JVP Hepatojugular reflex Pulmonary rales S3, S4, or summation gallop Displaced PMI Murmurs of mitral (tricuspid) regurgitation Hepatomegaly Ascites Edema Cachexia
What is the first sign you see with heart failure?
Elevated JVP
What pathological anatomy is seen with left sided heart failure?
pulmonary edema
- -blood overfills ventricle and then overflows back into the lungs
- -get high pulmonary venous pressure
Special symptoms of left sided heart failure
Paroxysmal nocturnal dyspnea
Orthopnea
With left sided heart failure, what exam findings would you expect?
Crackles or rales in lungs on auscultation
Dilated hepatic vein on US
What are some symptoms of right sided heart failure
Ankle swelling
Weight gain
Fatigue
Muscle atrophy
Pathophysiology of CHF
Decreased CO
Poor circulation to organs
- -low circulation to skeletal system - listlessness
- -low circulation to kidneys - activation of RAA system
- —salt and water retention –> edema
Sympathetic nervous system activation leading to increased contractility
CHF etiology
Coronary atherosclerosis Hypertension Diabetes Valvular Heart Disease Alcohol Viral Others like familial
How is heart failure staged?
Stage A • At risk for CHF - e.g. diabetes, HTN Stage B • Asymptomatic • Structural disease Stage C • Previous/current symptoms Stage D • Refractory • Symptoms • After treatment, can move back to stage C
How are heart failure symptoms classified?
Class I
• No symptoms
• No limitations to ordinary physical activity
Class II
• Mild symptoms to ordinary physical activity
Class III • Marked symptoms with less that usual activity • Comfortable at rest Class IV • Severe limitations & symptoms at rest • Bedbound patients
What exams/tests are done to diagnose heart failure?
Clinical exam ECG (usually abnormal but non-specific) Chest film BNP Echocardiography
Why is the clinical exam useful in heart failure?
To elicit signs
To take a good history to determine if sudden or gradual onset
- -sudden - look for acute reason like MI
- -gradual - know it is chronic problem like diabetes or HTN
What findings would expect on a chest X-ray of someone with CHF?
Look for enlarged heart borders and fluid on CXR
Big heart is inefficient or weak heart
What do you look for on an echo of someone with CHF?
Look for heart enlargements
Look for heart mm thickening
Look at valves
Look at strength of contraction - aka Ejection Fraction
What is BNP?
Brain naturetic peptide
* Comes from heart * Is released in correspondance to wall tension * Increased tension, increased BNP * Meaure in blood * Normal BNP < 100 * Can be relased in other conditions, but much higher in CHF than in other conditions
How do you determined EF?
What is normal?
EF = (LV EDV - LV ESV) / LV EDV
Normal = 55-65%
Heart failure = less than that
When > 65% = 65% hyperdynamic pumping
General chronic CHF treatment
Dietary sodium restriction
Daily weight
Vaccination
What treatments are used to just improve the symptoms of CHF?
Diuretics
Digoxin
What treatments are used to improve symptoms and prognosis in CHF?
ACE inhibitors/ARBs Hydralazine/isosorbide B-blockers Spironolactone Devices (ICD, resynchronization)
What does a defibrillator do?
Used to help contract the heart better
Also, used to prevent sudden death, which happens with heart failure patients
What does resynchronization do?
Help different portions of heart to contract in a synchronized way so that there is an effective contraction
Improves LV EF Improves symptoms and NHYA class Reduces functional MR
What are advanced therapies for CHF?
Chronic inotropic support
- Dobutamine - Milrinone
Left ventricular assist devices (LVAD)
- Bridge therapy - Destination therapy
Cardiac transplantation
What are the causes of acute decompensated CHF?
• Dietary noncomplicance • Medication noncomplicance • Inappropriate Treatment • Failure to seek care • Other - some of these are due to progression of disease itself ○ Acute ischemia ○ Uncontrolled HTN ○ Arrhythmias
Acute CHF treatment
Reduce fluid volume - diuretics
Decreased preload and after load - vasodilators
Augment contractility - ionotropes
When a pt comes to hospital with this, do the same things we’ve been doing, just more aggressively
Heart failure presenting with preserved LV EF is due to …
How do we treat this?
Increased LV filling pressure due to abnormalities in LV relaxation & compliance
Control BP Relieve myocardial ischemia Maintain sinus rhythm Diuretics No specific pharmacotherapy
