Congestive Heart Failure

Question 1

What is heart failure

Answer 1

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

Question 2

Systolic heart failure

Answer 2

difficulty pumping (depressed EF)

Question 3

Diastolic heart failure

Answer 3

difficulty filling (preserved EF)

Question 4

Symptoms of heart failure

Answer 4

Fatigue
Poor stamina
Dyspnea
Paroxysmal nocturnal dyspnea (PND)
Nocturnal cough ( Orthopnea)
Abdominal fullness, bloating, nausea
Edema

Question 5

Signs of heart failure

Answer 5

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

Question 6

What is the first sign you see with heart failure?

Answer 6

Elevated JVP

Question 7

What pathological anatomy is seen with left sided heart failure?

Answer 7

pulmonary edema

• -blood overfills ventricle and then overflows back into the lungs
• -get high pulmonary venous pressure

Question 8

Special symptoms of left sided heart failure

Answer 8

Paroxysmal nocturnal dyspnea

Orthopnea

Question 9

With left sided heart failure, what exam findings would you expect?

Answer 9

Crackles or rales in lungs on auscultation

Dilated hepatic vein on US

Question 10

What are some symptoms of right sided heart failure

Answer 10

Ankle swelling
Weight gain
Fatigue
Muscle atrophy

Question 11

Pathophysiology of CHF

Answer 11

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

Question 12

CHF etiology

Answer 12

Coronary atherosclerosis
Hypertension
Diabetes
Valvular Heart Disease
Alcohol
Viral
Others like familial

Question 13

How is heart failure staged?

Answer 13

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

Question 14

How are heart failure symptoms classified?

Answer 14

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

Question 15

What exams/tests are done to diagnose heart failure?

Answer 15

Clinical exam
ECG (usually abnormal but non-specific)
Chest film
BNP
Echocardiography

Question 16

Why is the clinical exam useful in heart failure?

Answer 16

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

Question 17

What findings would expect on a chest X-ray of someone with CHF?

Answer 17

Look for enlarged heart borders and fluid on CXR

Big heart is inefficient or weak heart

Question 18

What do you look for on an echo of someone with CHF?

Answer 18

Look for heart enlargements

Look for heart mm thickening

Look at valves

Look at strength of contraction - aka Ejection Fraction

Question 19

What is BNP?

Answer 19

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

Question 20

How do you determined EF?

What is normal?

Answer 20

EF = (LV EDV - LV ESV) / LV EDV

Normal = 55-65%
Heart failure = less than that
When > 65% = 65% hyperdynamic pumping

Question 21

General chronic CHF treatment

Answer 21

Dietary sodium restriction
Daily weight
Vaccination

Question 22

What treatments are used to just improve the symptoms of CHF?

Answer 22

Diuretics

Digoxin

Question 23

What treatments are used to improve symptoms and prognosis in CHF?

Answer 23

ACE inhibitors/ARBs
Hydralazine/isosorbide
B-blockers
Spironolactone
Devices (ICD, resynchronization)

Question 24

What does a defibrillator do?

Answer 24

Used to help contract the heart better

Also, used to prevent sudden death, which happens with heart failure patients

Question 25

What does resynchronization do?

Answer 25

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

Question 26

What are advanced therapies for CHF?

Answer 26

Chronic inotropic support

- Dobutamine
- Milrinone

Left ventricular assist devices (LVAD)

- Bridge therapy
- Destination therapy

Cardiac transplantation

Question 27

What are the causes of acute decompensated CHF?

Answer 27

• 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

Question 28

Acute CHF treatment

Answer 28

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

Question 29

Heart failure presenting with preserved LV EF is due to …

How do we treat this?

Answer 29

Increased LV filling pressure due to abnormalities in LV relaxation & compliance

Control BP
Relieve myocardial ischemia
Maintain sinus rhythm
Diuretics
No specific pharmacotherapy