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Cardiology Exam 4 > Congestive Heart failure > Flashcards

Congestive Heart failure Flashcards

1
Q

What is heart failure

A

I. Heart failure is not a disease: it is a symptom. II. Heart failure can be defined as the heart’s inability to pump enough blood to supply the body’s metabolic needs.

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2
Q

What happens in right heart failure? What are the symptoms?

A

Right heart failure reflects an elevated right atrial mean pressure (exceeding 6 millimeters of mercury). A. Symptoms. 1. Venous congestion. 2. Enlarged liver. 3. Peripheral edema. 4. Pitting edema.

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3
Q

What happens with Left heart failure? symptoms?

A

Left heart failure reflects an elevated left atrial mean pressure (exceeding 12 millimeters of mercury). A. Symptoms. 1. Dyspnea on exertion. 2. Orthopnea. 3. Acute pulmonary edema. 4. Fatigue and loss of muscle mass.

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4
Q

What happens with bi-sided heart failure?

A

Bi-sided heart failure reflects an elevation of the mean pressure in both atria

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5
Q

Causes of elevated atrial pressure with a normal or low corresponding ventricular diastolic pressure? (with their etiologies)

A

A. Mitral valve obstruction. 1. Rheumatic mitral stenosis. 2. Left atrial thrombus. 3. Left atrial myxoma. 4. Endocarditis. 5. Cor triatriatum. B. Tricuspid valve obstruction. 1. Carcinoid syndrome. 2. Rheumatic tricuspid stenosis. 3. Rare causes. a. Right atrial tumor. b. Tricuspid valve endocarditis. c. Right heart thromboembolism. d. Localized form of constrictive pericarditis. C. Mitral regurgitation. D. Tachycardias. E. Ventriculoatrial conduction.

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6
Q

Causes of elevated atrial pressure with an elevated ventricular diastolic pressure/ dilated ventricle with an ejection fraction depressed?

A

a. Severely increased afterload. (1) Left ventricular ejection fraction decreased secondary to increased afterload. (a) Critical aortic coarctation in the neonate. (b) Critical aortic stenosis. (c) Acute severe systemic hypertension. (2) Right ventricular ejection fraction decreased secondary to increased afterload. (a) Acute massive pulmonary thromboembolism (b) Other causes of pulmonary hypertension. (1) Cor pulmonale. (2) Chronic left heart disease. b. Myocardial disease (decreased contractility). (1) Left ventricular ejection fraction decreased secondary to decreased contractility. (a) Dilated (congestive) cardiomyopathy. (b) Myocarditis. (c) Coronary artery disease. (d) Left ventricular aneurysm. (e) Acute myocardial infarction. (f) (Aortic regurgitation). (2) Right ventricular ejection fraction decreased secondary to ventricular disorder. (a) Ebstein’s anomaly. (b) Uhl’s anomaly. (c) Right ventricular infarction.

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7
Q

Causes of elevated atrial pressure with an elevated ventricular diastolic pressure/ dilated ventricle with stroke volume increased?

A

a. Left or biventricular volume load. (1) Acute overload. (a) Acute severe aortic regurgitation. (b) Ventricular septal defect. (c) Patent ductus arteriosus. (2) Chronic overload. (a) Chronic aortic regurgitation. (b) Systemic high output states. (1) Anemia. (2) Systemic AV fistula. (3) Beriberi. (4) Hydatidiform mole. (5) Hepatic hemangiomatosis. (6) Renal cell carcinoma. (7) Paget’s disease of bone. (8) Carcinoid syndrome. b. Right ventricular volume overload. (1) Tricuspid regurgitation. (2) Atrial septal defect.

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8
Q

Causes of elevated atrial pressure with an elevated ventricular diastolic pressure but a non dilated ventricle?

A
  1. Abnormal left ventricular volume-compliance. a. Hypertrophic nondilated cardiomyopathy. b. Hypertension. c. Aortic stenosis. 2. Right ventricular volume-compliance abnormality. a. Pulmonary stenosis. b. Primary pulmonary hypertension. c. Cor pulmonale. 3. Biventricular volume-compliance abnormality. a. Nonhypertrophic nondilated cardiomyopathies. (1) Amyloid heart disease. (2) Endomyocardial disease. b. Constrictive pericarditis. c. Pericardial tamponade.
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9
Q

What conditions cause or complicate heart failure?

A

A. Cause and/or complicate heart failure. 1. Rupture of mitral valve chordae tendineae. 2. Infective endocarditis. 3. Painless acute nontransmural myocardial infarction. 4. Sodium load. 5. Hypoalbuminemia.

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10
Q

What are conditions that increase Cardiac output?

A
  1. Fever. 2. Infection. 3. Acute minor pulmonary thromboembolism. 4. Fluid overload. 5. Anemia. 6. High environmental temperatures. 7. Dietary salt excess. 8. Renal failure. 9. Thyrotoxicosis. 10. Pagets disease of bone. 11. Hepatic cirrhosis; hepatitis. 12. Acute abdominal disease (intestinal infarction or pancreatitis, for example). 13. Emotional stress. 14. Pregnancy. 15. Obesity. 16. Hyperosmolality of the serum (combined with renal failure). 17. Indomethacin administration. 18. Tachyarrhythmia. 19. Bradyarrhythmia. 20. Poor compliance with medical regimen. 21. Poorly controlled hypertension.
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11
Q

Heart failure epidemiology?

A

More than 4 million patients affected • 400,000 new cases annually • Approximately 1 million hospitalizations • $10 billion/year treatment costs

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12
Q

What percent of heart failure patient are re-admitted to the hospital?

A

within 6 months 50% readmissions.

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13
Q

What is the new approach to heart failure?

A

A Stage: High risk for developing heart failure (HF) Patient Description: • Hypertension • CAD • Diabetes mellitus • Family history of cardiomyopathy B Stage: Asymptomatic HF Patient description: • Previous MI • LV systolic dysfunction • Asymptomatic valvular disease C Stage: Symptomatic HF Patient Description: • Known structural heart disease • Shortness of breath and fatigue • Reduced exercise tolerance D Stage: Refractory end-stage HF Patient description: • Marked symptoms at rest despite maximal medical therapy (eg, those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions)

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14
Q

Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class?

A
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15
Q

Explain the pathologic progression of CV disease?

A
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16
Q

what is remodeling?

A
  • Process by which mechanical, neurohormonal, and possibly genetic factors alter ventricular size, shape, function
  • Occurs in most heart diseases: MI, cardiomyopathy, hypertension, aging, diabetes, valvular disease
  • Can be reversed or at least delayed
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17
Q

Risk of heart failure after MI?

A
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18
Q

explain the change in LV parameters after an MI?

A
19
Q

explain the relationship between LV remodeling and CV events post MI?

A
20
Q

what are the symptoms of heart failure? Physical findings? How to assess to cardiac function?

A
  • Symptoms* – Exertional dyspnea or fatigue – Orthopnea, paroxysmal nocturnal dyspnea
  • Physical findings† – Elevated jugular venous pressure, third heart sound, laterally displaced apical impulse, rales, edema, cardiomegaly on chest X-ray
  • Assess cardiac function – Echocardiography or radionuclide ventriculography may be used to assess ejection fraction
21
Q

what is the diagnostic algorithm for CHF?

A
22
Q

What are the principles of treating CHF?

A

Control edema and congestion:

  • Dietary restriction of sodium
  • Avoid excessive fluid intake
  • Restrict alcohol consumption
  • Exercise regularly
  • Diuretics
23
Q

Explain diuretics use in CHF?

A
  • No new data with diuretics
  • Most efficacious: loop diuretics – Most rapid relief of symptoms – Improves exercise capacity
  • No mortality benefit
  • Efficacy diminished as CHF advances – accompanying decline in renal perfusion may require dose increases and/or addition of second agent with complementary mode of action (e.g., metolazone)
24
Q

Advantages of Digitalis in CHF?

A
  • Not a sympathetic stimulator
  • May provide 4 –10 % increase in cardiac output
  • No development of tolerance
  • Well standardized and inexpensive
  • Extreme value in CHF associated with atrial fib
25
Q

Disadvantages of Digitalis in CHF?

A

Narrow therapeutic to toxic ratio
• Modest inotropic action in setting of sinus rhythm
• Hazardous drug interactions
• Dangerous in setting of hypokalemia

26
Q

What are the two systems targeted in the control of heart failure?

A
27
Q

what are the maladaptive effects of angiotensin 2?

A
28
Q

ACE inhibitors increase what effect of angiotensin 1?

A
29
Q

What is the RAS pathway in Heart failure?

A
30
Q

What is the consensus recommendation for ace inhibitor use in heart failure?

A

Consensus Recommendations
• All patients with heart failure due to left ventricular systolic dysfunction should receive an ACE inhibitor unless they have a contraindication to its use or cannot tolerate treatment with the drug
• Treatment with an ACE inhibitor should not be delayed until the patient is found to be resistant to treatment with other drugs

31
Q

Explain ACE use in each stage of HF?

A
32
Q

ARB’s in heart failure?

A
33
Q

ACE inhibitors and mortality and morbidity with HF?

A

ACE inhibitors alone will not decrease mortality and morbidity?

34
Q

effects of beta blockade?

A
35
Q

adrenergic pathway progression in heart failure?

A
36
Q

what is the selectivity of B-Blocking agents?

A
37
Q

General benefits of alpha blockade?

A
  • Mediates vasodilation, which can lead to improvement in both insulin resistance and lipoprotein/triglyceride metabolism*1
  • Decreases plasma triglyceride concentrations†1
  • Acts to improve renal blood flow and reduce peripheral vascular resistance2
38
Q

initiation of carvediolol in HF?

A
  • Ensure patient is on ACE inhibition and not fluid overloaded
  • Start at 3.125 mg bid
  • Increase the dose gradually – Any time after 2 weeks
  • Benefits begin at 6.25 mg and continue across dose range (6.25 to 25 mg bid)
39
Q

Remodeling of the heart and disease progression?

A
  • Adverse remodeling of the heart defines disease progression
  • At the cardiac, cellular, and molecular levels, neurohormonal activation drives adverse remodeling
  • Adverse remodeling can be reversed by neurohormonal interventions
40
Q

Reversal of remodeling with Pharmacology treatment?

A
41
Q

Alternatives therpies for CHF?

A
  • Combination of nitrates and hydralazine – For patients intolerant of ACE inhibitors or beta-blockers – Favorable effect on survival in patients with mild to moderate symptoms – Utility with end-stage disease unknown
  • Aldosterone antagonists – Decrease sudden death and overall mortality early after MI and in advanced CHF – Evidence largely has been derived in patients who have preserved renal function – Can produce dangerous hyperkalemia in patients with impaired renal function – However can protect against diuretic induced hypokalemia
42
Q

drugs that reduce mortality in HF with reduced ejection fraction?

A
43
Q

Diastolic dysfunction diagnosis? Treatment?

A
  1. Diagnosis a) Impossible to differentiate from systolic dysfunction from symptoms alone b) Echocardiogram is most helpful in establishing the diagnosis
  2. Treatment a) No proven mortality benefit with any Rx used for systolic dysfunction b) Main goal of therapy is to control BP and fluid overload a) Beta-blockers b) Diuretics c) ACE-I and ARBS ? d) Digoxin - NO BENEFIT

Cardiology Exam 4 (21 decks)

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