Congestive Heart Failure I - Exam 2 Flashcards
What is heart failure? What is important to note? What are the s/s related to?
ACCF/AHA/HFSA define HF as a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood
is it a SYNDROME not a disease, need to figure out the underlying cause
s/s related to reduced CO and volume overload
______ is MCC of HF
Ischemic heart disease
**What are the risk factors for heart failure?
Hypertension
CVD
Diabetes
Obesity
Exposure to cardiotoxic agents
Genetic variants for cardiomyopathy
Family history of cardiomyopathy
HF classifications are based on _____ and _____. Give the 3 options for classifications
timing and function
acute vs chronic
high output vs low output
reduced vs preserved EF
What is the difference between acute and chronic heart failure?
acute: last few days to weeks
chronic: symptoms present for months
Shortness of breath, paroxysmal nocturnal dyspnea (PND), orthopnea, and RUQ pain
acute or chronic s/s?
acute
Fatigue, anorexia, abdominal distention and edema
acute or chronic s/s?
chronic
What is the difference between high and low output heart failure?
High: heart is unable to meet the demands of the peripheral needs although it is working normally
think the body is the problem
Low: insufficient forward output
think heart is the problem
What is the difference between reduced and preserved EF? What is it called if the pt falls in the middle?
reduced: EF ≤40% HFrEF
preserved: EF ≥ 50% HFpEF
borderline EF is betwwen 41-49% EF
How do you determine treatment for a pt with borderline EF?
borderline is 41-49% and treatment is based on symptoms
What are the 4 different classifications with regards to EF? Draw the chart from lecture
What are the s/s of LEFT sided HF? What are the s/s of RIGHT sided HF?
First symptoms are from the LUNGS
-> Orthopnea, DOE
First symptoms are from the BODY ->
JVD, hepatic congestion, ascites, anorexia, LE edema
What is the MC cause of RIGHT sided HF?
Most common cause is left sided HF
**________ uses functional limitation classes to determine severity by assessing ______. Can it change?
New York Heart Association (NYHA)
effort needed to elicit symptoms in a HF patient
classification can change at any time
**What are the 4 different NYHA classification of severity?
_____ describes the evolution of HF. Helps to define the appropriate ______ and determine ______. Can it change?
American College of Cardiology Foundation (ACCF) // American Heart Association (AHA)
therapeutic approach and determine prognosis
CANNOT CHANGE
** What are the 4 different classifications for HF as defined by the ACC/AHA?
A and B have no symptoms
C and D have symptoms
What is afterload? What is preload?
afterload: the amount of pressure the heart needs to exert to pump blood out of the ventricles during a heartbeat
preload: the force that stretches the heart’s muscle before it contracts and a factor in bearings that improves running accuracy:
What are the neurohumoral adaptations for heart failure?
Maintain systemic pressure by vasoconstriction
Restores cardiac output by increasing myocardial contractility and heart rate
What are the 3 major determinants of the LV stroke volume?
Preload – venous return and end-diastolic volume
Contractility – the force generated at any given end-diastolic volume
Afterload – aortic impedance, vascular resistance, wall stress
The pressure-volume relationship with systolic dysfunction leads to a reduction in ______. Which leads to a reduction in _____ and _____. What does this promote?
reduction in myocardial contractility
reduction in SV and CO
Promotes salt and water retention, leading to expansion of blood volume, therefore raising end-diastolic pressure and volume
What type of HF?
systolic HF
What type of HF?
diastolic HF
What type of HF?
none! it is normal
_____ is one of the first responses to low cardiac output. What is the result? What happens to contractility and HR?
Activation of the SNS
Results in increased release and decreased reuptake of norepinephrine
Increases ventricular contractility and heart rate
activation of the SNS also leads to ______ and _______ which increases ______. In the kidney is leads to _________ and worsening _______
vasoconstriction and enhanced venous tone
increases peload
Also stimulates proximal tubular sodium reabsorption, contributing to sodium retention in HF → worsening fluid overload
What is the RAAS system stimulated by? What happens next?
Stimulated by decreased glomerular filtration and increased beta-1 adrenergic activity
increases sodium reabsorption and induces vasoconstriction
RAAS can act directly on _____ to promote pathologic remodeling via hypertrophy, apoptosis, necrosis leading to an increase in ________
myocytes
increase in AT2 receptors
Low cardiac output leads to activation of ______ and ______ which release _____ and stimulate _______
activation of carotid sinus and aortic arch baroreceptors → release of ADH and stimulation of thirst
ADH release leads to an increase in _________ and promotes _____ leading to _____
]increase in systemic vascular resistance
Promotes water retention → fluid overload!
ANP is released from the _____ in response to ______. When does it rise in HF?
atria
in response to volume expansion
ANP rises early in HF
BNP is released from the _______ in response to ________. When it is present? What does it reduce?
ventricles
high ventricular filling pressure
BNP is present in chronic and advanced HF
Reduces systemic vascular resistance and central venous pressure, while increasing natriuresis, which reduces afterload
What are the 2 natriuretic peptides? Which one has a longer half-life and is the preferred test?
ANP and BNP
BNP is preferred and is used to guide therapy
Consequences of Compensation include elevation in diastolic pressures that are then transmitted to the _____ and ______ and _____ venous circulation
atria
pulmonary
systemic venous circulations
as a consequence of compensation, the increased afterload can _____ cardiac function and _________.
depress cardiac function
enhance detorioration
_______ and _______can worsen coronary ischemia. ______ and ______ promote myocyte loss, resulting in cardiac remodeling
Catecholamine-stimulated contractility
increased heart rate
Catecholamines
angiotensin II
What are the cardinal symptoms of heart failure?
Dyspnea
Fatigue
Fluid retention: lower extremity edema
What is one way to tell if the edema present is due to HF?
Elevated jugular venous pressure will be present if edema is due to HF
What is the proper way to assess LE edema?
ALWAYS start at the feet, then work your way proximally to see how far the edema extends
need to check sacral and scrotal areas and need to check over a bone
**What is the edema rating scale? Specifically need to know time frame
Pulsus alternans is pathognomonic for _____
severe LV failure
What does a laterally displaced apical impulse indicate? May feel _____ with pulmonary HTN
indicates LV enlargement
parasternal lift of RV
______ is associated with systolic HF
______ more common to find in diastolic HF
S3 gallop
S4 gallop
What is the goal of diagnostic studies in HF?
is not only to confirm that symptoms are due to HF but then to determine the CAUSE of the HF
What are tests you want to order when working a pt up for HF? What are you looking for in each?
EKG -> arrhythmia that might be cause
CXR -> pulm edema or cardiomegaly
What are Kerley B lines? Where are they most commonly seen?
(thickened interlobular septa) are thin, 1-2 cm lines, virtually always at the lungs BASE and at the lung PERIPHERY lying perpendicular to the pleural surface to which they contact
What lab studies do you want to order in CHF?
BNP
Tropinin I and T
Magnesium
(plus all the normal ones)
_____ is the best lab for HF evaluation. Why is it really good? What is it used for?
BNP and NT-proBNP
really good at excluding HF because it has a very high negative predictive value
so if BNP is normal, swelling is from something else!!
Useful in supporting diagnosis and establishing severity
What are the normal ranges for BNP? NT-proBNP? What is the difference between the two?
Normal value for BNP is < 100 pg/mL (NT-proBNP <300)
Only difference is their half life - NT-proBNP is longer
a BNP of _____ and NT proBNP of _____ = Low probability of HF
a BNP of _____ and NT proBNP of _____ = intermediate probability of HF
a BNP of _____ and NT proBNP of _____ = high probability of HF
What are the limitations of BNP and NT-proBNP?
Pt may present with more than one cause for dyspnea, ex. PNA and HF
Pts with severe chronic HF may have persistently elevated levels of BNP
There are ____ causes of elevated BNP. Name a few
MANY!!
ACS, LVH, valvular disease, Afib, S/P Cardioversion
Increased age, Severe anemia, Renal failure
PNA, Pulm HTN
Sepsis, Severe burns
What does a significant elevation of troponin I or T indicate?
Significant elevations and upward trend typically indicates an ischemic source for the HF
but can be elevated without an ischemic cause
What are 2 non-ischemic related causes of elevated troponin?
ongoing myocardial injury or necrosis
associated with increased mortality rate
All HF pts need a ________. Why?
Echocardiography!!! ECHO!!
looks at ventricular size and function and can detect regional wall motion abnormalities
_____ is especially helpful in detecting _______. If that is normal, ____ needs to be considered
Stress testing
CAD
coronary angiography
**______ is the gold standard for diagnosing heart failure. What is being measured? **What number does it have to be to confirm diagnosis?
Right heart catheterization
identification of an elevated pulmonary capillary wedge pressure (PCWP) at rest or exercise on an invasive hemodynamic exercise test in a patient with symptoms of HF
**If a patient has symptoms consistent with HF and PCWP ≥15 mmHg at rest or ≥25 mmHg during exercise, a diagnosis of HF is confirmed, regardless of LVEF
What is the Pulmonary capillary wedge pressure (PCPW)?
is a measurement of the pressure in the pulmonary arterial system that estimates the pressure in the left atrium of the heart
What are the 5 classes of recommendations with regards to HF treatment options?
