DYPSNEA JOHNSTON

Question 1

Explain the definition of HF?

Answer 1

Definition:

• Inability of heart to meet the metabolic demands of the body
• Abnormality of cardiac structure and/or function resulting in signs and symptoms of HF
• Reduced ability of heart to fill and/or pump blood
• Poor quality of life, shortened survival

Question 2

Etiologies of HF?

Answer 2

• CAD – ischemic heart disease (IHD) 60-75%
• Idiopathic, dilated cardiomyopathy 18%
• Valvular Heart Disease (VHD) 12%
• Hypertension (increasing) 10%
• Less common – congenital, viral (Coxsackie A, B, Influenza A, B), toxins: alcohol, Adriamycin, Endocrine(thyroid), nutritional

Question 3

Which disorders can mimic HF? (differential diagnoses)

Answer 3

pulmonary : asthma, chronic bronchitis, COPD, pneumonia, PE
renal: edema, weight gain an dyspnea,
liver: cirrhosis
Venous: venous insufficiency and varicose veins

Question 4

Risk factors for HF?

Answer 4

• Diabetes Mellitus – major risk factor
- increases CVD risk 2-4x
• Hyperlipidemia – high LDL, low HDL, high TG
• Hypertension
• Metabolic Syndrome – Insulin resistant, HT, high TG, low HDL, obese
• Smoking
• Positive family history – CAD, sudden death, PVD
• Sedentary lifestyle (physically inactive)
• Obesity
• Age
• Gender
• Sleep disturbances – OSA
• Psychosocial stress

Question 5

symptoms/signs of HF?

Answer 5

• Weakness/fatigue – non specific
• Dyspnea (SOB)- most common symptom
• Dyspnea on Exertion (DOE)
• Orthopnea – difficulty breathing lying down
• Paroxysmal Nocturnal Dyspnea (PND) 
• Decreased exercise intolerance
-edema
-S3 gallop
-Wheeze/Cough – pink, frothy fluid
-JVD
-crackles

Question 6

AHA/ACC Stages A-D?

Answer 6

Stage A
• At risk for HF (DM, HT, CAD, Vascular disease, Metabolic Syndrome), but No Structural heart disease
• No symptoms
• 1 year mortality 5-10%
Stage B
• Structural heart disease (LVH, reduced EF, chamber enlargement, previous MI, VHD)
• No symptoms
• 1 year mortality 5-10%
Stage C
• Structural heart disease
• Heart failure symptoms currently or prior
• 1 year mortality 15-30%
Stage D
• Refractory heart failure
• Needs Biventricular pacemaker, LVAD, transplant
• 1 year mortality 50-60%

Question 7

NYHA stages 1-4?

Answer 7

Class I
• No limitation of physical activity
• Asymptomatic
• 1 year mortality 5-10%
Class II
• Slight limitation of physical activity
• Exertional symptoms with ordinary activity
• No symptoms at rest
• 1 year mortality 15-30%
Class III
• Marked limitations of physical activity
• Less than ordinary activity causes symptoms
• No symptoms at rest
• 1 year mortality 15-30% Class IV
• Unable to carry out physical activities without symptoms/discomfort
• SYMTOMATIC AT REST
• 1 year mortality 50-60%

Question 8

What are the 5 Types (classification) of Heart Failure (HF)?

Answer 8

• Systolic/Diastolic
• Acute/chronic
• High/low Cardiac Output
• Right/Left
• Forward/Backward

Question 9

Acute HF and Chronic HF

Answer 9

Acute HF
Due to acute MI, ruptured papillary muscle, mitral regur., aortic insufficiency, toxins
Chronic HF
Progresses slowly, decompensation, valvular heart disease, dilated cardiomyopathy, edema, weight gain.

Question 10

High Output and Low Output

Answer 10

High Output
EF reduced, but high cardiac output
Ex. Hyperthyroidism, pregnancy, anemia, Beriberi (Vit. B1 deficiency, thiamine), Paget’s disease (inc. bone vascularity)
Low Output
Ischemic heart disease, HTN
Dilated cardiomyopathy, valvular, pericardial disease

Question 11

Right Sided HF and Left Sided HF

Answer 11

Right Sided HF
Affects; RV; PulHTN, PE
Edema, hepatomegalia, venous distention
Left Sided
LV overload; aortic stenosis, AMI
Dyspnea, orthopnea due to pul congestion

Question 12

Tests – Imaging / Lab

Answer 12

• No single diagnostic test for HF; it’s largely a CLINICAL DIAGNOSIS based on H & P
• Imaging and lab tests enhance the clinical suspicion
• CXR – cardiomegalia, interstitial edema, hilar engorgement, cephalization of vessels toward upper lobes, pleural effusions
• Echocardiogram – chamber sizes, wall motion, muscle thickness, valvular function, pericardial effusion, systolic or diastolic dysfunction with ejection fraction
• ECG – rate, rhythm, axis, ischemia, infarction, hypertrophy, conduction disturbances (AV blocks, BBB, Hemiblocks), electrolyte abnormalities, miscellaneous
• Cardiac enzymes – Troponins I and T (increase 3-12 hours, peak 1-2 days, baseline 5-14 days
• BNP (Brain Natriuretic Peptide) – low EF, high BNP. < 100 Pg/ml, low likelihood of HF. Increased in HF, AMI, PE, renal failure, old age, Pul HT, severe COPD, ARDS, sepsis
• Check TSH, free T4 if patient has A. fib.
• Cardia MRI – assess ventricular structure, mass volumes

Question 13

Heart Failure Treatment (non pharmacologic)

Answer 13

• Proactive immunization against influenza and pneumococcal pneumonia
• Avoid NSAID; inhibit COX 1 & 2 enzymes/inhibit prostaglandin synthesis; get renal vasoconstriction, reduce renal blood flow, GFR, Na and K retention
• Reduce salt intake (chips, bacon, table salt)
• No smoking
• Avoid alcohol

Question 14

Heart Failure Treatment (pharmacologic)

Answer 14

• ACEI/ARB – contraindicated in pregnancy, angioedemia, bilateral RAS
• BB – don’t use in unstable, decompensated HF
• Statin
• ASA
• Nitro
• Diuretics - fluid volume, watch K
• Vasodilators - preload and/or afterload
• Inotropes – augment contractility
• Digitalis – useful in A. fib to slow vent rate
- improves quality of life, but not survival

Question 15

Diastolic/systolic Heart Failure

Answer 15

Diastolic Heart Failure (HFpEF) - preserved
• Normal EF
• Inability of ventricle to relax, increased stiffness, decreased compliance,
inc. resistance to vent. Filling
• Associated with myocardial fibrosis, amyloidosis, acute ischemia, constrictive pericarditis, restrictive cardiomyopathy
• SOB, DOE, pulmonary edema

Systolic Heart Failure (HFrEF) - reduced
• EF < 40% decreased vent. emptying ( decreased SV), hypoperfusion
• Weak, fatigued, decreased exercise tolerance
• DOE, orthopnea, PND, S3 gallop
• 50% of cases