EXAM #2: CHF I & II Flashcards
What is the definition of heart failure?
Inability of the heart to pump sufficient blood to meet the metabolic needs of the body
What is the definition of myocardial failure?
Defective myocardial contraction
What is the definition of circulatory failure?
Abnormality of a component of the circulatory system leads to inadequate CO
What is the neurohormonal model of heart failure?
A series of compensatory adaptations that normally preserve CO are activated:
1) SNS is activated while the PNS is suppressed
2) RAAS is activated
What are the results of the changes seen in the neurohormonal model of HF?
1) Peripheral arterial constriction
2) Na+/ water retention
3) Activation of inflammatory mediators that induce cardiac remodeling
What are the specific results of adrenergic stimulation in the neurohormonal model of HF?
1) Increased SNS tone
- Increased vascular tone
- Increase circulating NE
- Decreased myocardial NE
2) Beta-1 increased HR and contractility
3) Alpha-1 increased inotropism and peripheral vasoconstriction
When is the RAAS activated in HF?
Later than the SNS
What causes activation of the RAAS in the neurohormonal model of HF?
1) Decreased RBF
2) Decreased Na+ in the distal renal tubule
3) SNS increases renin release
What are the consequences of sustained high levels of Angiotensin II?
1) Organ fibrosis i.e. heart and kidney
2) Enhanced NE release
What is the difference between the hypertrophy of pressure and volume overload?
Pressure= parallel/ concentric
Volume= series/ eccentric
What are the adverse consequences of LV remodeling in HF?
1) Hypertrophy
2) APD increases
3) Contractile/ regulatory proteins altered
4) Increased myocardial wall tension
5) MV regurgitation
What is backward heart failure?
This is the sequelae that result from failure of the LV to fully eject its contents
What is forward heart failure?
This describes the effects of HF i.e. reduced CO
- Decreased perfusion of vital organs
- Mental clouding
- Weakness
- Na+ and water retention
What is the basic manifestation of left heart failure?
Central venous/ pulmonary congestion
What is the basic manifestation of right heart failure?
Systemic congestion
What is systolic heart failure?
Abnormal systolic function leading to high residual volume in the ventricle
*Leads to poor perfusion
What is diastolic heart failure?
Abnormal diastolic filling
*Leads to pulmonary and systemic congestion
What are the most common causes of HF?
1) Ischemia/ infarction
2) HTN
3) Arrhythmias
4) Infection/inflammatory disease
5) PE
What are the major sx. associated with HF?
1) Progressive dyspnea
2) Diminished exercise capacity
3) Fatigue
4) Nocturia
5) CNS impairment
Why do patients with HF get nocturia?
- Lying down= better renal perfusion
- Increased kidney function w/ increased perfusion
What is Class I HF?
Asymptomatic i.e. no activity limitation
What is Class II HF?
Slight activity limitation
*ORDINARY activity causes sx.
What is Class III HF?
Marked activity limitation
*LESS than ordinary activity causes sx.
What is Class IV HF?
Symptomatic at rest
“Conversational dyspnea”
What causes pallor and cool extremities in HF?
SNS tone that causes cutaneous vasoconstriction
What PE sign is indicative of LV failure?
Pulmonary rales
What PE signs are indicative of RV failure?
1) Jugular venous distention (no valves)
2) Kussmaul’s sign
What is Kussmaul’s sign?
Increased jugular venous distention with inspiration
What is hepatojugular reflux?
- RV failure= hepatomegaly
- Hold hand over dome of the liver
- After a minute, jugular venous pulses rise
What findings are associated with HF on cardiac PE?
1) Apical impulse displaced left and down
2) S3
3) Pulsus alternans
4) Murmurs
Note that “cardiac cachexia” is a late sign of HF
List the lab findings associated with HF.
1) Hyponatremia from H20 excess
2) Liver enzyme elevations
What CXR findings are associated with HF?
1) Cardiomegaly
2) Pulmonary congestion/effusion
3) Kerley “B” lines
What are Kerley B lines?
Congestion of the pulmonary lymphatics
What are the leading causes of death from HF?
1) Pump failure
2) Tachyarrhythmias
What factors are associated with worse prognosis in HF?
1) Males
2) IHD
3) S3
4) Low pulse pressure
5) High functional class (III and IV)
6) Reduced exercise capacity
What is high output HF?
Despite high CO, the metabolic demands of the body are NOT met
What are the four goals of therapy in HF?
1) Relieve sx.
2) Prolong survival
3) Improve quality of life
4) Delay or prevent progression of myocardial dysfunction
What is the therapy based on in HF?
Functional Class
What immunizations do patients with HF need?
1) Pneumonia
2) Influenza
What are the two major factors that lead to a worsening of HF?
1) Dietary indiscretion
2) Inappropriate reduction in HF meds
What is Stage A HF?
High risk for HF, but NO disease yet
E.g. HTN, IHD…etc.
What is Stage B HF?
Structural heart disease evident, but no symptoms
What is Stage C HF?
Structural disease with sx
What is Stage D HF?
Refractory HF
What are the general measures to treat HF?
1) Reduce risk factors
2) Education on lifestyle/diet modifications
3) Activity-modification
What type of diuretic should be used for a patient with a high creatinine?
Loop
*Thiazide is fine if creatinine is less than 2
What are the anti-neurohormonal durgs?
- ACEIs
- ARBs
- Beta-blockers
What are the “agents of choice” for HF?
ACEIs
E.g. Lispinopril/ enalapril
What is the hallmark ARB?
Losartan
*Note that Candasartan is more efficacious in treating HF
What type of beta-blockers are indicated for HF?
1) Beta-1 selective
2) Beta-1 + alpha-1
What are the two beta-blockers used to treat HF?
Metoprolol and Carvedilol*
In US, this is the only one approved for HF (Coreg)
What is the MOA of spironolactone?
Aldosterone antagonist
What are the non-pharmacologic therapies for HF?
1) Intra-aortic balloon pump
2) LV assist device
3) Transplant
