Heart Failure #1 Flashcards
A 45-year-old woman presents to the ED with complaints of worsening shortness of breath for the past week. The patient reports dyspnea on exertion after walking only 2 blocks, when walking upstairs, and sometimes at rest. Additionally, she is experiencing orthopnea and paroxysmal nocturnal dyspnea. She reports a viral illness 2 weeks ago, during which she had a runny nose and body aches. She took herbal tea for a few days, and the symptoms resolved. The patient denies any palpitation, fever, recent travel, sick contacts, or joint pains. Review of systems is otherwise unremarkable. She no past medical history, and past surgical history is significant for appendectomy. She denies use of tobacco, alcohol, or recreational drugs. She lives with her 2 kids and works for a software company. No significant family history is reported. She only takes cetirizine and multivitamins at home.
On arrival, her vital signs are stable, with a blood pressure of 127/70 mm Hg, pulse of 83 bpm, respiratory rate of 17 breaths/min, temperature of 37.1°C (98.8°F), and oxygen saturation of 96% on room air. PE is otherwise unremarkable except she appears lethargic. CV and resp examinations are unremarkable. Lab results show significantly elevated troponin and pro-B-type natriuretic peptide. ECG shows nonspecific ST/T–wave changes. Chest radiograph shows enlarged heart shadow. The patient is admitted to the telemetry floor for further workup.
How would you manage this case?
Orthopnea
paroxysmal nocturnal
Viral illness
young
Elevated biomarkers,
GET AN ECHO, so that you can look for wall abnormalities, dilated cardiomyopathy, ESSENTIAL to figure out.
Cardiomyopathy cause of heart failure
What does heart failure often mimic?
COPD
can hear crackles
Is heart failure a disease?
NO
it is a syndrome as a result of a disease process - which is why it is important to know the UNDERLYING cause if possible
What leads to heart failure?
clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.
eventually the compensatory mechanism does not work, and you get fluid overloaded
who has the highest risk of heart failure?
AA
What is the 5 year mortality rate of heart failure?
5 years :(
MC cause of death from heart failure?
Sudden cardiac death
Arrhythmias - stretched out LV can cause sudden death
Risk factors for heart failure
CAD / Atherosclerosis
DM
HTN
Metabolic syndrome / Obesity
labs for heart failure patients
HbA1c
lipids
TSH/T4
Biggest risk factor for heart failure
HTN!
in both men and women
2nd biggest risk factor for Heart failure in MEN
MI
Acute vs chronic heart failure
Acute: Symptoms began within last few days to weeks
Shortness of breath, PND, orthopnea, and RUQ pain
NOT compensated well in acute
Chronic: Symptoms present for months
Fatigue, anorexia, abdominal distention and edema
Can have an acute exacerbation in a chronic state
COMPENSATED well in chronic
(increased salt intake can cause acute on chronic)
How vs low output HF
High: heart is unable to meet the demands of the peripheral needs
Thyrotoxicosis, severe anemia, sepsis
Symptoms of reduced CO rather than volume overload
Low: insufficient forward output
Reduced EF, hypovolemia
HF with reduced LV EF vs HF with preserved EF
HFrEF → AKA HF with reduced EF (systolic)
EF ≤40% (lower or right at)
HFpEF → AKA HF with preserved EF (diastolic)
EF ≥ 50%
if 41-49%, it is harder to manage
How do you determine the ejection fraction (EF)?
ECHOOOOOO
it is interpreted by humans, so the EF may be +/- 5-10% (FYI)
Systolic HF is due to
decreased CONTRACTILITY because we are unable to get blood OUT
Diastolic HF is due to
What is the EF as a result?
STIFF ventricle
does not effect ejection fraction, because it has nothing to do with getting blood out of the ventricle to the aorta, meaning that EF is preserved!
What causes Left sided HF and what symptoms?
cardiomyopathies
Leads to DOE, PND, orthopnea, fatigue
because your body is not getting enough blood and you have less energy
What causes Right sided HF and what are the symptoms
Left sided HF!
(also
Often leads to ascities, JVD
Left vs right sided HF symptoms
Left: cool, pale extremeties, cyanosis
Right sided: ascities, weight, weight gain ect
How do you classify severity of heart failure?
New York Heart Association (NYHA) functional classes
It is based on effort needed to elicit symptoms in a HF patient
What are the different classifications of severity
Patient can change classifications
1: Heart disease but no limitation of physical activity
2: Heart disease and symptoms with ACTIVITY
3: Heart disease and symptoms with ACTIVITY
4: Heart disease with symptoms at rest.
not going to ask to differentiate between 1 and 2
What are the stages of heart failure?
Progressive and DO NOT change, because this has to do with the physical structure of the heart
What are the ACC/AHA stages of heart failure
A: At risk for HF but NO STRUCTURAL disease or symptoms of HF
B: Structural heart disease WITHOUT s/s of HF.
C: Structural HF symptoms at some point
D: Refractory HF (have difficult functioning
symptoms of heart failure
increased symptathetic NS
Pulmonary and systemic venous congestion
Cardiac dilation and hypertrophy
increased preload
sodium and water retention
increased afterload
Neurohormonal adaptations of heart failure
Compensatory mechanisms used by the body in an attempt to adjust for a reduction in cardiac output
Maintain systemic pressure by vasoconstriction
Restores cardiac output by increasing myocardial contractility and heart rate
Occurs with systolic and diastolic dysfunction
What does the RAAS system do?
Try to increase volume through
Renin
angiotensin
aldosterone
Allows you to increase preload so that you can have more blood flow
Epinephrine increases the heart’s contractility
How to combat the RAAS system?
ACE/ARBs
