Heart Failure

Question 1

Pathophysiology of Heart Failure

Answer 1

• Complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of ventricles to fill or eject blood (CO)
• Determinants of ventricular function include: Preload, afterload; contractility, stroke volume, CO; HR
• Left ventricular dysfunction:
• —-Increase in end systolic volume & diastolic volume; pulmonary congestion; decreased CO, hypoperfusion
• Compensatory systems:
• —-Sympathetic activation; RAAS

Question 2

Classification of Heart Failure: Stage A

Answer 2

American College of Cardiology Foundation/American Heart Association Heart Failure Classifications:
- High risk for development of HF; no underlying structural cardiac disease (HTN, diabetes mellitus, hyperlipidemia, etc.)

New York Heart Association Heart Failure Classifications:
- No correlation

Question 3

Classification of Heart Failure: Stage B

Answer 3

American College of Cardiology Foundation/American Heart Association Heart Failure Classifications:
- Structural heart disease but asymptomatic

New York Heart Association Heart Failure Classifications:
I. Patients with cardiac disease, but no limitation of physical activity

Question 4

Classification of Heart Failure: Stage C

Answer 4

American College of Cardiology Foundation/American Heart Association Heart Failure Classifications:
- Structural heart disease with past or current symptoms of HF

New York Heart Association Heart Failure Classifications:
II. Patients with slight, mild limitations of activity; causes fatigue, palpitations, dyspnea, or anginal pain; comfortable with rest & with mild exertion
III. Patients with marked limitations of activity, fatigue, palpitations, dyspnea, or angina; comfortable only at rest

Question 5

Classification of Heart Failure: Stage D

Answer 5

American College of Cardiology Foundation/American Heart Association Heart Failure Classifications:
- Refractory HF

New York Heart Association Heart Failure Classifications:
IV. Symptoms even at rest

Question 6

Treatment for HF: Stage A

Answer 6

Lifestyle modification: dyslipidemia, diabetes, HTN (diuretics or ACEIs)

ACEIs are drug of choice in patients with diabetes

ARBs are considered in ACEI-intolerant patients, but more expensive

Question 7

Treatment for HF: Stage B

Answer 7

ACEIs in all patients, ARBs for those who cannot tolerate an ACEI

BB in most

Question 8

Treatment for HF: Stage C

Answer 8

ACEIs and BBs in all patients

Diuretics, digoxin

Spironolactone

Question 9

Treatment for HF: Stage D

Answer 9

Entresto

Inotropes: dobutamine

Ventricular assist device, transplantation, hospice care

Question 10

Patient Variables & HF

Answer 10

• CAD: Nitrites & Aspirin
• Chronic A. Fib.: Warfarin or other new anticoagulants that reduce risk of stroke
• Diabetes: ACEIs, thiazides (may increase glucose levels), BBs avoided
• HTN: use of diuretics early to decrease preload, ACEIs
• Hyperlipidemia: statins
• Infants & Children: digoxin, thiazide, loop diuretics all used
• Pregnancy: ACEIs contraindicated, diuretics may decrease placental perfusion

Question 11

Treatment Considerations for HF

Answer 11

Early therapy works best
As HF progresses, non-selective BB with both alpha & beta impact work better than cardioselective types
The advent of neprilysyn inhibitors (i.e., Entresto) has dramatically decreased risk of death and hospitalization

Question 12

Heart Failure: Monitoring

Answer 12

Functional capacity
Fluid status
- Weight changes
- Jugular Venous distention

Cardiac rhythm

Lab tests:

• Electrolytes
• Creatinine
• Thyroid & liver function

Question 13

Heart Failure: Patient Education

Answer 13

Treatment plan

• Pathophysiology & chronicity of HF
• Home monitoring

Drug Therapy

• Patients should take exactly as directed
• Patients should not miss or double dose