Heart Failure

Question 1

New York Heart Association Classification of Heart Failure

Answer 1

1 - No limits to physical activity
2 - Symptoms with usual activities
3 - Symptoms with minimal activities, but no symptoms at rest
4 - Inability to carry out physical activity without symptoms, symptoms at rest

Question 2

Two Main Types of HF

Answer 2

HFrEF - HF with reduced ejection fraction (40% or lower)
HFpEF - HF with preserved ejection fraction (50% or more)

The gray area between is subjective and may be called HRmrEF (mid-range)

Question 3

HFrEF Characteristics

Answer 3

History of CAD or Valve disease
Cardiomegaly
Soft heart sounds
Edema
Low ejection fraction

Question 4

HFpEF characteristics

Answer 4

History of hypertension
Normal heart size
Left ventricular hypertrophy only
Preceding atrial fib or hypertension
Edema
Ejection fraction reduced, but still 50% or more

Question 5

Common disease associated with HF

Answer 5

Anatomic of functional problem with coronary vessels, myocardium, valves, contractility
Neurhormonal excess leading to over activation of RAAS
Extracardiac factors

Question 6

Key of HF symptoms

Answer 6

Symptoms that indicate volume excess

Question 7

Cardiac Remodeling

Answer 7

Dilation is a result of an increase in the ventricular end-diastolic volume and represents an early compensatory response in volume overload in an attempt to increase contractility and to preserve cardiac output. With an ischemic event, there is a loss of cardiomyocytes, leading to a thinning of the cardiac wall and decreased contractile activity. Dilation preserves stroke volume and maintains cardiac output, but it also significantly increases wall stress

Question 8

HF cardinal symptoms

Answer 8

dyspnea and fatigue

Question 9

HF Symptoms

Answer 9

Fatigue and dyspnea
peripheral edema
Pulmonary edema (crackles, frothy sputum)
neck vein distension
persistent cough
Lack of appetite
Confusion, impaired thinking (more common in elderly)
Tachycardia
Nocturia
Apical pulse displaced
Ascites, hepatomegaly

Question 10

HF Diagnostics

Answer 10

Chest x-ray shows cardiomegaly (50% increase in size)
EKG to rule out MI and shows enlargement (wide QRS)
BNP / pro-BNP elevated
Renal function panel

Question 11

Stress test in HF

Answer 11

Never order a stress test for HF

Question 12

HF Management non-medication

Answer 12

Low sodium diet
Exercise
Education
Weight loss
Lipid control

Question 13

HF Medications

Answer 13

Volume overload reduction via diuretics (thiazide trial then more potent loops)
HFrEF need ACE inhibitors to stop remodeling
Beta Blockers (metoprolol first line) after fluid overload corrected
Digoxin or rate control for HFrEF

Question 14

Cornerstone of HFrEF treatment

Answer 14

ACE Inhibitors

Question 15

Alternatives to ACE Inhibitors

Answer 15

ARBs
Hydralazine / Nitrates

Not as good as they don’t stop and reverse remodeling

Question 16

Diuretics Initial Doses

Answer 16

Hydrochlorothiazide 12.5-25 mg/day
Furosemide 20-40mg per day or twice per day (empty stomach)
Spironolactone 12.5-25 mg/day

Question 17

Digoxin

Answer 17

Low therapeutic index

Improves mortality in NHYA Class 2/3

Question 18

Refer criteria

Answer 18

New onset
Refractory to standard therapy
Arrhythmias
young patients with HF
NHYA class 3 or 4 must be cardiology managed

Question 19

How is HF Diagnosed?

Answer 19

No single determinant, need multiple tests and criteria to confirm a diagnosis
Usually a history / exam plus other tests

Question 20

Stages of HF and Therapy

Answer 20

A - Lifestyle / risk reduction
B - ACE Inhibitors, Beta Blockers, Statins if needed, diuretics if needed
C - Up doses, Add diuretics or change to loop diuretics, consider Digoxin
D- Cardiology managed