Heart Failure Flashcards
HF Clinical manifestations
- Dyspnea
- Fatigue
- Loss of Appetite
- SOB / DOE / wheezing / cough
- Orthopnea
- Paroxysmal Nocturnal Dyspnea (PND)
- Early Satiety
- Abdominal fullness/pain
- Nausea/Vomiting
- Lower Extremity Edema
- Cardiac Cachexia
HF major criteria
- Paroxysmal nocturnal dyspnea (PND)
- Neck vein distention
- Rales
- Radiographic cardiomegaly
- Acute pulmonary edema
- S3 gallop
- Increased central venous pressure (>16 cm H2O at right atrium)
- Hepatojugular reflux
- Weight loss >4.5 kg in 5 days in response to treatment
HF Minor criteria
- Bilateral ankle edema
- Nocturnal cough
- Dyspnea on ordinary exertion
- Hepatomegaly
- Pleural effusion
- Decrease in vital capacity by one third from maximum recorded
- Tachycardia (heart rate>120 beats/min.)
Dx of HF
Diagnosis of CHF requires the simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria.
NY Heart Association Classification
- NYHA Class I : cardiac disease but NO limitation in physical activity
- NYHA Class II : cardiac disease with slight limitation of physical activity
- NYHA Class III : cardiac disease with marked limitation of physical activity (comfortable at rest).
- NYHA Class IV : cardiac disease with inability to be physically active (symptoms at rest).
Stages of HF
- Stage A : At risk to develop HF but no structural heart disease or symptoms of HF
- Stage B : Structural heart disease without signs & symptoms of HF
- Stage C : Structural heart disease with prior or current symptoms of HF
- Stage D : Refractory HF requiring specialized interventions
HF diagnostic workup
-ECG
-CXR
-B-type Natriuretic Peptide or N-terminal pro-BNP (BNP)
–Screen all with dyspnea using BNP
—Use to determine severity of disease/exacerbations in those with known HF
-Transthoracic Echocardiogram (TTE) or other test to measure LV function
+/- Exercise Testing (VO2 treadmill)
ECHO
- LVEF reported; Normal > 50%
- Diastolic dysfunction reported if present
- —Grade I-IV
- –May say indeterminate
- Stroke volume, cardiac output, cardiac index
- Valvular function
- –graded mild, moderate, severe
- –Aortic and mitral valve disease most common with aging (Aortic Stenosis & Mitral Regurgitation)
- RVSP (Right Ventricular Systolic Pressure
- —Estimate of Pulmonary Artery (PA) pressure (> 40 mmHg is concerning for Pulmonary Hypertension but not diagnostic
Intracardiac Mass or Thrombosis or aortic aneurysm or dissection on echo
better visualized by TEE
HF w/ reduced EF HFrEF
-Impaired squeeze; Systolic dysfunction
-Impaired left ventricle pumping (squeeze)
-Blood backs up into LV, LA, pulmonary veins & lungs
-Congestive symptoms:
Increase PCWP, JVP
Rales/crackles
Dyspnea/SOB
S3, S4 rarely
HF w/ preserved EF HFpEF
- Impaired relaxation; Diastolic dysfunction
- LV filling delayed
- Decreased LV compliance
- Elevated end-diastolic filling pressures
- Increase in myocardial stiffness
- –Can occur alone or in combination with reduced ejection fraction—
Non-pharmacological management of HF
- Diet with Sodium / Fluid Restrictions
- Regular Physical Activity
- Self Monitoring of daily weights or other parameters as needed
- Avoid Alcohol / Tobacco Use
- Oxygen as needed
- Assess for Obstructive Sleep Apnea (OSA)
- –Treat OSA with CPAP
- –No adaptive-servo ventilation in Central Sleep Apnea due to increased mortality
- BNP prior to discharge from hospital
Pharmacological management of HFrEF
-Diuretics
-Ace Inhibitors OR Angiotensin-Receptor Blockers (ARBs) OR Angiotensin Receptor-Neprilysin Inhibitors (ARNi)
-Hydralazine & Nitrate combo (renal disease; African American population)
-Beta Adrenergic Receptor Blockers (BBs)
-Add Ivabradine (Colanor) if on maximum tolerated doses of BB therapy and HR > 70.
-Aldosterone Antagonists
-May consider Digoxin if GFR > 30
+/- Inotropes for refractory HF
-Treat anemia with IV iron for class II-III HF for improved functional status/quality
—Ferritin < 100 or Ferritin 100-300 if transferrin sat< 20%
Pharmacological management of HFpEF
- Not much defined treatment
- Treat Etiology (HTN, Afib, DM, OSA, lipids)
- Target SBP < 130
- Diuretics if volume overload
- Aldosterone Antagonists if LVEF>45%, elevated BNP or HF admission within 1 yr, GFR > 30 and creatinine <2.5 & potassium < 5.0.
- Treat anemia with IV iron for class II-III HF for improved functional status/quality
- –Ferritin < 100 or Ferritin 100-300 if transferrin sat< 20%
- No benefit of nitrates or phosphodiesterase-5 inhibitors (Sildenifil or Revatio)
Diuretics: Loop
-Furosemide 10-40 mg; max 600 mg/day;
-Bumetanide 0.5-2 mg; max 10 mg/day
PO or IV, monitor K+
-Toresmide 5-10 mg
PO only, but better gut absorption in HF; monitor K+
-Ethacrynic Acid 25-100 mg; max 100 mg/day
PO or IV, allergy to Furosemide, monitor K+
*Higher doses to treat HF
Aldosterone Antagonists / Mineralocorticoids:
- Spironolactone 12.5-50 mg
- Eplerenone ($) 25-50 mg; max 100 mg/day
- –HF, both increase K+
Beta Blockers: selective
-Metoprolol Tartarate (Lopressor) 25-200 mg BID PO; 5-10 mg IV
-Metoprolol Succinate ER (Toprol XL) 25-400 mg PO
preferred in HF
-Bisoprolol 2.5-20 mg daily; max 20 mg daily PO
May be better with bronchospasm & severe lung disease
Combined Alpha/Beta
Carvedilol 3.125-25 mg BID; max 50-100 mg/day
Reduced LV function, HF
Ivabradine (Colanor)
-Selectively inhibits the If current of the sinoatrial node to reduce heart rate
-Reduces CV death and HF hospitalizations
-Add Ivabradine (Colonor) if on maximum tolerated doses of BB therapy and HR > 70.
-May add if medical contraindication to BB.
Stable HFrEF (LVEF < 35%)
Class II-III
Angiotensin-Converting Enzyme (ACE) Inhibitors:
-Captopril 12.5-50 mg BID or TID; max 450 mg/day
Short-acting, post MI, LV dysfunction
-Lisinopril 5-40 mg QD or BID; max 80 mg/day
-Enalapril 5-40 mg daily
LV dysfunction, HF; caution in renal failure/bilateral renal artery stenosis; may cause angioedema
Angiotensin Receptor Blocking agents (ARBs):
-Candesartan 8-32 mg; max 32 mg/day
-Losartan 25-100 mg; max 100 mg/day
-Valsartan 80-320 mg; max 320 mg/day
HF; allergy to ACEi; caution in renal failure/bilateral renal artery stenosis
Angiotensin Receptor-Neprilysin Inhibitors (ARNi): If previously on an Ace inhibitor, stop and wait 36 hours before starting Entresto
DO NOT USE in combination with an ARB
- Sacubitril a pro-drug
- active metabolite inhibits Neprilysin allowing natriuretic peptides to persist longer in promoting vasodilatation, diuresis, and natriuresis
- prevents the neurohormonal effects or the RAAS system that cause cardiac damage
- Used in place of an Ace inhibitor or ARB
- 20% reduction in CV mortality & hospitalization when compared to ACE or ARB in RCT (HFrEF)
- Now approved for treatment of HFpEF as well (2/2021)
- Risk for hypotension, renal impairment, hyperkalemia and angioedema
SGLT2 Inhibitors
-Causes natriuresis, glucosuria, lower BP, decrease afterload, improved insulin sensitivity, weight loss, without risk hypoglycemia
-Approved for HFrEF & now HFpEF with or without DM Type 2
-Do not use in DM Type 1, or GFR < 60
-Monitor for risk of genital fungal infections (Fournier’s gangrene) due to glucosuria
-Can cause hypotension, dehydration, or hyponatremia
-Improved CV & renal outcomes
-Reduces CV death & hospitalizations
-Dapagliflozin, Empaglifozin, Cangalifozin, Ertuglifozin
$$$$