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
