Heart Failure Flashcards
1. Discuss the etiology and pathophysiological mechanisms involved with right and left sided heart failure 2. Compare the different causes and symptoms systolic and diastolic heart failure also called heart failure with preserved ejection fraction (HF-PEF). 3. Contrast the differences in presentation between right and left sided heart failure 4. Contrast the physical findings associated with right sided an left sided heart failure (Bates- Physical Exam text may be useful for this) 5. Summari
A clinical syndrome characterized by systemic perfusion inadequate to meet the body’s metabolic demands as a result of impaired pump function.
Heart Failure
True or False: A definitive lab test can determine/diagnose heart failure.
False
It is multifactorial
What is the final goal of treatment?
Improve Symptoms
Improve Survival
Shrink the Heart Down to Size
Keep them out of the Hospital
Seven Major Classes of Biomarkers Contributing to Heart Failure Profile
- Myocardial Stretch
- Myocyte Injury
- Matrix Remodeling
- Inflammation
- Renal Dysfunction
- Neurohumoral Activation
- Oxidative Stress
Etiology of Heart Failure
- Ischemic Cardiomyopathy (50-75%)
- Non-Ischemic CM
- Unknown (20-30%)
- HTN (13%)
- Valvular Dz (10-12%)
- Others: ETOH, Cocaine, OSA, Nutritional Deficiency, Viral Myocarditis, HIV, Tachycardia, Hemochromatosis, Sarcoid, SLE, etc.
When does Postpartum Heart Dz develop?
1 month before delivery
or
5 months after delivery
What are the two overarching forms of Heart Failure?
- Low Output
2. High Output
Which form of Heart Failure is most common?
Low Output
Definition of Low Cardiac Output
- Resulting from HTN, Ischemic Heart Dz, Valvular Dx, and CM
- Exam reveals impaired peripheral circulation: Cold, pale, cyanotic extremities with a narrow pulse pressure
Definition of High Cardiac Output
- Characteristic of thyrotoxicosis, AV fistula, anemia, pregnancy, and Paget’s Dz of Bone
- Exam reveals warm extremities with normal or widened pulse pressure
Long QRS on EKG would indicate:
Right and Left ventricles not contracting at the same time
Bad prognostic indicators of Heart Failure (5)
- Prolonged QRS
- Low Na+
- low lymphocytes
- hypotension
- poor renal fxn
What causes excess absorption of Na+ in Heart Failure patients?
Decreased perfusion to the kidneys will make it think you are dehydrated, so you will want to keep salt and therefore water.
What Diagnostic Tests would you order for suspected HF?
- EKG
- 2-D Echo
- Labs (Electrolytes, CBC, Liver Enzymes, TSH, Na, Crea, BUN, Troponin)
- CXR
- Cardiac Catherization
Seattle Heart Failure Model
Want to check Percent of Lymphocytes because they will be lower if there is wasting of the body due to poor nutrition.
occurs when the heart is incapable of meeting the metabolic demands of the body tissue
heart failure
In systolic heart failure that occurred as a result of ischemic heart disease, would the patient’s EF be normal or less than normal?
Systolic heart failure is “pump failure”.
EF < 55%
Is it common to have left AND right heart failure simultaneously?
YES! “Most people who have had HF from ischemia (#1 cause) will have both right and left systolic heart failure.”
If you have right systolic HF, and normal LV function, what are the potential causes?
Cause must be somewhere BETWEEN the RV and LV. So is could be the 1) pulm valve 2) lungs (pulm htn) 3) mitral valve stenosis
What are the common symptoms of right sided systolic heart failure?
JVD, peripheral edema, fatigue (fluid back up in the body)
What are the common symptoms of left sided heart failure?
congestion in the lungs (crackles, cough, dyspnea). Increased pressure in lungs quickly leads to right sided failure as well
Systolic Heart failure is caused by a problem with what?
The ventricles. “Pump problem”
Diastolic heart failure is caused by what problem?
A stiff heart! This is a filling problem.
What are the main causes of diastolic (filling) heart failure?
diabetes, htn
Which side of the heart is typically more effected by diastolic heart failure?
TRICKSTER: typically effects both sides at the same time, and effect is equal on either side
When both sides of the heart fail in diastolic heart failure, which sided failure produces the most troubling side effects?
The left sided failure is typically more symptomatic (lung congestion)
In diastolic heart failure, is the EF low or normal?
Normal. (Less blood getting into ventricles in the first place, so The heart still pumps out 60% of the blood in the ventricles, but its 60% of a much smaller number)
What are some signs/symptoms that your HF patient might not be getting adequate perfusion?
1) Narrow pulse pressure
2) cool extremities
3) decreased mental status (confused, sleepy)
4) low sodium
5) elevated creatinine (low renal fxn)
6) hypotension
What are some signs/symptoms that your HF patient might be experiencing fluid overload?
1) orthopnea
2) JVD or increased JVP
3) peripheral edema
4) ascites
5) rales/crackles
6) an S3 heart sound (gallop)
“Good perfusion” = WARM and “fluid overload” = WET. If your patient is warm and wet, what should you do?
decrease the afterload (vasodilate) and diurese.
“Good perfusion” = WARM and “fluid overload” = WET. If your patient is cold and wet, what should you do?
Increase perfusion by using inopropic agents
“Good perfusion” = WARM and “fluid overload” = WET. If your patient is cold and dry, what should you do?
discontinue diuretics and give fluids
“Good perfusion” = WARM and “fluid overload” = WET. If your patient is warm and dry, what should you do?
sing and dance. you’ve found the promised land.
How far has a patient’s HF progressed by the time they become symptomatic?
They already have increased pulmonary pressure and there has been remodeling of the heart before any symptoms are detected
What medications are ideally given to all HF patients following their first onset of symptoms? (3)
1) Diuretics for symptom control
2) ACE inhibitors to block the RAAS which will be active following the diuretics
3) BB to reverse cardiac remodeling
If your HF patient is already on a diuretic, an ACEI, and a BB, but they are still having symptoms, what is the best medication to adjust (of the above 3)?
Increase the BB (continuing to shrink the heart has the best improvement in mortality)
What are the most common MAJOR diagnostic criteria for dxing HF?
PND, DOE, JVD, rales, CM, pulm edema/htn, S3
What are the most common MINOR diagnostic criteria for dxing HF?
ankle edema, night cough, hepatomegaly, pleural effusion, decreased vital capacity, tachycardia (>120), 4.5kg wt loss within 5 days of treatment
How many of the major/minor s/s must be met to make a HF diagnosis?
Either 2 major OR 1 major and 2 minor
What happens to the brain natriuretic peptide (BNP) as fluid overload increases?
It rises
What produces the BNP?
the ventricles of the heart
When does the heart secrete BNP?
when it is stretched by excess fluid or high pressures
What does BNP do in the body once secreted?
1) dilates vessels to reduce afterload and
2) wastes Na+ and H2O to reduce fluid volume
What does the heart do to protect itself from excess fluid volume generated as a result of the RAAS?
Secretes BNP
What is the term for the alteration of right heart structure and/or function which is caused by a lung problem?
Cor pulmonale
Essentially what is happening in cor pulmonale?
pulmonary htn creates strain on the right ventricle and leads to RV hypertrophy
What are some underlying conditions that lead to cor pulmonale?
COPD, PE, OSA, CF
What is the best treatment for cor pulmonale?
treat underlying lung dz!
What percent of the general population has been diagnosed with heart failure?
2%
What percent of the elderly population has heart failure?
20%
Does advanced HF affect cognition?
Yes! Remember Dick Chaney?
What type of care is consistently neglected in HF patients?
Palliative care!
What are some things to consider when talking about palliative care in HF patients?
DNR, disabling pacers, comfort care
Fromm said know this
What are the poor prognostic indicators that suggest life expectancy < 6 months?
1) Sodium (<20%
8) frequent hospitalizations
9) cachexia (poor nutricion)
10) Lymphopenia
What types of HF symptoms are you targeting with palliative care?
pain, dyspnea, edema, lightheadedness, wasting fatigue, nausea, depression/anxiety