HEART FAILURE Flashcards
Drugs that may precipitate heart failure
Negative Initropes
Cardiotoxic Drugs
Drugs that cause sodium and Water retention
TNF- alpha inhibitors
DPP-4 Inhibitors
Negative inotropic drugs
Antiarrhythmics
Beta blockers
Dihydropyridine CCBs
Itraconazole
Primary manifestation of HF
Dyspnoea
Fatigue
What is the simplest and most reliable symptom of fluid overload in HF
Jugular venous distention
Signs of systemic congestion in HF
Jugular venous distension
Hepatojugular reflex in mild congestion
Hepatomegaly
Ascites
Manifestations of peripheral edema in HF
Sacral edema in bedridden patients
Pedal edema
Indicators of low CO in HF
Worsening Renal function
Cool extremities
Altered mental status
Resting tachycardia
Low systolic BP
Narrow pulse pressure
Primary complaint associated with hypoperfusion in HF
Fatigue
What is H2FPEF
Clinical score for diagnosing HFpEF
Explain the H2FPEF score
H-Heavy-BMI >30kg/m2- 2 points
H-Hypertension-2 or more antihypetensive drugs- 1 point
F- atrial Fibrillation- Paroxysmal or Persistent- 3 points
P-Pulmonary Hypertension- Doppler Echocardiographic estimated Pulmonary Artery Systolic Pressure > 35mmHg- 1 point
E- Elder- Age> 60 yrs - 1 point
F- Filling pressure -Doppler echocardiographic E/e’>9- 1 point
Role of serum creatinine in HF diagnosis
To evaluate hypoperfusion
The ACC/AHA heart failure stages
Stage A- at risk of developing HF
Stage B- structural heart disease but not HF symptoms
Stage C- structural heart disease and current or previous HF symptoms
Stage D- refractory HF requiring specialized interventions
The NYHA classification of HF
I- Cardiac disease but not imitations of activity
II- cardiac disease with slight/minimal limitations of activity
III- cardiac disease with marked limitation of activity
IV- cardiac disease with inability to carry out physical activity without discomfort, symptoms at rest
Treatment of Stage A heart failure
Risk factor management
Treatment of Stage B heart failure
For reduced LVEF, give ACEI/ARB + B blocker
For reduced LVEF nd previous MI, give ACEI/ARB + B blocker + Statin
Treatment of Stage C HF
Combinations of ACEI/ARB/ARNI + B BLOCKER + Aldosterone antagonist
Others- Loop diuretics, Hydralazine-ISDN, Digoxin, Ivabradine
Non-pharmacologic therapy- ICD or CRT with biventricular pacemaker
What is CRT in heart failure
Cardaic resynchronization therapy is used to correct asynchronous contraction of the ventricles improve ventricular fucntion and hemodynamics.
Which patients require CRT
NYHA II-III or ambulatory class IV symptoms with QRS duration> 150 secs and LVEF , 35%
Role of ICD in managing heart failure
Implantable cardioverter device prevents sudden cardiac death in HF patients
When is ICD used
NYHA II-III symptoms and LVEF < 35% and expected to live for at least 1 year
NYHA I with LVEF < 30% for primary prevention if life expectancy exceeds 1 year
What is the optimum serum concentrations for digoxin in heart failure
0.5-0.9ng/ml or mcg/L or
0.6-1.2 nmol/L
Most common cause of heart failure
Coronary Artery Disease
Classify heart failure based on ejection fraction
HFrEF < 40%
HFmEF 41-49%
HFpEF >50%
Risk factors for HFpEF
Age
Obesity
Hypertension
Female
Atrial Fibrillation
Diabetes
Give 3 examples of aldosterone antagonists
Spirinolactone
Eplerenone
Finerenone
What factors determine stroke volume
Preload
Afterload
Contractilité
State the Frank Starling Mechanism
The ability of the heart to alter the force of contraction depends on changes in preload
What is the primary determinant of preload
Left ventricular end diastolic volume (LVEDV)
What hémodynamic measurement is used to determine LVEDV
Pulmonary capillary wedge pressure (PCWP) or
Pulmonary Artery Occlusion Pressure (PAOP)
What are the major components of afterload
Ejection impedance
Wall tension
Régional wall geometry
What are the causes of HFpEF
Impaired myocardial relaxation
Increases diastolic stiffness
Does HFpEF affect systolic or diastolic function
Diastolic function
Does HFrEF affect systolic or diastolic function
Systolic function
What are the four compensatory mechanisms in HFrEF
- Tachycardia and increased contractility though the SNS
- The Frank-Starling mechanism, increase preload results in increased SV
- Vasoconstriction
- Ventricular hypertrophy and remodeling
Why does vasoconstriction occur in patients with HFrEF
To redistribute blood flow away from nonessential organs to coronary and cerebral circulation
What is ventricular hypertrophy
Increase in ventricular mass
What is cardiac or ventricular remodeling
Changes in both myocardial cells and and extra cellular matrix resulting in changes in shape, size, structure and function of the heart
Hormones involved in ventricular remodeling
Vasopressin
Norepinephrine
Aldosterone
Angiotensin II
Endothelin
Numerous inflammatory cytokines
Types of hypertrophy in HF and their causes
Pressure overload and neurohormonal activation in HTN causes concentric hypertrophy
Systolic dysfunction or previous MI causes eccentric hypertrophy
Explain the neurohormonal model of HF
An intimidating even (MI or long-standing HTN) leads to decreased CO and begins the HF state. The progression of the disease is mediated by neurohormones and autocrine or paracrine factors
Functions of AT-II in HF
Vasoconstrictor through AT-I receptors
Causes release of aldosterone and endothelin-1
Facilitates release of NE from the SNS
Promotes sodium retention directly and through aldosterone release
Vasoconstriction of efferent artérioles helps maintain renal perfusion
Plays a role in ventricular hypertrophy and remodeling
Role of NE in HF
Tachycardia
Vasoconstriction
Increase contractility and plasma renin activity
Increase risk of arrhythmias
Ventricular hypertrophy and remodeling
Myocardial loss by stimulating both necrosis and apoptosis
Role of Aldosterone in HF progression
Sodium and water retention
Interstitial cardiac fibrosis
Induces a systemic proinflammatory state
Increases oxidative stress
Wasting of soft tissues and bones
Secondary hyperparathyroidism
What are the types of natriuretic peptides
ANP
BNP- most important in HF
CNP
Role of vasopressin in HF progression
Increase renal free water absorption
Vasoconstriction
Cardiac remodeling through hypertrophy and extra cellular matrix collagen deposition
Two examples of vasopressin antagonists
Tolvaptan
Conivaptan
Which vaccines are given in HF and why
Pneumococcal and Influenza vaccines to prevent pulmonary infections which might exacerbate the HF condition
How is JVD assessed
Examine the right internal jugular vein with patient at 45degrees angle
The presence of JVD more than 4cm above the sternal angle suggests systemic venous congestion
In mild congestion, application of pressure to the abdomen will cause elevation of the JVD( hepatojuguoar reflex)
How much fluid weight gain normally occurs in adults with HF before trace peripheral edema is evident
10-lb or 4.5kg
What are the effects of abdominal swelling in RSHF
Early satiety
Nausea
Constipation
Reduced absorption
Feeling of Bloating
Anorexia
Weight gain
Symptoms of LSHF
Dyspnoea
Orthopnoea
PND
Symptoms of RSHF
Fluid retention
GI bloating
Fatigue
Peripheral edema
Counterregulatory hormoes in HF
Natriuretic peptides
Bradykinin
Nitric oxide
Sources of the different natriuretic peptides
Atrial NP- atrial myocytes in response to stretch
B-type NP- ventricles in response to myocardial wall stress
C-type NP- limited to vascular endothelium and CNS
Functions of natriuretic peptides
Natriuresis
Vasodilation
Suppression of RAAS
Symptoms of HF
Exertional Dyspnoea
Orthopnoea
PND
Fatigue
Cough
Anorexia
Nausea
Weight gain or loss
Bloating
Nocturia
Abdominal pain
Poor appetite
Signs of HF
Ascites
Pulmonary râles
Pulmonary edema
Tachypnea
Cardiomégaly
Peripheral edema
JVD
HJR
Hepatomegaly
Cachexia
Mental status changes
Pleural effusion
Tachycardia
S3 Gallop, mitral régurgitant murmur
Function of cardiac cathetherization in HF
To measure
pulmonary artery pressure
left atrial wedge pressure
Left ventricular end diastolic pressure
Effect of alcohol on the heart
Alcohol has a negative inotropic effect
Benefits of CRT in heart failure
Restores synchronous activation of ventricles
Improves LVEF
Associated with reverse remodeling
Difference between functions of Beta blockers in HFrEF and HFpEF
HFrEF
BB improves morbidity and mortality
HFpEF
Decrease heart rate
Increase diastolic duration
Modify hemodynamic response to exercise
Which drugs are seldom used in HFrEF but predominantly used in HFpEF
Calcium channel blockers
Diltiazem
Verapamil
Amlodipine
Which thiazide-like diuretic is used together with loop diuretics in HF
Metolazone
Which thiazide diuretic retains its potency even in renal failure
Metolazone
Under which conditions in HF are thiazide diuretics preferred to loop diuretics
Mild congestion and elevated blood pressure
How do NSAIDS affect the action of loop diuretics
NSAIDS prevent the prostaglandin like activity of loop diuretics. This porstaglandin like activity increases renal blood flow and contributes to their diuretic effect.
Give three examples of loop diuretics
Furosemide
Torsemide
Bumetanide
Difference between the bioavailability of the different loop diuretics
Torsemide and Bumetanide have complete (80-100) bioavailability
Furosemide has about 50% bioavailability
How do loop diuretics get to their site of action
Secretion into the nephrons through the organic acid transporter
Relationship between the IV and oral doses of the different loop diuretics
For torsemide and bumetanide, IV=oral dose
For furosemide, oral dose = twice IV dose
Effect of food on the absorption of the loop diuretics
Food reduces the bioavailability of bumetanide and furosemide, but has no effect on absorption of torsemide
………………….is preferred in patients with persitent fluid retention despite high doses of other diuretics
Torsemide
Wat causes ceiling effect of diuretics in HF
Decresed absorption of diuretics
Increased proximal tubule activity due to increase in Na/K/2Cl cotransporter
How is ceiling effect of diuretics in HF overcome to increase diuresis
Giving combination diuretic
Giving the diuretic more often , two or three times daily
Dose titration of ACE inhibitors is usually accomplished by doubling the dose every
2 weeks
Monitoring parameters for patients on ACE inhibitors
Blood pressure
Renal function
Serum potassium
Most common adverse effects of ACE inhibitors
Hypotension
Renal dysfunction
Hyperkalemia
How can hypotension be avoided in HF patients on numerous vasoactive medications
Space the administration of vasoactive medications throughout the day
When is ACE inhibitor dose reduced
Increase in serum creatinine of >0.5 mg/dL (44 µmol/L) if the baseline creatinine is <2 mg/dL (177 µmol/L) or
Of >1 mg/dL (88µmol/L) if the creatinine is >2 mg/dL (177 µmol/L)
……………… or……………………………… can be used to prevent hyperkalemia in HF patients on ACEI and at high risk of hyperkalemia
Patiromer or sodium zirconium cyclosilicate
Which ARBs are recommended for HF treatment by guidelines
Valsartan
Candesartan
Losartan
ACE inhibitors should be discontinued ………………..prior to initiating ARNI; no waiting period is needed in patients receiving an ARB
36 hours,
Favourable effects of beta blockers in heart failure;
Reversal of ventricular remodeling, Reduction in myocyte death
from catecholamine-induced necrosis or apoptosis
Improvement in left ventricular systolic function
Reductions in HR and ventricular wall stress
Reducing myocardial oxygen demand
Inhibition of plasma renin release.
Beta blockers used in heart failure
Carvedilol
Bisoprolol
Metoprolol succinate
Nebivolol
Adverse effects of beta blockers
bradycardia or heart block
hypotension
fatigue
impaired glycemic control in diabetics
bronchospamsin in asthmatics
worsening HF
Contraindications to beta blocker use
Uncontrolled bronchospastic disease
Symptomatic bradycardia
Advanced heartblock without a pacemaker
Acute decompensated heart failure
Contraindications to beta blocker use
Uncontrolled bronchospastic disease
Symptomatic bradycardia
Advanced heartblock without a pacemaker
Acute decompensated heart failure
In Stage A patients with type 2 diabetes and either established CVD or at high cardiovascular risk, ……………. should be used to prevent hospitalizations for HF.
SGLT2i
Treatment for Stage A patients with hypertension
Optimal Control of BP
Treatment for Stage A patients with CVD
Optimal management of CVD
For patients at risk of developing HF, …………………………… biomarker–based
screening followed by team-based care
natriuretic peptide
What are some methods for assessing clinical congestion in HF
JVD
Orthopnoea
Bendopnea
Leg edema
Square wave response to the Valsava maneuver
Differences between high output and low output heart failure
High output heart failure is the inability of the heart to meet increased metabolic demands of body tissues despite normal or increased cardiac output
Low output heart failure occurs when there is a reduced cardiac output or reduced ejection fraction
The main types of cardiomyopathies
Dilated or Congestive CM
Restrictive CM
Hypertrophic CM
Laboratory evaluations in HF
Complete blood count
Urinalysis
Serum electrolytes(including Na, K, Ça and Mg)
Blood urea nitrogen
Fasting lipid profile
Liver function tests
Iron studies
Thyroid function tests
What is Takotsubo cardiomyopathy or broken heart syndrome or stress cardiomyopathy
Takotsubo cardiomyopathy is a heart disease characterized by transient dysfunction and ballooning of the left ventricle of the heart. It mostly affects elderly women and is often triggered by severe physical or emotional stress.
Which test is used to assess cardiac structure and Function in HF
Transthoracic echocardiography
Function of chest X ray in HF
Assess heart size and pulmonary congestion
Detect alternative cardiac, pulmonary and other diseases contributing to symptoms
Which invasive evaluations are used in HF and when
Endomyocardial biopsy is used when a specific diagnosis is suspected that would influence therapy
Invasive hemodynamic monitoring is used in HF patients with persistent or worsening conditions and diagnostic parameters in whom hemodynamics is uncertain
