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Internal Med EOR > Heart failure > Flashcards

Heart failure Flashcards

1
Q

what is heart failure?

A

complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood

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2
Q

heart failure is characterized by s/s of …… and ……

A

reduced CO; volume overload

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3
Q

MC cause of death for HF

A
  • progressive HF
  • sudden cardiac death
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4
Q

risk factors for HF

A
  • CAD/atherosclerosis
  • DM
  • HTN
  • Obesity
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5
Q

what is considered acute HF

A

symptoms began within last few days to weeks

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6
Q

s/s of acute HF

A
  • SOB
  • paroxysmal nocturnal dyspnea
  • orthopnea
  • RUQ pain
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7
Q

what is considered chronic HF

A

symptoms present for months

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8
Q

s/s of chronic HF

A
  • fatigue
  • anorexia
  • abdominal distention
  • pitting edema
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9
Q

High vs Low Output HF

A
  • high: heart is unable to meet the demands of the peripheral needs
  • low: insufficient forward output
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10
Q

Causes of high output heart failure

A
  • thyrotoxicosis
  • severe anemia
  • sepsis
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11
Q

Causes of Low Output Heart Failure

A
  • reduced EF
  • hypovolemia
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12
Q

HFrEF vs HFpEF

A
  • HFrEF: reduced EF (systolic) (EF below 40)
  • HFpEF: preserved EF (diastolic) (EF over 50)
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13
Q

patients with EF 41-49 can appear similarly to patients with ….

A

HFpEF

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14
Q

MC side of HF

A

left

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15
Q

s/s related to LHF

A
  • DOE
  • PND
  • orthopnea
  • fatigue
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16
Q

MCC of RHF

A

LHF

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17
Q

causes of RHF

A
  • COPD
  • PE
  • Pulm HTN
  • valvular disorders
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18
Q

s/s associated with RHF

A
  • JVD
  • hepatic congestion
  • ascites
  • anorexia
  • lower extremity edema
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19
Q

NYHA classification of HF

A
  • Class 1: no limitations
  • Class 2: slight limitations of physical activity
  • Class 3: Marked limitation of physical activity
  • Class 4: inability to do physical activity without discomfort and sx at rest
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20
Q

ACC/AHA stages of HF classify based on the _____ of HF

A

evolution

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21
Q

ACC/AHA stages of HF

A
  • A: at risk for HF but no structural heart disease or symptoms of HF
  • B: structural heart disease without s/s of HF
  • C: structural heart disease with prior or current symptoms of HF
  • D: refractory HF requiring specialized interventions
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22
Q

neurohormonal adaptations of HF

A

compensatory mechanisms used in attempt to adjust for a reduction in cardiac output

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23
Q

compensatory mechanisms

A
  • maintain systemic pressure by vasoconstriction
  • restored cardiac output by increasing myocardial contractility and HR
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24
Q

drugs used to treat the compensatory mechanisms of HF such as:
* increased sympathetic activity
* vasoconstriction
* RAAS system

A
  • increased sympathetic activity: beta blockers
  • vasoconstriction: vasodilators
  • RAAS: ACEI/ARBS/aldosterone antagonists
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25
Q

… is one of the first responses to low CO

A

activation of the SNS

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26
Q

activation of the SNS results in … and … of NE

A
  • increased release
  • decreased uptake
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27
Q

effects of activated SNS

A
  • increased ventricular contractility
  • increased HR
  • vasoconstriction
  • enhanced venous tone
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28
Q

SNS stimulated proximal tubular …. rebsorption

A

Na

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29
Q

SNS results in an increase of ….. concentration

A

plasma NE

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30
Q

RAAS system is stimulated by ….

A
  • decreased glomerular filtration
  • increased beta-1- adrenergic activity
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31
Q

actions of RAAS

A
  • increases Na reabsorption
  • induces systemic and renal vasoconstriction
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32
Q

RAAS and apoptosis

A

RAAS can be detrimental because as HF progresses, myocytes develop more AT2 receptors, which results in cell apoptosis

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33
Q

low CO and ADH

A

activation of baroreceptors cause release of ADH and thirst stimulation

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34
Q

ADH promotes ……

A

water retention

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35
Q

the degree of ….. with ADH release parallels the severity of HF

A

hyponatremia

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36
Q

ANP

A

Released from atria in response to increased volume

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37
Q

ANP rises in ….

A

early HF

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38
Q

BNP

A

released from the ventricles in response to high ventricular filling pressures

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39
Q

BNP is present in …..

A

chronic or advanced HF

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40
Q

why is BNP the preferred test?

A

longer half life

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41
Q

maladaptive consequences of HF

A

elevation in diastolic pressures are transmitted to the venous circulations which leads to pulmonary vascular congestion and peripheral edema

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42
Q

PE of pulmonary vascular congestion

A

rales/crackles in lung bases

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43
Q

increase in ….. can depress cardiac function and enhance deterioration

A

peripheral resistance (afterload)

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44
Q

….. and …… can worsen coronary ischemia

A
  • catecholamine-stimulated contractility
  • increased HR
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45
Q

…. and ….. promote myocyte loss, resulting in cardiac remodeling

A
  • catecholamines
  • angiotensin II
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46
Q

3 major determinants of the LV stroke volume

A
  • preload: venous return and end diastolic volume
  • contractility: force generated at any given end-diastolic volume
  • afterload: vascular resistance
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47
Q

with systolic dysfunction, there is a reduction in …..

A

myocardial contractility

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48
Q

presenting s/s of HF

A

symptoms due to low CO and fluid accumulation
* dyspnea
* fatigue
* fluid retention

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49
Q

vital signs of HF

A
  • resting sinus tachy
  • narrow pulse pressure
  • diaphoresis
  • diminished peripheral pulses
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50
Q

volume assessment of HF

A
  • pulmonary congestion
  • peripheral edema
  • elevated jugular venous pressure
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51
Q

cardio PE findings for HF

A
  • pulsus alternans
  • precordial palpitation
  • heart sounds
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52
Q

….. is pathognomonic of severe LV failure

A

pulsus alternans

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53
Q

precordial palpatation

A

laterally displaces apical impulse usually indicated LV enlargement

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54
Q

heart sounds of HF

A
  • S3 in systolic HF
  • S4 in diastolic HF
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55
Q

initial testing for HF

A
  • EKG
  • chest xray
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56
Q

EKG for HF

A

may show an arrhythmia that is the cause or result of HF

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57
Q

CXR of HF

A
  • pulmonary congestion
  • cardiomegaly
  • kerley b lines
  • pleural effusions
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58
Q

best test for HF evaluation

A

BNP and NT-proBNP

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59
Q

BNP is used to …… as a cause of symptoms because it has a …….

A

exclude HF;very high negative predictive value

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60
Q

normal BNP

A

under 100

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61
Q

normal NT-proBNP

A

under 300

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62
Q

NP-proBNP and BNP both arise from …

A

proBNP

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63
Q

Limitations to BNP/ NT-proBNP

A
  • may present with more than one cause of their sx
  • patients with severe chronic HF may have persistently elevated elevated BNP
  • other causes of BNP elevation
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64
Q

significant elevation in troponin I or T indicates…

A

ischemic source of HF

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65
Q

echo of HF provides…

A
  • info on ventricular size and fxn
  • detect regional wall motion abnormalities
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66
Q

t/f denying CP is enough reason to exclude CAD

A

false

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67
Q

when is stress testing useful in the diagnosis of HF?

A

when you’re trying to rule out CAD

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68
Q

even if stress test is normal, if no other cause can be determined…

A

the patient should undergo coronary angiography

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69
Q

treatment of HF is aimed at …

A
  • relieving symptoms
  • improving functional status
  • preventing death and hospitalizations
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70
Q

BNP greater than ….. is suggestive of HF

A

100

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71
Q

HFrEF

A

EF < 40%

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72
Q

HFpEF

A

EF > 50%

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73
Q

treatment of HF is aimed at …

A
  • relieving symptoms
  • improving functional status
  • preventing death and hospitalizations
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74
Q

which type of HF has the most evidence for clinical benefits?

A

HFrEF

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75
Q

treatment of HFpEF is focused on …

A
  • improving symptoms
  • managing comorbidities
76
Q

classes of intervention recommendations for HF treatment

A
  • class 1: evidence that it is effective and is recommended
  • class 2a: should be considered
  • class 2b: may be considered
  • class 3: is not recommended
77
Q

management of RHF is the same as …..

A

HFpEF

78
Q

t/f there is no clear evidence that pharm, diet, or other therapies can reduce the mortality risk of HFpEF patients

A

true

79
Q

HFpEF patients should follow up every …. months

A

1-6

80
Q

key components of HFpEF management

A
  • ongoing monitoring
  • chronic disease management
  • lifestyle modifications
81
Q

rule of 2s for HFpEF patients

A
  • if they gain 2 lbs in 1 day, they need to take an extra diuretic
  • no more than 2L of fluids every day
  • no more than 2g of Na per day
82
Q

pharmacological treatment of choice for HFpEF

A

diuretics

83
Q

added therapies for HFpEF

A
  • SGLT2i (2a)
  • ARNI (2b)
  • MRA (2b)
  • ARB (2b)
84
Q

do patients need to be on diuretics if they are not symptomatic?

A

no

85
Q

diuretic of choice for mild fluid retention in HFpEF

A

thiazides

86
Q

diuretic of choice for severe fluid retention in HFpEF

A

loop

87
Q

what must be monitored when patients are on loop diuretics?

A
  • renal fxn
  • K+
88
Q

combination of loop and thiazide

A

it is possible to give the patient both if they continue to have symptoms, but be cautious of massive diuresis and electrolyte abnormalities

89
Q

……should be initiated when patients are on loop diuretics

A

K replacement

90
Q

monitoring for diuretic therapy

A
  • assess weight daily
  • BMP one week after initiation or dose change
91
Q

if the patient gains 2 lbs in 1 day or 5 lbs in 1 week, …

A

take an extra diuretic

92
Q

can you take SGLT2i for HF if you dont have DM?

A

yes, it has a diuresis effect

93
Q

examples of SGLT2i

A
  • jardiance
  • farxiga
  • invokana
94
Q

therapy dosing for HFrEF

A

low doses titrated to target doses based on tolerability

95
Q

class 1 options for HFrEF

A
  • diuretics
  • ARNI (NYHA class 2 and 3)
  • ACE/ARB (NYHA class 2-4)
  • BB
  • MRA
  • SGLT2
96
Q

ARNI

A

Sacubitril/Valsartan (Entresto)

97
Q

loop diuretics provide symptoms relieve due to …

A

fluid overload

98
Q

when are ARBs given in HFrEF?

A
  • if ACEs cannot be tolerated (class 1)
  • if patient is already on ARB at time of dx (class 2a)
  • add to ACE if aldosterone antagonist is CI (class 2b)
99
Q

use BB cautiously in what populations?

A
  • bradycardia
  • acute HF
  • first degree Av block
  • hx of asthma
  • hypotension
100
Q

why can you give BB in chronic HF but not in acute?

A

in the acute phase, the heart is beating extra hard to compensate. if you give a BB in acute phase, it will slow down the heart, compensation will not happen, and the patient will die

101
Q

aldosterone antagonists reduce …. in HFrEF

A

cardiac remodeling

102
Q

aldosterone antagonists CI

A
  • elevated K
  • GFR under 30
103
Q

MOA of entresto

A

inhibits neprilysin, which limits the breakdown of BNP and allows it to stay around longer

104
Q

t/f entresto can be used along with an ACE/ARB

A

false. it is used in place of the ACE/ARB

105
Q

process of switching someone from ACEi to entresto?

A

patient will need a 36 hour washout period of ACEI prior to starting entresto

106
Q

CI of entresto

A

hx of angioedema with ACEi

107
Q

recommendation class for hydralazine

A
  • class 1 in black patients
  • class 2a in non-black patients
108
Q

MOA of corlanor

A

inhibits funny channel in the sinus node which slows down the sinus rate

109
Q

when can corlanor be used?

A
  • stable
  • HR over 70
  • in sinus rhythm
  • on max dose of BB or BB are CI
110
Q

digoxin has greater …… effects than …..

A

negative chronotropic; ionotropic

111
Q

which CBB are harmful in HFrEF and should be avoided?

A

diltiazem and verapamil

112
Q

preferred agents in treating arrhythmias in HFrEF

A
  • amiodarone
  • dofetilide
113
Q

what drugs should be avoided in HFrEF?

A

NSAIDs

114
Q

cardiac rehab is recommended to which NYHA classes?

A
  • 2 and 3
  • 1 does not have sx so they don’t need cardiac rehab
  • 4 has symptoms even at rest, so the patient wouldn’t be able to do it
115
Q

functions of cardiac rehab

A
  • increases exercise capacity
  • improves quality of life
  • reduces hospitalizations
  • improves survival
116
Q

cardiac resynchronization therapy (CRT)

A

a treatment for heart failure in which a device paces both ventricles to synchronize contractions

117
Q

what would you see on an EKG for ventricular dessynchrony?

A

wide QRS

118
Q

functions of CRT therapy

A
  • improve exercise tolerance
  • improve NYHA functional class
  • reduce morbidity and mortality
119
Q

recommendations for LVEF for CRT

A

less than 35%

120
Q

recommended NYHA classed for CRT

A

3 and 4

121
Q

t/f ventricular arrythmias are common in patients with HF and cardiomyopathy

A

true

122
Q

preventing sudden cardiac arrest

A

implantable defibrillator

123
Q

primary prevention of SCA

A

for patients who have not suffered SCA before

124
Q

indications for primary prevention implantable defibrillator in ischemic CM

A
  • EF is less than 35
  • NYHA class 2 or 3
  • over 40 days post MI
125
Q

indications for primary prevention implantable defibrillator in nonischemic CM

A
  • EF is less than 35
  • NYHA class 2 or 3
  • more than 90 days post diagnosis
  • expected survival over 1 year
126
Q

what do we give to the patient in the 90 days prior to the implantable defibrillator in nonischemic CM?

A

external defibrillator (life vest)

127
Q

indications for secondary prevention of SCA

A

implantable defibrillator in patients who have survived an episode of SCA

128
Q

indications for defibrillator in unexplained syncope

A
  • patients with LVEF under 30
  • unexplained syncope
129
Q

acute decompensated HF

A

common and potentially fatal cause of acute respiratory distress

130
Q

causes of acute decompensation

A
  • medication noncompliance
  • MI
  • tachyarrhythmia
  • excessive salt intake
131
Q

acute decompensated HF is characterized by…

A
  • acute dyspnea
  • rapid accumulation of fluid
132
Q

acute decompensated HF requires rapid …. and …

A

assessment
; stabilization

133
Q

presentation of acute decompensated HF

A
  • acute pulmonary edema
  • dyspnea
  • pink, frothy sputum
  • diaphoresis
  • cyanosis
  • inspiratory rales on auscultation
134
Q

why do you see pink frothy sputum in acute decompensated HF?

A

due to vessel damage in their lungs

135
Q

management of acute decompensated HF

A
  • oxygen (if needed)
  • IV diuretics
  • vasodilators
136
Q

goal O2 sat for acute decompensated HF

A

94%

137
Q

method of oxygen supplementation in acute decompensated HF

A
  • nonrebreather mask with high flow o2
  • noninvasive positive pressure ventilation (CPAP or BPAP)
138
Q

if NPPV fails or cannot be tolerated, the patient should be …..

A

intubated

139
Q

what type of diuretics are first line in acute decompensated HF?

A

loop

140
Q

cardiorenal syndrome in acute decompensated HF

A

AKI due to elevated venous pressure and reduced CO, but may improve with diuresis

141
Q

t/f if loops do not diurese the patients enough, you can add on a second diuretic

A

true

142
Q

vasodilator therapy is recommended for patients without ….. and …..

A

hypotension; severe symptomatic fluid overload

143
Q
A
144
Q

MC used vasodilator in acute decompensated HF

A

NTG

145
Q

administration of vasodilators in acute decompensated HF

A

continuous IV infusion

146
Q

nitropress has both ….. and …. effects

A

venous ; arteriolar

147
Q

nitropress is used when …… is needed

A

afterload reduction

148
Q

risks of nitropress

A

CN toxicity

149
Q

why may vasodilators cause reflex tachycardia?

A

because the heart is pumping harder and faster to get more blood out

150
Q

…… is highly effective in pulmonary edema

A

morphine

151
Q

how does morphine lead to CO2 retention?

A

reducing respiratory rate

152
Q

natrecor

A

recombinant BNP

153
Q

when can ACE/ARBs be initiated in acute decompensated HF?

A

after they are stable

154
Q

patients that are already on ACE/ARBs can continue to take them during acute decompensated HF, unless that patient has…

A
  • hypotension
  • AKI
  • hyperkalemia
155
Q

if patient are on chronic BB therapy when they have acute decompensated HF…

A

hold therapy

156
Q

when can you initiate BB therapy in acute decompensated HF?

A

once patient is stable

157
Q

ionotropic agents, such as milrinone and dobutamine, are indicated for patients with…

A

severe LV systolic dysfunction to maintain systemic perfusion and preserve end-organ performance

158
Q

venous thromboembolism prophylaxis

A
  • anticoagulants
  • wraps around legs that inflate and deflate to break up clots if anticoagulants are CI
159
Q

ultrafiltration

A

process using peripheral venous access to remove excess fluid without affecting BP and electrolytes too much

160
Q

mechanical cardiac assistance is considered for patients in…

A

cardiogenic shock

161
Q

indications for mechanical cardiac assistance

A
  • cardiac index less than 2
  • systolic pressure less than 90
  • pulmonary capillary wedge pressure above 18
162
Q

2 types of mechanical cardiac assistance

A
  • intraaortic balloon counterpulsation
  • LVAD
163
Q

if the patient has a really high pulmonary wedge pressure, that tells us that they probably also have a really high pressure in the …..

A

left atria

164
Q

mechanical cardiac assistance is a bridge to ….

A

transplant

165
Q

presentation of cardiogenic shock

A
  • cool, clammy skin
  • hypotensive
  • tachicardia
166
Q

wedge pressure in cardiogenic shock

A

over 15

167
Q

cardiac index of cardiogenic shock

A

less than 2.2

168
Q

cardiac index

A

cardiac output per minute per square meter of body surface area

169
Q

cardiac index provides info on …

A

LV function

170
Q

normal CI range

A

2.6-4.2

171
Q

principle feature of shock

A

hypotension with evidence of end-organ hypoperfusion

172
Q

diagnostics for cardiogenic shock

A
  • EKG for underlying cause
  • echo
  • CXR
173
Q

treatment of cardiogenic shock

A
  • oxygen supplementation
  • vasopressors/ionotropes
174
Q

if the patient has a suspected MI that has caused circulatory shock, how should that be managed?

A
  • treat the MI
  • ASA, heparin, urgent cath, revascularize
175
Q

a swan ganz catheter provides an indirect estimate of …..

A

Left Atrial pressure

176
Q

normal pulmonary capillary wedge pressure

A

8-10mmHg

177
Q

pulmonary capillary wedge pressure in cardiogenic shock

A

elevated

178
Q

actions of ionotropic/vasopressor agents

A

increase contractility of the heart, heart rate, and peripheral vascular tone

179
Q

examples of ionotropic/vasopressor agents

A
  • dopamine
  • dobutamine
  • norepinephrine
180
Q

doses of dopamine and their effects

A
  • low dose: predominately dilated renal arterioles
  • intermediate dose: beta 1 receptor stimulation and enhances myocardial contractility
  • higher doses: alpha receptor stimulation in addition to continues beta1 stimulation and tachycardia
181
Q

dobutamine effects in cardiogenic shock

A

strong B1 and B2 effects resulting in increased CO, BP, and HR

182
Q

difference in dobutamine compared to dopamine

A
  • does not cause renal vasodilation
  • much stronger B2 effect
183
Q

NE effects in cardiogenic shock

A
  • strong b1 and alpha adrenergic effects and moderate B2 effects
  • increases CO and HR
184
Q

how should ionotropes/vasopressors be administered?

A

central line. can cause necrosis if administered peripherally

185
Q

circulatory support devices in cardiogenic shock

A

intra-aortic balloon pump and LVAD

Internal Med EOR (17 decks)

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