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Clinical Medicine II > Heart failure > Flashcards

Heart failure Flashcards

1
Q

What side of heart failure has these symptoms:
Systemic congestion
JVD
Hepatosplenomegaly
Dependent extremity pitting edema
Weight gain
GI symptoms – abdominal bloating, anorexia, early satiety (due to bowel wall + hepatic congestion), RUQ pain
Anasarca = development of massive edema involving entire body w/ recurrent pleural effusions +/o ascites

Signs of fluid overload predominate

A

right

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2
Q

Most common cause of RHF is

A

LHF

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3
Q

RHF is _____

A

systemic congestion

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4
Q

Traffic in 3 roads to the heart is

A

right heart failure

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5
Q

What does this PE tell you
Peripheral edema
Ascites
Scrotal edema
Hepatosplenomegaly
Elevated JVP >3 cm above sternal, 8 above RA
Crackles, rhonchi, wheezing
Right ventricular heave or parasternal lift in biventricular or severe HF

A

right sided heart failure

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6
Q

Kussmaul’s sign

A

rise in JVP w/ inspiration – severe biventricular HF + poor outcome

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7
Q

RHF: Dx lab value

A

elevated BNP

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8
Q

What’s first line for all heart failure?

A

Lifestyle changes – cessation or restriction ETOH, tobacco cessation, limit sodium to 2.5g/day, fluid restriction only if class IV, weight loss

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9
Q

What are the four pillars of meds for heart failure?

A

PRIMARY: 4 pillars of meds
Renin-angiotensin system inhibitors:
Preferred: sacubitril/valsartan
Beta blockers:
Preferred: carvedilol, carvedilol, metoprolol, succinate, bisoprolol
Mineralocorticoid receptor antagonists:
Preferred: spironolactone, eplerenone
SGLT2 inhibitors:
Preferred: dapagliflozin, empagliflozin

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10
Q

What are addition meds for heart failure?

A

Diuretics (loop) + low sodium diet
Cardiac rehab

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11
Q

What are secondary meds (don’t memorize) for HF?

A

SECONDARY: don’t memorize
vasodilators/nitrates (isosorbide dinitrate + hydralazine)
Alt to ACEI/ARB, for persistent symptoms, anti-HTN, shown to decrease mortality
Ivabradine
Persistent symptoms, esp tachycardia w/ max BB
Vericiguat
Persistent symptoms
Digoxin
Persistent symptoms

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12
Q

How do you treat heart failure with life-threatening arrhythmias?

A

Life-threatening arrhythmias = implantable ICD, pacemaker for bradycardia or prolonged QRS (most get both)

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13
Q

What side of heart failure is this:
Pulmonary congestion → pulmonary edema
Dyspnea
Paroxysmal nocturnal dyspnea (increased venous return when flat)
Orthopnea
Crackles
Wheezes
Cough
Decreased flow to the kidneys = increased fluid retention
Edema
Hepatic congestion + ascites

A

left

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14
Q

What are risk factors for HF?

A

Old age
Higher heart rate
HTN
CAD/previous MI
Valvular HD
Diabetes
Smoking
obesity

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15
Q

What does this cause?
Poor pumping (systolic) or rigid/scarred/hypertrophic wall that resists filling (diastolic)

Most common cause = CAD, HTN

Chronic = long standing (months-years)

Due to pulmonary congestion

A

left sided HF

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16
Q

What is NYHA class I?

A

asymptomatic

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17
Q

What is NYHA class II?

A

slight limitation of physical activity, comfortable at rest but ordinary physical activity results in undue fatigue

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18
Q

What is NYHA class III?

A

marked limitation of physical activity, comfortable at rest, but less than ordinary physical activity results in undue fatigue

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19
Q

What is NYHA class IV?

A

unable to carry on any physical activity without discomfort

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20
Q

What are candidates for thrombophilia workup if results will influence management?

A
  • patients <50 y of age
  • strong family history of VTE
  • clot in unusual locations
  • recurrent thromboses
  • women of childbearing age
  • suspicious for APS
  • VTE provoked by transient non major risk factor
  • VTE ass with pregnancy
  • VTE ass with oral contraceptives
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21
Q

What type of HF:
Well nourished + comfortable at rest – dyspnea w/ minimal ex
High HR + P initially
Chronic = HR <70-75 + BP in normal-low range

A

mild/moderate HF

22
Q

What type of HF:
Sit upright + anxious, diaphoretic, dyspneic at rest
Pallor due to anemia
Duskiness (low output)
Cool extremities and peripheral cyanosis
HOTN, narrow pulse pressure, rapid/thready pulse

A

severe HF

23
Q

What does this PE indicate:
Rales, crackles, wheezing, rhonchi (congestion)
pleural effusions (dullness to percussion, decreased breath sounds at base)
Displacement of apical impulse (down + left)
S3 or S4 gallop
*

A

HF

24
Q

What does this indicate:
BNP or NT-proBNP
Elevated
CBC: anemia and infection can exacerbate pre-existing HF
CMP: hyponatremia, renal impairment, electrolytes + renal function for meds, LFTs

A

heart failure

25
Q

How can you dx HF?

A

CXR to differentiate
echo (alone cannot diagnose/exclude)
look at atrial/ventricular sizes

26
Q

What are acute HF symptoms?

A

SOA and DOE
Orthopnea
Paroxysmal nocturnal dyspnea

27
Q

What are chronic HF symptoms?

A

Fatigue
Anorexia
Abdominal distention
Peripheral edema
Dyspnea (less pronounced – due to w/d of activity)

28
Q

Who are at risk for reduced HF EF?

A

Poor prognosis: older age, male sex, HF-related hospitalization (25% after single hospitalization)

29
Q

Reduced EF HF

A

systolic HF

MCC of death – CAD, valvular heart disease, myopathy, congenital heart disease, infection, autoimmune, chronic lung disease

30
Q

EF </ 40%

A

reduced EF HF

31
Q

What does this indicate
EKG: abnormality (amyloid disease, A-fib/arrhythmia, acute MI/previous MI, LVH
S3 gallop - systolic

A

HF w/ reduced EF

32
Q

Criteria for diagnosis of reduced HF EF

A

> / 1 categories of high-specificity or >/ 3 of intermediate = diagnosis

low specificity or 1-2 = exercise test and refer

33
Q

How do you treat reduced HF EF?

A

all 4 pillars - starting dose + work up to goal dose

34
Q

preserved HF EF

A

diastolic HF
long standing HTN, valvular heart disease, CAD, cardiomyopathy, constrictive pericarditis, aging, endocardial fibroelastosis

35
Q

What does this indicate:
Precordial palpation often normal
S4 gallop - diastolic

A

preserved EF HF

36
Q

EF >/ 50%
EKG normal

A

preserved EF HF

37
Q

In order to diagnose HF EF preserved you need -

A

1+ symptoms of HF
LVEF>/50%
no apparent other cause

score: H2 FPEF
0=unlikely
1-5=intermediate
6-9=highly likely

38
Q

H2FPEF

A

H2 = heavy, HTN (2), (1)
F = A fib (3)
P = pulmonary HTN (1)
E = elder (1)
F = filling pressure (1)

39
Q

How do you treat preserved HF EF?

A

Cardiac rehab + diet = small improvements in exercise tolerance

Diuretics for volume overload – loop + low salt diet

Class II or III + elevated BNP + SGLT2 inhibitor + mineralocorticoid receptor antagonist

Secondary medications:
Sacubitril-valsartan
ACEI/ARB
Beta blocker

40
Q

> 50% EF

A

high output EF

41
Q

When can holosystolic murmurs MR and TR be heard?

A

AHF

hyponatremia on CMP

42
Q

How do you treat advanced HF?

A

IV loop diuretics, fluid + sodium restriction
All conventional therapies employed
Referral to advance HF program
Palliative care

43
Q

What are short term devices for AHF?

A

Short term devices - intra-aortic balloon pump, percutaneous circulatory assist devices, extracorporeal membrane oxygenation (ECMO)

44
Q

What are long term devices for AHF?

A

Long term devices - left ventricular assist devices (LVAD) - bridging time for transplant

45
Q

What are severe treatments for AHF?

A

Cardiac transplant – Class IV, cardiogenic shock, not amenable to percutaneous or surgical revascularization, life-threatening arrhythmias unresponsible to therapy

CIs: life expectancy <2 years, irreversible pulmonary HTN, severe cerebrovascular disease, substance use, inability to comply

46
Q

What do these symptoms indicate: Rapid onset or worsening of symptoms –
Left sided: pulmonary symptoms, progressive dyspnea, cough, rales

Right sided: systemic symptoms of abdominal and peripheral congestion

A

acute decompensated HF

47
Q

What can contribute to acute decompensated HF?

A

Nonadherence to meds, dietary salt, usage of meds that exacerbate HF, arrhythmias, valvular heart disease, systemic infection, PE

48
Q

What causes acute decompensated HF?

A

Acute HF – most from worsening of chronic HF but also can occur from ACS, acute valvular dysfunction, hypertensive urgency

49
Q

What does this indicate:
S3 sound and laterally displaced apex beat

Lower extremity edema

A

acute decompensated HF

50
Q

diagnosis of acute decompensated heart failure is based on

A

Signs and symptoms + supported by BNP(>100 or p-BNP >125), CXR, ECG, and doppler

51
Q

What does this indicate:
Troponin elevated

Based on:
Signs and symptoms + supported by BNP(>100 or p-BNP >125), CXR, ECG, and doppler

CXR: cephalization of flow, Kerley B lines, bat wing appearance, cardiomegaly, pleural effusions, pulmonary edema

A

acute decompensated HF

52
Q

How do you treat acute decompensated HF?

A

Start with IV loop diuretic (refractory, add thiazide)

Decongestion occurred if:
Change in weight
Improvement in clinical symptoms
Predischarge measurement of BNP

Oxygen

Vasodilators (IV nitroglycerin, sodium nitroprusside)

Inotropic therapy (dopamine, dobutamine)

Clinical Medicine II (15 decks)

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