Heart failure Flashcards
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
right
Most common cause of RHF is
LHF
RHF is _____
systemic congestion
Traffic in 3 roads to the heart is
right heart failure
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
right sided heart failure
Kussmaul’s sign
rise in JVP w/ inspiration – severe biventricular HF + poor outcome
RHF: Dx lab value
elevated BNP
What’s first line for all heart failure?
Lifestyle changes – cessation or restriction ETOH, tobacco cessation, limit sodium to 2.5g/day, fluid restriction only if class IV, weight loss
What are the four pillars of meds for heart failure?
PRIMARY: 4 pillars of meds
Renin-angiotensin system inhibitors:
Preferred: sacubitril/valsartan
Beta blockers:
Preferred: carvedilol, metoprolol, succinate, bisoprolol
Mineralocorticoid receptor antagonists:
Preferred: spironolactone, eplerenone
SGLT2 inhibitors:
Preferred: dapagliflozin, empagliflozin
What are addition meds for heart failure?
Diuretics (loop) + low sodium diet
Cardiac rehab
What are secondary meds (don’t memorize) for HF?
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
How do you treat heart failure with life-threatening arrhythmias?
Life-threatening arrhythmias = implantable ICD, pacemaker for bradycardia or prolonged QRS (most get both)
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
left
What are risk factors for HF?
Old age
Higher heart rate
HTN
CAD/previous MI
Valvular HD
Diabetes
Smoking
obesity
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
left sided HF
What is NYHA class I?
asymptomatic
What is NYHA class II?
slight limitation of physical activity, comfortable at rest but ordinary physical activity results in undue fatigue
What is NYHA class III?
marked limitation of physical activity, comfortable at rest, but less than ordinary physical activity results in undue fatigue
What is NYHA class IV?
unable to carry on any physical activity without discomfort
What are candidates for thrombophilia workup if results will influence management?
- 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
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
mild/moderate HF
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
severe HF
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
*
HF
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
heart failure
How can you dx HF?
CXR to differentiate
echo (alone cannot diagnose/exclude)
look at atrial/ventricular sizes
What are acute HF symptoms?
SOA and DOE
Orthopnea
Paroxysmal nocturnal dyspnea
What are chronic HF symptoms?
Fatigue
Anorexia
Abdominal distention
Peripheral edema
Dyspnea (less pronounced – due to w/d of activity)
Who are at risk for reduced HF EF?
Poor prognosis: older age, male sex, HF-related hospitalization (25% after single hospitalization)
Reduced EF HF
systolic HF
MCC of death – CAD, valvular heart disease, myopathy, congenital heart disease, infection, autoimmune, chronic lung disease
EF </ 40%
reduced EF HF
What does this indicate
EKG: abnormality (amyloid disease, A-fib/arrhythmia, acute MI/previous MI, LVH
S3 gallop - systolic
HF w/ reduced EF
Criteria for diagnosis of reduced HFrEF
> / 1 categories of high-specificity or >/ 3 of intermediate = diagnosis
low specificity or 1-2 = exercise test and refer
How do you treat reduced HF EF?
all 4 pillars - starting dose + work up to goal dose
preserved HF EF
diastolic HF
long standing HTN, valvular heart disease, CAD, cardiomyopathy, constrictive pericarditis, aging, endocardial fibroelastosis
What does this indicate:
Precordial palpation often normal
S4 gallop - diastolic
preserved EF HF
EF >/ 50%
EKG normal
preserved EF HF
In order to diagnose HF EF preserved you need -
1+ symptoms of HF
LVEF>/50%
no apparent other cause
score: H2 FPEF
0=unlikely
1-5=intermediate
6-9=highly likely
H2FPEF
H2 = heavy(BMI>/30), HTN (2), (1)
F = A fib (3)
P = pulmonary HTN (1) >35
E = elder (1) >60
F = filling pressure (1) velocity and pulm artery pressure >9 by echo
How do you treat preserved HF EF?
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
> 50% EF
high output EF
When can holosystolic murmurs MR and TR be heard?
AHF
hyponatremia on CMP
How do you treat advanced HF?
IV loop diuretics, fluid + sodium restriction
All conventional therapies employed
Referral to advance HF program
Palliative care
What are short term devices for AHF?
Short term devices - intra-aortic balloon pump, percutaneous circulatory assist devices, extracorporeal membrane oxygenation (ECMO)
What are long term devices for AHF?
Long term devices - left ventricular assist devices (LVAD) - bridging time for transplant
What are severe treatments for AHF?
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
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
acute decompensated HF
What can contribute to acute decompensated HF?
Nonadherence to meds, dietary salt, usage of meds that exacerbate HF, arrhythmias, valvular heart disease, systemic infection, PE
What causes acute decompensated HF?
Acute HF – most from worsening of chronic HF but also can occur from ACS, acute valvular dysfunction, hypertensive urgency
What does this indicate:
S3 sound and laterally displaced apex beat
Lower extremity edema
acute decompensated HF
diagnosis of acute decompensated heart failure is based on
Signs and symptoms + supported by BNP(>100 or p-BNP >125), CXR, ECG, and doppler
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
acute decompensated HF
How do you treat acute decompensated HF?
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)
High = orthopnea, JVD, PND, S3, pulses alternans, displaced PMI, pulmonary edema, elevated BNP
ECHO- <30% LVEF
What are these high specificity for?
Heart failure with reduced ejection fraction — key for diagnosis
