Heart Failure '24 Flashcards
1
Q
What are the stages of heart failure?
A
AT RISK, PRE-HEART FAILURE, HEART FAILURE, ADVANCED HEART FAILURE
2
Q
What characterizes the AT RISK stage of heart failure?
A
Risk factors but no structural changes or symptoms
3
Q
What characterizes the PRE-HEART FAILURE stage of heart failure?
A
Structural changes but no symptoms
4
Q
What characterizes the HEART FAILURE stage of heart failure?
A
Symptoms like shortness of breath and fatigue
5
Q
What characterizes the ADVANCED HEART FAILURE stage of heart failure?
A
Symptoms don’t respond to treatment
6
Q
What is Heart Failure (HF) defined as?
A
Impairment of ventricular filling or blood ejection
7
Q
What are the clinical manifestations of heart failure?
A
Fatigue, dyspnea, weakness, edema, weight gain
8
Q
How is HF classified based on ejection fraction (EF)?
A
HFrEF (EF ≤ 40%) and HFpEF (EF ≥ 50%)
9
Q
What is the label for a patient with EF between 40-50%?
A
Borderline HFpEF
10
Q
Is diastolic dysfunction present in both HFrEF and HFpEF?
A
Yes
11
Q
What serves as the main marker for establishing HF risk factors, treatment, and outcomes?
A
Ejection fraction (EF)
12
Q
What percentage of heart failure patients have normal ejection fraction?
A
Approximately half
13
Q
What conditions are contributing to the increasing prevalence of HFpEF?
A
HTN, DM, A-fib, obesity, metabolic syndrome, COPD, renal insufficiency, anemia
14
Q
What are some modifiable risk factors more common in HFrEF compared to HFpEF?
A
Smoking, hyperlipidemia
15
Q
What proportion of heart failure cases are HFpEF?
A
52%
16
Q
Which gender is more likely to be affected by HFpEF?
A
Women
17
Q
Which gender is more likely to be affected by HFrEF?
A
Men
18
Q
What is the primary determinant of HFpEF?
A
LV diastolic dysfunction
19
Q
What factors determine the LV’s ability to fill?
A
Pulmonary venous blood flow, LA function, mitral valve dynamics, pericardial restraint, and elastic properties of LV
20
Q
When is LV diastolic function considered normal?
A
When factors provide sufficient COP without increasing pulmonary venous and LA pressures
21
Q
What are most measurements of LVDD dependent on?
A
HR, loading conditions, myocardial contractility
22
Q
What is needed to achieve normal end-diastole volume in HFpEF patients?
A
Higher LV filling pressures
23
Q
What can a steeper rise of the end-diastolic pressure-volume curve indicate?
A
Delayed LV relaxation
24
Q
What is a form of ‘active stiffening’ related to LV end-diastolic dysfunction?
A
Delays in relaxation
25
What can delays in relaxation be caused by in LV end-diastolic dysfunction?
Failure of actin-myosin disassociation
26
How does high afterload affect LV relaxation in hypertensive patients?
D/O LV relaxation
27
What exacerbates the failure of LV relaxation in LV end-diastolic dysfunction?
Tachycardia
28
What is seen in HFpEF despite having only a modestly depressed LV systolic function?
Profound exercise intolerance
29
How do delays in LV relaxation affect coronary artery compression?
Prolong compression
30
How does prolonged compression of coronary arteries contribute to LV end-diastolic dysfunction?
Restricts diastolic coronary blood flow
31
What does restricted diastolic coronary blood flow contribute to in LV end-diastolic dysfunction?
Subendocardial ischemia
32
What are the most common symptoms associated with HF?
fatigue, tachypnea, dyspnea at rest or exertion, paroxysmal nocturnal dyspnea, orthopnea, S3 gallop, JVD, peripheral edema, exercise intolerance, reduced tissue perfusion
33
Which symptoms are more common with HFpEF?
paroxysmal nocturnal dyspnea, pulmonary edema, dependent edema
34
Which symptom is more common with HFrEF?
S3 gallop
35
How is the diagnosis of HFpEF more challenging compared to HFrEF?
Initial diagnosis is often more difficult, especially when patient is asymptomatic or only mildly symptomatic at rest
36
What does a mean pulmonary capillary occlusion pressure >15mmHg at rest or 25mmHg during exercise indicate?
Strong evidence of HFpEF and predictor of mortality
37
What may a chest X-ray detect in the diagnosis of heart failure?
Pulmonary disease, cardiomegaly, pulmonary venous congestion, pulmonary edema
38
What is an early radiographic sign of left ventricular failure and associated pulmonary venous hypertension?
Distention of pulmonary veins in the upper lobes
39
What does perivascular edema appear as on a chest X-ray in heart failure?
Hilar or perihilar haze
40
What are Kerley lines in heart failure?
Reflect edematous interlobular septae, honeycomb pattern
41
How does alveolar edema appear on a chest X-ray in heart failure?
Homogeneous densities in butterfly pattern
42
What are the diagnostic criteria for HFpEF according to ACC/AHA?
HF sx, EF >50%, evidence of LVDD
43
What are the limitations of the ACC/AHA criteria for HFpEF diagnosis?
May be simplistic for subclinical HFpEF
44
What does the ESC diagnostic criteria for HFpEF involve?
Specific echocardiographic indices based on 2D measurements
45
How does ESC differ from ACC/AHA in their approach to HFpEF diagnosis?
Relies entirely on resting echocardiographic assessment
46
Why are ESC guidelines limited in HFpEF diagnosis?
Do not incorporate provocative testing
47
What EKG abnormalities are common in patients with heart failure?
LVH, previous MI, arrhythmias, conduction abnormalities
48
What is the predictive value of EKG alone in diagnosing heart failure?
Low predictive value
49
What are the important biomarkers used in heart failure diagnosis?
BNP & NT-proBNP
50
What are brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) concentrations related to in heart failure?
LV end-diastolic wall stress
51
What type of LV remodeling is common in HFrEF?
Eccentric remodeling
52
What type of LV remodeling is common in HFpEF?
Concentric hypertrophy
53
What laboratory marker reflects the inflammatory component of heart failure?
CRP and GDF15
54
What are the two classification systems for HF?
NYHA and ACC/AHA
55
What aspect does the NYHA classification focus on?
Degree of limitation during physical activity
56
What type of information does the ACC/AHA classification provide?
Presence and severity of the disease
57
Why is it important to note that the stages of HF are progressive?
Linked to reduced 5-year survival
58
How are patients often classified in terms of HF?
Combination of both scoring systems
59
What is the difference in mortality trends between patients with HFrEF and HFpEF?
HFrEF improving, HFpEF unchanged
60
What is the approach to medication treatment in HFpEF patients?
Relatively futile
61
What type of patients benefit from medication treatments in heart failure?
HFrEF patients
62
What is the treatment approach for HFpEF?
Mitigate symptoms, treat associated conditions, exercise, weight loss
63
Which medications are commonly used in treating HFrEF?
Β-blockers and ACE-inhibitors
64
What are loop diuretics recommended for in chronic HF treatment?
Reduce LV filling pressures, decrease pulmonary venous congestion, improve HFpEF/HFrEF sx
65
In which patients can thiazide diuretics be useful to prevent the onset of HFpEF?
Pts with poorly controlled HTN
66
Beta-Blockers are strongly recommended for which type of HF?
HFrEF
67
Is the benefit of Beta-Blockers clearly established for HFpEF?
Benefit not clearly established
68
What are the mainstay treatments for HFrEF?
ACE-inhibitors and ARBs
69
In which type of heart failure do studies not show benefit for ACE-inhibitors and ARBs unless used for treatment of HTN?
HFpEF
70
How does aerobic fitness impact patients with heart failure?
Reduces symptoms and increases quality of life
71
What major risk factors for heart failure can weight loss help mitigate?
HTN & DM
72
What does the DASH diet improve in patients with HFpEF?
LV diastolic function, decreases arterial stiffness, and facilitates more favorable LV-arterial coupling
73
What should be controlled in patients with heart failure?
HTN and blood glucose
74
What is the goal of surgical treatment for chronic heart failure?
Prevent ventricular remodeling
75
How can coronary revascularization help in chronic heart failure?
Reverse LV dysfunction
76
What can successful early revascularization prevent in chronic heart failure?
Permanent EF reductions
77
How much does CABG reduce 10-year mortality in chronic heart failure?
By 7%
78
What is cardiac resynchronization therapy (CRT) also known as?
'Biventricular pacing'
79
When is CRT recommended for patients with chronic heart failure?
NYHA class III or IV disease, EF < 5%, QRS duration 120-150 ms
80
What benefits do patients who undergo CRT experience?
Fewer HF symptoms, better exercise tolerance, improved ventricular function, fewer hospitalizations, decreased mortality
81
What are some risks associated with cardiac resynchronization therapy (CRT)?
Infection, misplacement, device failure
82
What is the purpose of implantable hemodynamic monitoring in chronic heart failure?
Observe changes in intracardiac pressures to prevent decompensation
83
How does the CardioMEMS Heart Failure system help manage heart failure?
Measuring LV filling pressures for medication titration
84
What is the main function of implantable cardioverter-defibrillators (ICDs) in heart failure?
Prevent sudden death
85
What percentage of heart failure deaths are attributed to sudden cardiac dysrhythmias?
Approximately 50%
86
What is the benefit of LV assist devices for patients in the terminal stages of heart failure?
Increased survival and improved quality of life
87
What can LV assist devices do in patients with heart failure?
Take over partial or total function of the damaged ventricle
88
When are LVADs used for temporary ventricular assistance?
While heart is recovering its function
89
What is the primary function of a continuous-flow LVAD?
To pump blood from left ventricle to aorta
90
What components are included in a continuous-flow LVAD?
Motor, pump housing, outlet stater, diffuser, rotor, inlet stator, blood-flow straightener
91
How is the blood flow in a continuous-flow LVAD described?
Perpetual
92
What is chronic heart failure classified as?
Long-standing disease
93
How is acute heart failure characterized?
Rapid onset, life-threatening
94
What is the treatment goal for acute heart failure?
Decrease volume, stabilize hemodynamics
95
What does ADHF stand for and what are its symptoms?
Acute decompensated heart failure, fluid retention, weight gain, dyspnea
96
What is de novo AHF characterized by?
Sudden increase in intracardiac filling pressures, acute myocardial dysfunction
97
What is the leading cause of de novo heart failure?
Cardiac ischemia
98
What are some nonischemic causes of de novo heart failure?
Viral, drug-induced, peripartum cardiomyopathy
99
How is management of de novo heart failure focused?
Stabilizing hemodynamics & restoring myocardial perfusion
100
What might de novo heart failure lead to in the long term?
Long-term cardiac dysfunction
101
What may allow for complete restoration of myocardial function in de novo heart failure?
Management of underlying cause
102
What are the first-line treatment for Acute Heart Failure (AHF)?
Diuretics
103
What should be given immediately in patients with fluid overload to mitigate symptoms and reduce mortality?
Diuretics
104
What may AHF patients with hypotension or cardiogenic shock require prior to diuretic therapy?
Hemodynamic support
105
Which medications like furosemide, bumetanide, and torsemide can be given as bolus or continuous infusions in AHF?
Loop diuretics
106
What do loop diuretics cause the release of and decrease in AHF patients?
Prostaglandins and acute pulmonary edema
107
How do pharmacologic agents increase cAMP?
Increase intracellular calcium
108
What is the result of increased cAMP?
Efficient excitation-contraction coupling
109
Why do different inotropic agents have unique side effects?
Due to different mechanisms of increasing cAMP
110
How do catecholamines interact with β-receptors on the myocardium?
Activate adenylyl cyclase to increase cAMP
111
How do PDE-inhibitors (milrinone) increase cAMP levels?
Inhibiting its degradation
112
What is Nesiritide?
Recombinant BNP
113
How does Nesiritide work?
Inhibits RAAS, promotes vasodilation
114
What effects does Nesiritide have on LVEDP?
Decreases it
115
What are some effects of Nesiritide?
Induces diuresis and natriuresis, relaxes cardiac muscle
116
Is Nesiritide superior to traditional vasodilators?
No
117
When is urgent mechanical circulatory support (MCS) indicated in AHF?
When medical management fails and organ dysfunction is present.
118
What does the Inter-agency Registry of Mechanically Assisted Circulatory Support (INTERMACS) assist in?
MCS decision-making process.
119
How does the Intraaortic Balloon Pump work?
Balloon inflation after aortic valve closure, deflation during systole
120
What does the IABP significantly improve?
LV coronary perfusion
121
What are the primary methods for evaluating placement of IABP?
TEE and x-ray
122
How does the support provided by IABP vary?
Set augmentation volume, balloon size, supported beats ratio
123
What indicates full support in IABP?
1:1 ratio (one inflation for every heartbeat)
124
What is the ideal setting for tachycardic patients using IABP?
1:2 ratio (one inflation per every two heartbeats)
125
What improvements does IABP offer in cardiac output?
0.5-1 L/min
126
What limitation does IABP have in terms of long-term use?
Generally immobilizes patients
127
What is Impella?
VAD for reducing LV strain in acute heart failure
128
How is Impella placed?
Via the femoral artery under fluoroscopy or TEE guidance
129
What is the purpose of Impella?
Transition to recovery or a bridge to cardiac procedures
130
What types of surgical AHF treatment are there?
Peripheral VAD/ECMO and Central VAD/ECMO
131
What is the difference between ECMO and VAD devices?
ECMO devices have an oxygenator in-line, while VAD devices do not
132
Where are cannulas placed for central ECMO?
Right atrium (outflow) and aorta (inflow)
133
What are the benefits of central ECMO?
Ventricular decompression, limb impairment avoidance, SVC syndrome avoidance
134
What effect does ECMO have on lung perfusion?
Reduced lung perfusion
135
How does ECMO affect the use of INH anesthetics?
INH anesthetics are limited
136
What anesthesia should be considered for patients on ECMO?
TIVA
137
Why do many agents, including fentanyl, become sequestered within the ECMO circuit?
The ECMO membrane is lipophilic
138
What is an alternative approach for biventricular support in AHF surgical treatment?
Centrally cannulate right and left sides separately
139
How can separate circuits for biventricular support be achieved in AHF surgical treatment?
Percutaneous placement of ProtekDuo and Impella
140
Why may it be desirable to decouple support of the ventricles with two independent circuits in AHF surgical treatment?
To allow for weaning of either side
141
What are some risks that heart failure patients have in the preoperative period?
Renal failure, sepsis, pneumonia, cardiac arrest
142
What should all patients with known heart failure undergo before surgery?
Comprehensive exam for compensation
143
What signs may suggest volume overload in a patient with heart failure?
Elevated JVP, S3/S4 gallop, peripheral edema
144
When should surgery be postponed in heart failure patients?
Decompensated state, recent change in status, de novo acute heart failure
145
Should diuretics be held the day of surgery for heart failure patients?
Yes
146
Why is maintaining beta-blocker therapy essential for heart failure patients?
Reduces perioperative morbidity and mortality
147
Are ACE-inhibitors recommended for perioperative use in heart failure patients?
May put patients at risk of intraoperative hypotension
148
What does the 2014 ACC/AHA guidelines recommend regarding cardiovascular therapy during the perioperative period?
Maintain therapy
149
When is a transthoracic echocardiogram indicated during preoperative evaluation in heart failure patients?
Worsening dyspnea
150
Is a chest X-ray routinely recommended for preoperative heart failure evaluation?
No
151
Which labs are recommended for preoperative assessment in heart failure patients?
CBC, Electrolytes, liver function, coags
152
Is BNP routinely recommended for preoperative heart failure evaluation?
No
153
What should be done with ICDs and pacemakers during preoperative management of heart failure?
Interrogated
