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724: Medical Lectures > Heart Failure > Flashcards

Heart Failure Flashcards

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USMLE® Step 1 flashcards
1
Q

How many Americans have heart failure?

A

5 million

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2
Q

Heart failure is primarily a disease of ____.

A

aging

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3
Q

75% of new cases occur in individuals over __ years of age

A

65

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4
Q

The prevalence of heart failure rises from < 1% in individuals below 60 years to nearly 10% in those over __ years of age

A

80

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5
Q

What are the symptoms of left heart failure?

A
  • dyspnea (predominant feature)
  • low cardiac output
  • elevated pulmonary venous pressure
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6
Q

What symptoms predominate in right heart failure?

A

fluid retention

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7
Q

What is the primary cause of right heart failure?

A

LV dysfunction

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8
Q

Approximately half of patients with heart failure have preserved left ventricular systolic function but have ______ dysfunction

A

diastolic

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9
Q

What is the common cause of systolic dysfunction?

A

Coronary artery disease (CAD) with resulting myocardial infarction and loss of functioning myocardium

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10
Q

Systolic function of the heart and resulting cardiac output is governed by what four major determinants?

A
  • the contractile state of the myocardium
  • the preload of the ventricle
  • the afterload applied to the ventricles
  • heart rate
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11
Q

What is the preload of the ventricle resultant of?

A

The end-diastolic volume and the resultant fiber length of the ventricles prior to onset of the contraction

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12
Q

What 2 things can cause an increased impedance to left ventricular ejection (afterload)?

A
  • aortic stenosis

- severe HTN

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13
Q

What does elevated diastolic pressure in the left ventricle cause?

A

High-output heart failure

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14
Q

High-output heart failure patients have ____ systolic function.

A

normal

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15
Q

With time, the overload associated with high-output heart failure causes what?

A

systolic failure

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16
Q

What 5 diseases/disorders can cause high-output heart failure?

A
  • thyrotoxicosis
  • severe anemia
  • arteriovenous shunting (including dialysis fistulas)
  • Paget disease of bone
  • thiamine deficiency (beriberi
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17
Q

What do chest images of high-output heart failure patients show?

A

An enlarged heart and pulmonary venous congestion

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18
Q

What is the most common cause of diastolic dysfunction?

A

left ventricular hypertrophy

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19
Q

The abnormal filling associated with diastolic dysfunction is due to what?

A
  • impaired myocardial relaxation

- noncompliant chamber due to excessive hypertrophy or changes in the composition of the myocardium

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20
Q

In diastolic dysfunction diastolic pressures are elevated and cardiac output is ____

A

reduced

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21
Q

What does the decreased cardiac output associated with diastolic dysfunction cause?

A
  • fluid retention
  • dyspnea
  • exercise intolerance
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22
Q

Diastolic dysfunction comprises about __% of all clinical heart failure and is especially common in the elderly

A

50%

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23
Q

HF leads to _____ stroke volume which leads to a(n) ______ in end-diastolic volume and pressure

A

decreased

increase

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24
Q

An increased end-diastolic volume leads to an increase in myocardial fiber length which results in _____ systolic shortening. Due to what law?

A

greater

Starling law of the heart

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25
Q

Chronic elevation of diastolic pressures will be transmitted to the atria and to the pulmonary and systemic venous circulation, resulting in what?

A

pulmonary or systemic edema

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26
Q

Reduced cardiac output can lead to reductions in arterial pressure and perfusion to what organs?

A

the kidneys

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27
Q

Reduced perfusion to the kidneys will activate what?

A

several neural and humoral systems

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28
Q

Increased sympathetic nervous system activity leads to _______ myocardial contractility, HR, and venous tone

A

increased

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29
Q

This increase in myocardial contractility, heart rate, and venous tone precipitates what?

A

ischemia (inadequate blood supply to the heart muscles)

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30
Q

Increased sympathetic nervous system activity leads to _______ peripheral vascular resistance

A

increased

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31
Q

Increased sympathetic nervous system activity initiates a series of myocellular events that contribute to what?

A

adverse ventricular remodelling and progressive ventricular dysfunction

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32
Q

What does an increased preload lead to?

A

worsened pulmonary congestion

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33
Q

Reduced cardiac output leads to a _____ in renal blood flow, which leads to _____ glomerular filtration rate, which leads to what?

A

reduction

decreased

sodium and fluid retention

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34
Q

Sodium and fluid retention leads to activation of what system?

A

Renin-angiotensin-aldosterone system

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35
Q

The renin-angiotensin-aldosterone system increases what 3 things?

A
  • peripheral vascular resistance
  • LV afterload
  • sodium and fluid retention
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36
Q

Heart failure leads to _____ vasopressin levels which leads to what?

A

increased

vasoconstriction and inhibition of water excretion

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37
Q

Heart failure is characterized by _ hemodynamic derangements

A

2

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38
Q

Describe the first hemodynamic derangement associated with heart failure

A

A reduction in cardiac reserve, or in other words a reduction in the ability to increase cardiac output in response to increased demands imposed

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39
Q

Describe the second hemodynamic derangement associated with heart failure

A

Elevation of ventricular diastolic pressures

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40
Q

Elevated ventricular diastolic pressures is the primary derangement in _____ heart failure, but the secondary derangement in _____ heart failure.

A

diastolic

systolic

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41
Q

What 3 things can cause systolic heart failure?

A
  • HTN
  • Dilated or congestive cardiomyopathy
  • Valvular heart disease
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42
Q

What 6 things can cause systolic heart failure?

A
  • LVH
  • Hypertrophic or restrictive cardiomyopathy
  • Diabetes
  • Pericardial disease
  • Atrial fibrillation with or without rapid ventricular rate
  • Aging
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43
Q

There are _ stages of heart failure

A

4 (A, B, C, and D)

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44
Q

Describe stage A heart failure

A

These are the people that are at a high risk for developing heart failure because of the presence of conditions that are strongly associated with the development of heart failure

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45
Q

What are some examples of stage A heart failure?

A
  • systemic hypertension
  • coronary heart disease
  • diabetes mellitus
  • history of cardiotoxic drug therapy or alcohol abuse
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46
Q

Describe stage B heart failure

A

These are the patients who have developed structural heart disease that is strongly associated with the development of heart failure but who have never shown symptoms or signs

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47
Q

What are some examples of stage B heart failure?

A
  • left ventricular hypertrophy or fibrosis
  • left ventricular dilation or hypocontractility
  • asymptomatic valvular heart disease
  • previous MI
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48
Q

Describe stage C heart failure

A

These are the patient who have current or prior symptoms of heart failure associated with underlying structural heart disease

49
Q

What are some examples of stage C heart failure?

A
  • dyspnea or fatigue due to left ventricular systolic dysfunction
  • asymptomatic patients who are undergoing treatment for poor symptoms of heart failure
50
Q

Describe stage D heart failure

A

These are the patients with advanced structural heart disease and marked symptoms of heart failure at rest despite maximal medical therapy and who require specialized interventions

51
Q

What are the symptoms of left heart failure?

A
  • SOB (exertional dyspnea)
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Rest dyspnea
  • Cough that is worse in the recumbent position
  • Nocturia
  • Fatigue
  • Exercise intolerance
52
Q

What are the symptoms of right heart failure?

A
  • Fluid retention (edema)
  • Hepatic congestion
  • Loss of appetite
  • Nausea
  • Ascites
53
Q

Right heart failure is often indistinguishable from what?

A

cor pulmonale

54
Q

What is cor pulmonae?

A

Enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs

55
Q

What 7 things may cause an acute exacerbation of chronic stable heart failure?

A
  • alterations in therapy (or patient noncompliance)
  • excessive salt and fluid intake
  • arrhythmias
  • excessive activity
  • pulmonary emboli
  • intercurrent infection
  • progression of the underlying disease
56
Q

What is another classification of heart failure, but is rarely used due to its limitations in that patient reports are subjective and in that symptoms vary from day to day?

A
  • class I (asymptomatic)
  • class II (symptomatic with moderate activity)
  • class III (symptomatic with mild activity)
  • class IV (symptomatic at rest)
57
Q

Some patients with heart failure may appear comfortable at rest while others appear what?

A

dyspneic during conversation or minor activity

58
Q

How do patients with long standing severe heart failure appear?

A

Cachetic or cyanotic

59
Q

What vital sign abnormalities are present in patients with heart failure?

A
  • tachycardia
  • hypotension
  • reduced pulse pressure
60
Q

These patients have increased ______ nervous system activity that presents as what?

A

sympathetic

cold extremities or diaphoresis

61
Q

What are the pulmonary signs of heart failure?

A
  • Crackles at the base of the lungs
  • Pleural effusion that causes bibasilar dullness to percussion
  • Expiratory wheezing and rhonchi
62
Q

Patients with severe right heart failure have a positive hepatojugular reflux greater than 1 cm, what does this mean?

A

There is distension of the neck veins precipitated by firm pressure over the liver

63
Q

What are the cardinal cardiac examination signs?

A
  • parasternal lift
  • enlarged and sustained LV impulse
  • diminished first heart sound
  • S3 gallop
  • S4 in a diastolic heart failure patient
64
Q

True or False

In chronic heart failure, many of the expected signs of heart failure may be absent despite markedly abnormal cardiac function and hemodynamic measurements

A

True

65
Q

What 2 blood count findings have poor prognostic value in heart failure patients?

A
  • anemia

- high RBC distribution width (RDW)

66
Q

Chronic _____ disease is a poor prognostic factor in heart failure

A

kidney

67
Q

What does hypokalemia increase the risk of?

A

arrhythmias

68
Q

What does hyperkalemia limit the use of?

A

inhibitors of the renin-angiotensin system

69
Q

What is hyponatremia an indicator of?

A

marked activation of the renin-angiotensin system

70
Q

Thyroid tests should be assessed to detect what?

A

occult thyrotoxicosis or myxedema

71
Q

Iron studies should be assessed to test what?

A

hemochromatosis

72
Q

Why may a myocardial biopsy be required?

A

to rule out the diagnosis of amyloidosis

73
Q

Serum ___ is a powerful prognostic factor that adds to clinical assessment in differentiating dyspnea due to heart failure and from noncardiac diseases

A

BNP (Brain Natriuretic Peptide)

74
Q

When is BNP elevated?

A

when ventricular filling pressures are high

75
Q

In what type of patients is BNP sensitive to?

A

patients with symptomatic heart failure

76
Q

In what type of patients is BNP not sensitive to?

A

older patients, women, and patients with COPD

77
Q

Elevation of serum _______ is common in both chronic and acute heart failure, and is associated with higher risk of adverse outcomes?

A

troponin

78
Q

ECGs indicate what 6 things associated with heart failure?

A
  • Secondary arrhythmias
  • MI
  • Low voltage
  • Intraventricular conduction defects
  • LVH
  • Nonspecific repolarization changes
79
Q

What is a poor prognostic factor found on chest radiographs?

A

cardiomegaly (abnormal enlargement of the heart)

80
Q

Evidence of pulmonary venous hypertension includes what 4 things?

A
  • relative dilation of the upper lobe veins
  • perivascular edema (haziness of vessel outlines)
  • interstitial edema
  • alveolar fluid
81
Q

True or False

Patients with chronic heart failure may show relatively normal pulmonary vasculature on chest radiograph despite markedly elevated pressures

A

True

82
Q

What 2 stress imaging procedures are often indicated?

A
  • dobutamine echocardiogram (most useful)

- perfusion scintigraphy

83
Q

What does the echocardiogram reveal?

A

the size and function of both ventricles and of the atria

84
Q

What does radionuclide angiography measure?

A

LV ejection fraction and permits analysis of regional wall motion

85
Q

When is stress testing indicated?

A

when myocardial ischemia is suspected cause of LV dysfunction

86
Q

What is cardiac catherterization helpful in defining?

A

the presence and extent of CAD

87
Q

What are 3 reversible causes of heart failure?

A
  • CAD
  • HTN
  • valvular lesions
88
Q

What 4 drugs should be avoided because they may contribute to worsening heart failure?

A
  • Calcium channel blockers (specifically verapamil or diltiazem)
  • antiarrhythmic drugs
  • thiazolidinediones
  • nonsteroidal anti-inflammatory agents
89
Q

What are 3 metabolic and infiltrative cardiomyopathies may be partially reversible, or their progression may be slowed?

A
  • hemochromatosis
  • sarcoidosis
  • amyloidosis
90
Q

What should be the initial treatment in most symptomatic patients with heart failure and reduced LV EF?

A

A combination of a diuretic and an ACE inhibitor with early addition of a beta-blocker

91
Q

What are 6 pharmacologic treatment options?

A
  • diuretic therapy
  • inhibitors of the renin-angiotensin-aldosterone system
  • beta-blockers
  • digital glycosides
  • vasodilators
  • ivabradine
92
Q

What are the most effective means of providing symptomatic relief to patients with moderate to severe HF?

A

Diuretics

93
Q

What type of diuretic should be used when fluid retention is mild?

A

Thiazide diuretics (hydrochlorothiazide or Metolazone)

94
Q

Patients with more severe HF should be treated with what type of diuretics?

A

oral loop diuretics (furosemide, bumetanide, and torsemide)

95
Q

Oral _____-sparing agents are often useful in combination with the loop and thiazide diuretics

A

potassium

96
Q

What do triamterene and amiloride (2 potassium-sparing agents) do?

A

Act on the distal tubule to reduce potassium secretion

97
Q

What do spironolactone and eplerenone (2 potassium-sparing agents) do?

A

they inhibit aldosterone

98
Q

What are 3 inhibitors of the renin-angiotensin-aldosterone system?

A
  • ACE (angiotensin converting enzyme) inhibitors
  • Angiotensin II receptor blockers
  • aldosterone inhibitors
99
Q

ACE inhibitors reduce mortality by approximately __% in patients with symptomatic heart failure and have been shown also to prevent hospitalizations, increase exercise tolerance, and reduce symptoms in these patients

A

20%

100
Q

What is a significant concern when administering ACE inhibitors?

A

hypotension (systolic <100)

101
Q

What are 4 types of ACE inhibitors?

A
  • captopril
  • enalapril
  • ramipril
  • lisinopril
102
Q

Angiotensin II receptor blockers provide more complete blockade of the ___ receptor

A

AT1

103
Q

What are 2 types of ARBs?

A
  • candesartan

- valsartan

104
Q

What are 2 aldosterone inhibitors?

A
  • Spironolactone

- Eplerenone

105
Q

What is a major concern of all inhibitors of the renin-angiotensin-aldosterone system?

A

hyperkalemia (high potassium in the blood)

106
Q

What do beta blockers do?

A

produce consistent substantial rises in EF and reductions in LV size and mass

107
Q

What are 3 examples of beta blockers?

A
  • carvedilol
  • metoprolol succinate
  • bisoprolol
108
Q

What type of heart failure patients should be treated with a beat-blocker?

A

stable patients

109
Q

What are 2 adverse side-effects of beta blockers?

A

dizziness and hypotension

110
Q

Digitalis glycosides work as inhibitors of what?

A

the sodium-potassium pump

111
Q

What 4 drugs increase levels of digoxin?

A
  • amiodarone
  • quinidine
  • propafenone
  • verapamil
112
Q

What do vasodilators do to help treat HF?

A

Reduce cardiac preload and afterload by achieving both venous and arterial vasodilation

113
Q

What are 2 types of vasodilators used for HF patients? What vascular structure does each dilate?

A
  • Hydralazine: dilates arteries

- Nitrates: dilates veins

114
Q

In patients with atrial fibrillation or who have large recent anterior myocardial infarction, should generally be anticoagulated with what drug for 3 months following the myocardial infarction.

A

warfarin

115
Q

What are 5 nonpharmacologic treatment options for patients with HF?

A
  • Implantable cardioverter defibrillators
  • Biventricular pacing (resynchronization)
  • Case management, diet and exercise training
  • Coronary revascularization
  • Cardiac transplantation
116
Q

The 1 year survival rate for heart transplant patients is __-__% and the 5 year survival is __%

A

80-90

70

117
Q

What is the 5 year mortality rate for patients with heart failure?

A

50%

118
Q

Mortality rates vary from less than _% per year in those with no or few symptoms to greater than __% per year in those with severe and refractory symptoms

A

5

30

119
Q

Higher mortality rates are related with what?

A
  • older age
  • lower LV EF
  • more severe symptoms
  • chronic kidney disease
  • diabetes

724: Medical Lectures (42 decks)

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