Heart Failure Flashcards
How many Americans have heart failure?
5 million
Heart failure is primarily a disease of ____.
aging
75% of new cases occur in individuals over __ years of age
65
The prevalence of heart failure rises from < 1% in individuals below 60 years to nearly 10% in those over __ years of age
80
What are the symptoms of left heart failure?
- dyspnea (predominant feature)
- low cardiac output
- elevated pulmonary venous pressure
What symptoms predominate in right heart failure?
fluid retention
What is the primary cause of right heart failure?
LV dysfunction
Approximately half of patients with heart failure have preserved left ventricular systolic function but have ______ dysfunction
diastolic
What is the common cause of systolic dysfunction?
Coronary artery disease (CAD) with resulting myocardial infarction and loss of functioning myocardium
Systolic function of the heart and resulting cardiac output is governed by what four major determinants?
- the contractile state of the myocardium
- the preload of the ventricle
- the afterload applied to the ventricles
- heart rate
What is the preload of the ventricle resultant of?
The end-diastolic volume and the resultant fiber length of the ventricles prior to onset of the contraction
What 2 things can cause an increased impedance to left ventricular ejection (afterload)?
- aortic stenosis
- severe HTN
What does elevated diastolic pressure in the left ventricle cause?
High-output heart failure
High-output heart failure patients have ____ systolic function.
normal
With time, the overload associated with high-output heart failure causes what?
systolic failure
What 5 diseases/disorders can cause high-output heart failure?
- thyrotoxicosis
- severe anemia
- arteriovenous shunting (including dialysis fistulas)
- Paget disease of bone
- thiamine deficiency (beriberi
What do chest images of high-output heart failure patients show?
An enlarged heart and pulmonary venous congestion
What is the most common cause of diastolic dysfunction?
left ventricular hypertrophy
The abnormal filling associated with diastolic dysfunction is due to what?
- impaired myocardial relaxation
- noncompliant chamber due to excessive hypertrophy or changes in the composition of the myocardium
In diastolic dysfunction diastolic pressures are elevated and cardiac output is ____
reduced
What does the decreased cardiac output associated with diastolic dysfunction cause?
- fluid retention
- dyspnea
- exercise intolerance
Diastolic dysfunction comprises about __% of all clinical heart failure and is especially common in the elderly
50%
HF leads to _____ stroke volume which leads to a(n) ______ in end-diastolic volume and pressure
decreased
increase
An increased end-diastolic volume leads to an increase in myocardial fiber length which results in _____ systolic shortening. Due to what law?
greater
Starling law of the heart
Chronic elevation of diastolic pressures will be transmitted to the atria and to the pulmonary and systemic venous circulation, resulting in what?
pulmonary or systemic edema
Reduced cardiac output can lead to reductions in arterial pressure and perfusion to what organs?
the kidneys
Reduced perfusion to the kidneys will activate what?
several neural and humoral systems
Increased sympathetic nervous system activity leads to _______ myocardial contractility, HR, and venous tone
increased
This increase in myocardial contractility, heart rate, and venous tone precipitates what?
ischemia (inadequate blood supply to the heart muscles)
Increased sympathetic nervous system activity leads to _______ peripheral vascular resistance
increased
Increased sympathetic nervous system activity initiates a series of myocellular events that contribute to what?
adverse ventricular remodelling and progressive ventricular dysfunction
What does an increased preload lead to?
worsened pulmonary congestion
Reduced cardiac output leads to a _____ in renal blood flow, which leads to _____ glomerular filtration rate, which leads to what?
reduction
decreased
sodium and fluid retention
Sodium and fluid retention leads to activation of what system?
Renin-angiotensin-aldosterone system
The renin-angiotensin-aldosterone system increases what 3 things?
- peripheral vascular resistance
- LV afterload
- sodium and fluid retention
Heart failure leads to _____ vasopressin levels which leads to what?
increased
vasoconstriction and inhibition of water excretion
Heart failure is characterized by _ hemodynamic derangements
2
Describe the first hemodynamic derangement associated with heart failure
A reduction in cardiac reserve, or in other words a reduction in the ability to increase cardiac output in response to increased demands imposed
Describe the second hemodynamic derangement associated with heart failure
Elevation of ventricular diastolic pressures
Elevated ventricular diastolic pressures is the primary derangement in _____ heart failure, but the secondary derangement in _____ heart failure.
diastolic
systolic
What 3 things can cause systolic heart failure?
- HTN
- Dilated or congestive cardiomyopathy
- Valvular heart disease
What 6 things can cause systolic heart failure?
- LVH
- Hypertrophic or restrictive cardiomyopathy
- Diabetes
- Pericardial disease
- Atrial fibrillation with or without rapid ventricular rate
- Aging
There are _ stages of heart failure
4 (A, B, C, and D)
Describe stage A heart failure
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
What are some examples of stage A heart failure?
- systemic hypertension
- coronary heart disease
- diabetes mellitus
- history of cardiotoxic drug therapy or alcohol abuse
Describe stage B heart failure
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
What are some examples of stage B heart failure?
- left ventricular hypertrophy or fibrosis
- left ventricular dilation or hypocontractility
- asymptomatic valvular heart disease
- previous MI
Describe stage C heart failure
These are the patient who have current or prior symptoms of heart failure associated with underlying structural heart disease
What are some examples of stage C heart failure?
- dyspnea or fatigue due to left ventricular systolic dysfunction
- asymptomatic patients who are undergoing treatment for poor symptoms of heart failure
Describe stage D heart failure
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
What are the symptoms of left heart failure?
- SOB (exertional dyspnea)
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Rest dyspnea
- Cough that is worse in the recumbent position
- Nocturia
- Fatigue
- Exercise intolerance
What are the symptoms of right heart failure?
- Fluid retention (edema)
- Hepatic congestion
- Loss of appetite
- Nausea
- Ascites
Right heart failure is often indistinguishable from what?
cor pulmonale
What is cor pulmonae?
Enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs
What 7 things may cause an acute exacerbation of chronic stable heart failure?
- alterations in therapy (or patient noncompliance)
- excessive salt and fluid intake
- arrhythmias
- excessive activity
- pulmonary emboli
- intercurrent infection
- progression of the underlying disease
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?
- class I (asymptomatic)
- class II (symptomatic with moderate activity)
- class III (symptomatic with mild activity)
- class IV (symptomatic at rest)
Some patients with heart failure may appear comfortable at rest while others appear what?
dyspneic during conversation or minor activity
How do patients with long standing severe heart failure appear?
Cachetic or cyanotic
What vital sign abnormalities are present in patients with heart failure?
- tachycardia
- hypotension
- reduced pulse pressure
These patients have increased ______ nervous system activity that presents as what?
sympathetic
cold extremities or diaphoresis
What are the pulmonary signs of heart failure?
- Crackles at the base of the lungs
- Pleural effusion that causes bibasilar dullness to percussion
- Expiratory wheezing and rhonchi
Patients with severe right heart failure have a positive hepatojugular reflux greater than 1 cm, what does this mean?
There is distension of the neck veins precipitated by firm pressure over the liver
What are the cardinal cardiac examination signs?
- parasternal lift
- enlarged and sustained LV impulse
- diminished first heart sound
- S3 gallop
- S4 in a diastolic heart failure patient
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
True
What 2 blood count findings have poor prognostic value in heart failure patients?
- anemia
- high RBC distribution width (RDW)
Chronic _____ disease is a poor prognostic factor in heart failure
kidney
What does hypokalemia increase the risk of?
arrhythmias
What does hyperkalemia limit the use of?
inhibitors of the renin-angiotensin system
What is hyponatremia an indicator of?
marked activation of the renin-angiotensin system
Thyroid tests should be assessed to detect what?
occult thyrotoxicosis or myxedema
Iron studies should be assessed to test what?
hemochromatosis
Why may a myocardial biopsy be required?
to rule out the diagnosis of amyloidosis
Serum ___ is a powerful prognostic factor that adds to clinical assessment in differentiating dyspnea due to heart failure and from noncardiac diseases
BNP (Brain Natriuretic Peptide)
When is BNP elevated?
when ventricular filling pressures are high
In what type of patients is BNP sensitive to?
patients with symptomatic heart failure
In what type of patients is BNP not sensitive to?
older patients, women, and patients with COPD
Elevation of serum _______ is common in both chronic and acute heart failure, and is associated with higher risk of adverse outcomes?
troponin
ECGs indicate what 6 things associated with heart failure?
- Secondary arrhythmias
- MI
- Low voltage
- Intraventricular conduction defects
- LVH
- Nonspecific repolarization changes
What is a poor prognostic factor found on chest radiographs?
cardiomegaly (abnormal enlargement of the heart)
Evidence of pulmonary venous hypertension includes what 4 things?
- relative dilation of the upper lobe veins
- perivascular edema (haziness of vessel outlines)
- interstitial edema
- alveolar fluid
True or False
Patients with chronic heart failure may show relatively normal pulmonary vasculature on chest radiograph despite markedly elevated pressures
True
What 2 stress imaging procedures are often indicated?
- dobutamine echocardiogram (most useful)
- perfusion scintigraphy
What does the echocardiogram reveal?
the size and function of both ventricles and of the atria
What does radionuclide angiography measure?
LV ejection fraction and permits analysis of regional wall motion
When is stress testing indicated?
when myocardial ischemia is suspected cause of LV dysfunction
What is cardiac catherterization helpful in defining?
the presence and extent of CAD
What are 3 reversible causes of heart failure?
- CAD
- HTN
- valvular lesions
What 4 drugs should be avoided because they may contribute to worsening heart failure?
- Calcium channel blockers (specifically verapamil or diltiazem)
- antiarrhythmic drugs
- thiazolidinediones
- nonsteroidal anti-inflammatory agents
What are 3 metabolic and infiltrative cardiomyopathies may be partially reversible, or their progression may be slowed?
- hemochromatosis
- sarcoidosis
- amyloidosis
What should be the initial treatment in most symptomatic patients with heart failure and reduced LV EF?
A combination of a diuretic and an ACE inhibitor with early addition of a beta-blocker
What are 6 pharmacologic treatment options?
- diuretic therapy
- inhibitors of the renin-angiotensin-aldosterone system
- beta-blockers
- digital glycosides
- vasodilators
- ivabradine
What are the most effective means of providing symptomatic relief to patients with moderate to severe HF?
Diuretics
What type of diuretic should be used when fluid retention is mild?
Thiazide diuretics (hydrochlorothiazide or Metolazone)
Patients with more severe HF should be treated with what type of diuretics?
oral loop diuretics (furosemide, bumetanide, and torsemide)
Oral _____-sparing agents are often useful in combination with the loop and thiazide diuretics
potassium
What do triamterene and amiloride (2 potassium-sparing agents) do?
Act on the distal tubule to reduce potassium secretion
What do spironolactone and eplerenone (2 potassium-sparing agents) do?
they inhibit aldosterone
What are 3 inhibitors of the renin-angiotensin-aldosterone system?
- ACE (angiotensin converting enzyme) inhibitors
- Angiotensin II receptor blockers
- aldosterone inhibitors
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
20%
What is a significant concern when administering ACE inhibitors?
hypotension (systolic <100)
What are 4 types of ACE inhibitors?
- captopril
- enalapril
- ramipril
- lisinopril
Angiotensin II receptor blockers provide more complete blockade of the ___ receptor
AT1
What are 2 types of ARBs?
- candesartan
- valsartan
What are 2 aldosterone inhibitors?
- Spironolactone
- Eplerenone
What is a major concern of all inhibitors of the renin-angiotensin-aldosterone system?
hyperkalemia (high potassium in the blood)
What do beta blockers do?
produce consistent substantial rises in EF and reductions in LV size and mass
What are 3 examples of beta blockers?
- carvedilol
- metoprolol succinate
- bisoprolol
What type of heart failure patients should be treated with a beat-blocker?
stable patients
What are 2 adverse side-effects of beta blockers?
dizziness and hypotension
Digitalis glycosides work as inhibitors of what?
the sodium-potassium pump
What 4 drugs increase levels of digoxin?
- amiodarone
- quinidine
- propafenone
- verapamil
What do vasodilators do to help treat HF?
Reduce cardiac preload and afterload by achieving both venous and arterial vasodilation
What are 2 types of vasodilators used for HF patients? What vascular structure does each dilate?
- Hydralazine: dilates arteries
- Nitrates: dilates veins
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.
warfarin
What are 5 nonpharmacologic treatment options for patients with HF?
- Implantable cardioverter defibrillators
- Biventricular pacing (resynchronization)
- Case management, diet and exercise training
- Coronary revascularization
- Cardiac transplantation
The 1 year survival rate for heart transplant patients is __-__% and the 5 year survival is __%
80-90
70
What is the 5 year mortality rate for patients with heart failure?
50%
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
5
30
Higher mortality rates are related with what?
- older age
- lower LV EF
- more severe symptoms
- chronic kidney disease
- diabetes
