Heart Failure Flashcards
Systolic Heart Failure heart shape
Big, globular, larger volume
Diastolic HF heart shape
Normal shape, thicker, has problems with eccentric relaxation
High-Output cardiac failure pathophysiology
Peripheral vascular resistance is detected as being lower so the body holds onto more salt
Low-output cardiac failure pathophys
Body reads low cardiac output
Drivers of these changes
Maintaining MAP for brain and kidneys
Cornerstone of therapy
Volume control
Can HF get better?
Yes, you can take them out of HF.
New York Heart Association Class
Know this for presentations.
Class I: normal exercise tolerance
Class II: symptoms with ordinary exertion
Class III: symptoms with only mild exertion
Class IV: symptom at rest
EF and disease class relationship
There is no association
ACC/AHA 2001 Guideline for Stages
Stage A: High risk (no HF): HTN, CAD, DM, FH of CM
Stage B: Asymptomatic HF: Previous MI, LV systolic dysfunction (no symptoms), asymptomatic valvular disease
Stage C: Symptomatic: Known heart disease, SOB and fatigue, reduced exercise tolerance
Stage D: Refractory end-stage HF: Can’t improve symptoms or can’t sustain improvements
Systolic/Diastolic dysfunction and Staging
Both forms of dysfunction follow the same Stages.
Do Stages change?
No, once you are Stage C you will always be stage C or worse. The Classes can change, the stages can’t.
Number 1 goal for management
Stabilizing patient (symptom relief), then stabilize the disease
What causes dyspnea
Elevated LV end diastolic pressure / PCW pressure
What causes exercise intolerance
Inability to increase cardiac output
What happens to SVR during exercise
It goes down as muscles fill with blood
Fatigue cause
Decreased CO
What causes edma
Increased venous pressure/sodium retention
Neurohormonal activation
Sympathetics and Renin-Angiotensin System
Causes of decompensation
Infection: 1 degree C increase causes 10-15% increase of O2 consumption
Infarction/Ischemia
Indiscretion: too much salt
Iatrogenesis: NSAIDs effect on kidneys can cause decompensation. CCBs are bad for systolic dysfunction.
Narrow pulse pressure means
Means diminished stroke volume. Systolic is lower and diastolic is higher because of increased End diastolic volume)
Most reliable sign of volume overload
JVD
Right sided HF signs
Elevated JVP, edema, ascites/pulsatile liver, tachy, hypotension with severe disease (low preload)
Left sided HF signs
Dyspnea, orthopnea, Paroxsymal nocturnal dyspnea, rales, presence of S3, tachy, narrow pulse pressure, hypotension
BNP use
Useful in general medicine, can distinguish the heart from the lungs. Not useful in established disease.
Most useful diagnostic test
2D echo
Where do you biopsy the heart?
The septum to avoid perforation leading to tamponade
Why biopsy
Hemochromatosis, amyloidosis, sarcoidosis (infiltrative cardiomyopathies)
Giant-cell myocarditis
Auto-immune, elevated troponin with normal arteries
Does EF tell you how bad the disease is?
No, no association
Volume Status vs. Perfusion
Wet and Warm: Diuretic, Vasodilators
Wet and Cold: Inotropes, vasodilators, diuretic
Dry and Warm: Optimize chronic medical therapy
Dry and Cold: Inotropes
Touch the patients to determine if they are warm or cold
Measure of perfusion
Mental status, peripheral warmth, cap refill, urine output
Measures of Volume Status
JVP, peripheral edema,
High afterload on the failing heart
Increased SVR to keep up perfusion hurts the heart in the long run.
Vasodilating does what in HF
Decreases afterload, can increase CO.
When people are wet can you use vasodilators?
Yes, they have a ton of preload so vasodilating is a good thing
How to tell someone is dry
Low JVP
How to treat someone who is cold and dry
Inotropes
When patients are wet tx
Vasodilators and diuretics, inotropes for Cold
How to treat the Stage B patients
Give them beta-blockers and ACEIs to prevent disease progression to symptomatic disease
Stage C patients tx
Most patients in the hospital. All patients get ACEI or ARB and Beta blocker, then follow subsequent guidelines
Diuretics and natural history
Make you feel better but have no effect on natural history
ACEIs and mortality
Reduce death and hospitalizations
Beta blockers and mortality
Reverse remodeling and decrease mortality
Beta blockers contraindication
Do not give to people who are acutely decompensated, they will go into shock
ARBs
Decrease mortality, delay remodeling
Digoxin
Symptoms improve, mortality doesn’t
Spironolactone/Epleronone
Saves lives
Hydralizine
Vasodilator
Nitrates
Venodilator
Cardiac-Resynchronization Therapy for Heart Failure
Synchronizes ventricles to decrease mortality in patients with LBBB. The lead isn’t in the Left ventricle, it wraps around the outside
Drugs for diastolic HF
There are no drugs, all the drugs are for systolic HF
