Heart Failure Flashcards
Myocardial diseases may include
- Systolic dysfunction (lack of vigor)
- Diastolic dysfunction (compliance)
State where heart cannot deliver cardiac output that matches the requirements of the metabolic demands of the tissues
Heart Failure
Symptoms of heart failure
Relating to decreased forward flow:
- Exertional fatigue
- Hypotension
NYHA Class 1
No symptoms with ordinary activity
BNP/pro-BNP as indicator for SOB
Low levels - not heart failure
Elevated levels consistent with heart failure
May help guide therapy!
Two ways to improve oxygen supply
- Increase cardiac output
- Strip more oxygen off
Physical exam findings
Vital signs: narrowed pulse pressure, relative tachycardia at rest (trying to support CO with diminished SV); elevated respiratory rate (reaction to pulmonary congestion)
NYHA Functional Classification applies to
Symptoms due to angina or due to heart failure –> Can change between classes
NYHA Class III
Symptoms with less than ordinary activity
Decreased ejection fraction is characteristic of _______ myocardial dysfunction
SYSTOLIC myocardial dysfunction
+ S3 gallop
NYHA Class II
Symptoms with ordinary activity
S3 gallop is characteristic of
Systolic dysfunction
Approaching heart failure:
1) What is underlying cause?
2) Why did symptoms come on?
NYHA Class IV
Symptoms at rest, any physical activity
Left sided physical exam findings in heart failure
Crackles/wheezing, especially at bases posteriorly, d/t pulmonary congestion
Sometimes apical S3 gallop
Systolic dysfunction hallmarks:
- Enlarged end-diastolic volume
- Cardiomegaly on CXR
- Poor contractility
- Decreased ventricular ejection fraction
- S3 gallop (lub-dub)
- Elevated end-diastolic pressure
Right sided physical exam findings in heart failure
Dependent edema
Ascites if severe
Elevated JVP/positive HJ reflex
Non-compliant ventricles are characteristic of
Diastolic dysfunction (stiffer ventricle)
Chest X Ray findings in heart failure
May show cardiomegaly (not diagnostic of heart failure)
Etiology of HF
- Arrhythmia (3rd degree block)
- Myocardial disease
- Mechanical causes
Echocardiography in heart failure
Systolic and/or diastolic dysfunction with/without ventricular hypertrophy with/without valve abnormality
Diastolic dysfunction hallmarks:
- Normal end-diastolic volume
- Minimal/no cardiomegaly
- Normal contractility
- Decreased compliance
- Normal ventricular ejection fraction
- S4 gallop (a-dup-op)
- High end-diastolic pressure
Mechanical causes of heart failure
- Pressure overload/increased afterload resistance (stenosis/HTN)
- Volume overload/increased preload (insufficiency/shunt)
- Pericardial
- — Cardiac tamponade (acute)
- — Constrictive pericarditis (chronic)
Aldosterone Antagonists for HF
Spironolactone
Eplerenone
(Caution! esp Renal insufficiency or baseline hyperkalemia)
Drugs to avoid in systolic heart failure
Anti-arrhythmic drugs
Calcium channel blockers
Nonsteroidal Anti-inflammatory drugs
If low ejection fraction, particularly high risk of
Sudden cardiac death
Precipitating causes of heart failure
- Pathological ‘high output states’
(fever/infection, anemia, pregnancy, thyrotoxicosis) - Intercurrent ‘stresses/demands’
(physical/dietary, arterial HTN, PE) - New direct cardiac insults
(valvular/endocarditis/rupture, myocardial infarction/myocarditis, arrhythmia)
Approved Beta Blockers for HF
Carvedilol
Metoprolol
Also useful for Diastolic HF by controlling rapid rate
Treatment for Stage C disease
Control risk factors Salt restriction Dieuretics for symptoms ACE-I's (or ARBs) Beta-blockers
If wide QRS (bundle branch block) this can help
bi-ventricular pacemaker
Initial Lab Workup of new HF
EKG
CXR
CBC/Chem screen/TSH
Echocardiogram
ACE-Inhibitor Side effects
Orthostatic HypOtension HypERkalemia Increasing BUN/creatinine Angioedema Cough
NON-hypotensive (Normal BP) Pulmonary Edema Treatment
Oxygen!
IV morphine (dilatiation)
IV furosemide (diuretic)
Vasodilators/SLNG (take away afterload, get IV in)
Aminophylline (rare)
Digoxin (rare)
Classification of heart failure
A- high risk w/o disease
B- structural w/o disease
C- heart failure symptoms (current or past)
D- refractory HF
Cannot be reclassified
Use this if nothing else is working for symptoms
Digoxin
no survival benefit but improved QOL
Stage A Treatment
Fix risk factors!
Captopril (ACE-I) half life
Less than 3 hours
Usual ~12 hours
Drugs work particularly well in AA population
Isosorbide dinitrate + Hydralazine
Use of ACE-I
Start low
Titrate up slow (+ caution)
Adjust diuretic if BP down, BUN up
If K+ up, add Thiazide diuretic
Stage D management
hospice
transplant
Side effects include: Orthostatic hypOtension HypERkalemia Increasing BUN/Creatinine Angioedema Cough
ACE-Inhibitors
