Heart Failure

Question 1

Myocardial diseases may include

Answer 1

• Systolic dysfunction (lack of vigor)

- Diastolic dysfunction (compliance)

Question 2

State where heart cannot deliver cardiac output that matches the requirements of the metabolic demands of the tissues

Answer 2

Heart Failure

Question 3

Symptoms of heart failure

Answer 3

Relating to decreased forward flow:

• Exertional fatigue
• Hypotension

Question 4

NYHA Class 1

Answer 4

No symptoms with ordinary activity

Question 5

BNP/pro-BNP as indicator for SOB

Answer 5

Low levels - not heart failure
Elevated levels consistent with heart failure

May help guide therapy!

Question 6

Two ways to improve oxygen supply

Answer 6

• Increase cardiac output

- Strip more oxygen off

Question 7

Physical exam findings

Answer 7

Vital signs: narrowed pulse pressure, relative tachycardia at rest (trying to support CO with diminished SV); elevated respiratory rate (reaction to pulmonary congestion)

Question 8

NYHA Functional Classification applies to

Answer 8

Symptoms due to angina or due to heart failure –> Can change between classes

Question 9

NYHA Class III

Answer 9

Symptoms with less than ordinary activity

Question 10

Decreased ejection fraction is characteristic of _______ myocardial dysfunction

Answer 10

SYSTOLIC myocardial dysfunction

+ S3 gallop

Question 11

NYHA Class II

Answer 11

Symptoms with ordinary activity

Question 12

S3 gallop is characteristic of

Answer 12

Systolic dysfunction

Question 13

Approaching heart failure:

Answer 13

1) What is underlying cause?

2) Why did symptoms come on?

Question 14

NYHA Class IV

Answer 14

Symptoms at rest, any physical activity

Question 15

Left sided physical exam findings in heart failure

Answer 15

Crackles/wheezing, especially at bases posteriorly, d/t pulmonary congestion

Sometimes apical S3 gallop

Question 16

Systolic dysfunction hallmarks:

Answer 16

• Enlarged end-diastolic volume
• Cardiomegaly on CXR
• Poor contractility
• Decreased ventricular ejection fraction
• S3 gallop (lub-dub)
• Elevated end-diastolic pressure

Question 17

Right sided physical exam findings in heart failure

Answer 17

Dependent edema
Ascites if severe
Elevated JVP/positive HJ reflex

Question 18

Non-compliant ventricles are characteristic of

Answer 18

Diastolic dysfunction (stiffer ventricle)

Question 19

Chest X Ray findings in heart failure

Answer 19

May show cardiomegaly (not diagnostic of heart failure)

Question 20

Etiology of HF

Answer 20

• Arrhythmia (3rd degree block)
• Myocardial disease
• Mechanical causes

Question 21

Echocardiography in heart failure

Answer 21

Systolic and/or diastolic dysfunction with/without ventricular hypertrophy with/without valve abnormality

Question 22

Diastolic dysfunction hallmarks:

Answer 22

• Normal end-diastolic volume
• Minimal/no cardiomegaly
• Normal contractility
• Decreased compliance
• Normal ventricular ejection fraction
• S4 gallop (a-dup-op)
• High end-diastolic pressure

Question 23

Mechanical causes of heart failure

Answer 23

• Pressure overload/increased afterload resistance (stenosis/HTN)
• Volume overload/increased preload (insufficiency/shunt)
• Pericardial
• — Cardiac tamponade (acute)
• — Constrictive pericarditis (chronic)

Question 24

Aldosterone Antagonists for HF

Answer 24

Spironolactone
Eplerenone

(Caution! esp Renal insufficiency or baseline hyperkalemia)

Question 25

Drugs to avoid in systolic heart failure

Answer 25

Anti-arrhythmic drugs
Calcium channel blockers
Nonsteroidal Anti-inflammatory drugs

Question 26

If low ejection fraction, particularly high risk of

Answer 26

Sudden cardiac death

Question 27

Precipitating causes of heart failure

Answer 27

• 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)

Question 28

Approved Beta Blockers for HF

Answer 28

Carvedilol
Metoprolol

Also useful for Diastolic HF by controlling rapid rate

Question 29

Treatment for Stage C disease

Answer 29

Control risk factors
Salt restriction
Dieuretics for symptoms
ACE-I's (or ARBs)
Beta-blockers

Question 30

If wide QRS (bundle branch block) this can help

Answer 30

bi-ventricular pacemaker

Question 31

Initial Lab Workup of new HF

Answer 31

EKG
CXR
CBC/Chem screen/TSH
Echocardiogram

Question 32

ACE-Inhibitor Side effects

Answer 32

Orthostatic HypOtension
HypERkalemia
Increasing BUN/creatinine
Angioedema
Cough

Question 33

NON-hypotensive (Normal BP) Pulmonary Edema Treatment

Answer 33

Oxygen!
IV morphine (dilatiation)
IV furosemide (diuretic)
Vasodilators/SLNG (take away afterload, get IV in)

Aminophylline (rare)
Digoxin (rare)

Question 34

Classification of heart failure

Answer 34

A- high risk w/o disease
B- structural w/o disease
C- heart failure symptoms (current or past)
D- refractory HF

Cannot be reclassified

Question 35

Use this if nothing else is working for symptoms

Answer 35

Digoxin

no survival benefit but improved QOL

Question 36

Stage A Treatment

Answer 36

Fix risk factors!

Question 37

Captopril (ACE-I) half life

Answer 37

Less than 3 hours

Usual ~12 hours

Question 38

Drugs work particularly well in AA population

Answer 38

Isosorbide dinitrate + Hydralazine

Question 39

Use of ACE-I

Answer 39

Start low
Titrate up slow (+ caution)
Adjust diuretic if BP down, BUN up
If K+ up, add Thiazide diuretic

Question 40

Stage D management

Answer 40

hospice

transplant

Question 41

Side effects include:
Orthostatic hypOtension
HypERkalemia
Increasing BUN/Creatinine
Angioedema
Cough

Answer 41

ACE-Inhibitors