Heart Failure Flashcards
When the heart cannot pump blood fast enough to meet the requirements of metabolizing tissues or can only do so from an abnormally elevated diastolic pressure/volume
Heart failure
How many patients in the US have heart failure?
5 million
Why are numbers of heart failure deaths increasing despite advances in medications?
Increased salvage of patients with acute MI
Numbers rising as baby boomers age
What are the different etiologies of heart failure?
Coronary heart disease Primary pump failure Valvular heart disease Congenital heart disease Long standing, uncontrolled HTN
MI’s or ischemia superimposed on prior infarction(s) make up ___% of all HF cases
(This is coronary heart disease) 75%
Cardiomyopathies and viral myocarditis are examples of?
Primary pump failure
What causes heart failure?
Progressive weakening of the myocardium and consequences from the weakness lead to heart failure
Primary contraction abnormality causing inadequate delivery of O2 to tissues; issue with ejecting the blood from the heart to the rest of the body
Systolic heart failure
Elevation of ventricular filling pressures and associated symptoms; When the heart has a decreased ability to fill with blood correctly
Diastolic heart failure
Do systolic and diastolic failure occur together in heart failure?
Often
Inadequate cardiac output to the body with pulmonary congestion and related symptoms (post MI, aortic/mitral valve disease)
Left heart failure
Inadequate flow of blood to the pulmonary system due to COPD/pulmonary hypertension, pulmonic stenosis, etc.
Associated with peripheral edema and hepatic congestions
Right heart failure
What is the most common cause of right heart failure?
Left heart failure!
Dyspnea, cough, orthopnea, and PND are all symptoms of which type of heart failure?
Left sided heart failure - left side fails and fluid backs up into lungs causing all of these symptoms
Peripheral edema, increased liver size, and ascites are all symptoms of which type of heart failure?
Right sided heart failure - Right side fails and backs fluid up to the body (limbs, liver, etc.)
Inadequate ventricular emptying; pressures in the atrium and venous system behind the failing ventricle rise resulting n transudation of fluid into interstitial spaces
Backward failure
Inadequate forward cardiac output; Na and water retention result from diminished renal perfusion and activation of renin-antiogensin-aldosterone system
Forward failure
What are some compensatory mechanisms for the body to overcome heart failure?
Redistribution of cardiac output to vital organs (less blood flow to skin and muscle)
Sodium and water retention
What mediates the redistribution of cardiac output to vital organs?
Adrenergic nervous system - primarily sympathetic nervous system with norepinephrine release
Why would the body want to retain Na and water?
Helps maintain CO
How does Na and water retention help maintain CO?
Starling mechanism
What is the cost of Na and water retention?
Volume overload from accumulation of fluid and increased afterload from increased SVR
Is the adrenergic system beneficial or harmful?
Both!
Increased levels of norepinephrine result in an increase in ???
HR, contractility, and SVR
Increased levels of norepinephrine helps maintain?
Arterial perfusion pressure (BP) in presence of decreased CO
What is the cost of elevated SVR?
Increased after load
Increased O2 requirements of the failing ventricle
Long term elevation of _______ leads to progressive myocardial damage and fibrosis
Catecholamines
Where and when is Renin released?
Released by kidneys with decreased perfusion or decreased BP
What converts angiotensinogen to angiotensin I?
Renin
What converts angiotensin I to angiotensin II? Where does this occur?
Angiotensin converting enzyme in LUNGS
What is the problem with angiotensin II?
Very potent vasoconstrictor! Increases SVR and RAISES BP!!
What does Angiotensin II stimulate in the adrenal glands?
Aldosterone
What does aldosterone do?
Increases renal Na and H2O reabsorption - causes edema!
What does long term activation of angiotensin II and aldosterone lead to?
Myocardial thinning and fibrosis
No limitation of physical activity; no symptoms of SOB, CP, dizziness, etc.
Stage 1 HF
Slight limitation of physical activity. Some (ordinary) activities (exercise, exertion, etc) cause symptoms.
Stage 2 HF
Marked limitation of physical activity. Less than ordinary activities (walking, dressing, etc.) cause symptoms.
Stage 3 HF
Symptomatic at rest or minimal activity; unable to engage in any physical activity.
Stage 4 HF
What are the 3 major clinical manifestations of HF?
Dyspnea, orthopnea, PND
Initially occurs with activity, then at rest; due to elevation of pulmonary venous pressure
Dyspnea
Dyspnea in recumbent position; redistribution of fluid from abdomen and lower extremities into chest
Orthopnea
Attacks of severe SOB, coughing and wheezing awakening patient from sleep
PND
What is a classic sign of HF that results from sodium and water retention?
Unexplained weight gain and swelling of legs
What causes cerebral symptoms in patients with HF?
Decreased perfusion to the brain
Severe dyspnea at rest as pulmonary congestion preogresses; elevation of PCP leading to interstitial then alveolar edema
Acute pulmonary edema
Acute pulmonary edema is considered a ___?
Medical emergency!
PCW greater than 20mmHg
Interstitial edema
PCW greater than 25mmHg
Alveolar edema
How do you measure PCP?
Right heart cath
Common PE findings in patient with HF
JVD!
Tachycardia
Cyannosis (hypoxemia)
Patient uncomfortable lying flat
What might you hear on lung auscultation of a patient with HF?
Moist inspiratory crackles that begin at bases and progress upwards through the lungs
What might you hear when auscultating a patients heart in a patient with HF?
S3 gallop: Low pitched sound in early diastole
Hepato-jugular reflex in a HF patient will be ?
+
What might you find when palpating the liver of a HF patient?
Congestive hepatomegaly
“wasted appearance” - weight loss, anorexia, nausea
Cardiac cachexia
What causes cardiac cachexia?
Increased levels of cytokines (tNF)
What might you find on CXR of a patient with HF?
Cardiomegaly; distention of pulmonary veins; venous redistribution to apices; Pleural effusions; interstitial or alveolar edema
What is the best non-invasive tool for assessing HF?
Echo-doppler
What will an echo-doppler identify in a patient with HF?
Ventricular dysfunction and EF
What is a common ECG finding of a patient with HF?
LVH
What is a good blood test to check for acute ventricular dysfunction leading to symptomatic heart failure? Why?
BNP - hormone produced by ventricle in response to wall stress
What is a common BNP result in patients with HF? What is normal?
Normal is less than 50
HF usually greater than 100
What drugs help decrease preload in patients with HF?
Diuretics and venodilators (nitrates)
What drugs help with excess Na retention with edema in HF patients?
Diuretics
What drugs help decrease after load in patients with HF?
Vasodilator therapy (ACEIs and ARBs)
What drugs improve cardiac contractility?
Digoxin
What drugs slow progression of cardiac deterioration by preventing remodeling?
ACEIs
Beta blockers
Spironolactone
Once your patient with HF is symptomatic, what is their prognosis?
Poor
What are the goals of drug therapy to control the HF state?
Reduction of cardiac workload
Control of excessive Na/water retention
What drug therapy do you want to initiate EARLY for patients with HF?
ACEI/ARB
What should you add to ACEI/ARB in the black population?
Hydralazine and nitrates
What are the general goals of therapy in HF?
Remove precipitating factors
Treat underlying cause
Control HF state
Enhance cardiac contractility
How can you reduce the cardiac workload? (Non-pharm and pharm)
Decrease/limited activity
Elastic stockings
Anxiolytic therapy
Control dietary sodium
Ideal diet for a patient with HF?
No added salt, no salt in preparation of foods, AVOID FOODS WITH HIGH SODIUM CONTENT
4gm Na or LESS!
Most potent diuretics and cornerstone of diuretic Rx in CHF
Loop diuretics
Side effects of loop diuretics
Hyperkalemia
Hyperuricemia
Metabolic alkalosis
What is always elevated in heart failure? Why?
LV afterload
Constricuted vascular bed and increased SVR
What is increased due to Na/H2O retention?
Preload
Treatment with vasodilators results in?
Decreased SVR
Increased CO
Decreased PCW
Relief of symptoms
Decreased mortality!
What do ACEI’s do?
Reduce after load and preload
How do ACEIs reduce preload?
Decreasing production of angiotensin II and aldosterone
What is the equation for cardiac output using BP and SVR?
CO = BP/SVR
ACEIs decrease remodeling of the ____
How?
LV
Reducing wall thinning, fibrosis, and by interfering with apoptosis
ACEIs are less effective in which population?
Black
If an ACEI is needed in a black patient, what should you add?
Hydralazine + long acting nitrate
BiDil!!
What must you monitor on your patient taking an ACE?
Renal function
What causes the cough that is a side effect of ACEIs?
Bradykinin
Which medication used to be contradicted in HF, but is now proven to reduce mortality and improve cardiac function?
Beta blockers
When do you begin a patient with HF on beta blocker therapy?
Once patient is stable and euvolemic (normal blood volume)
Beta blocker DOC in patients with HF?
Carvedilol
By blocking aldosterone, spironolactone should be considered as a ______ antagonist rather than narrowly as a K sparing diuretic.
neurohumonal
______ mediates some of the deleterious effects of renin-angiotensin-aldosterone system activation, such as myocardial remodeling and fibrosis.
Aldosterone
Why do you need to monitor potassium levels in a patient on spironolactone or aldosterone?
Hyperkalemia
Digoxin improves CHF symptoms but not ____
Mortality
If QRS > 120ms (.12s) and severe refractory CHF, _______ (CRT*) improves symptoms and quality of life. Improves EF.
Synchronized biventricular pacing
When should you suggest an Implantable Cardioverter Defibrillator to your patient?
If your patient was resuscitated from cardiac arrest/Vfib or are in hemodynamically unstable vtach
If your patients EF is less than 3.5 with mild to moderate HF symptoms
What can you recommend to your patient for end-stage HF?
LVAD (LV assist devices)
Decreases workload of native heart and buys time to heart transplant
What is the problem with cardiac transplantation?
Not enough donor hearts
