Heart failure Flashcards
heart failure
complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood
systolic dysfunction
impaired cardiac contractile function
diastolic dysfunction
abnormal cardiac relaxation, stiffness or filling
SNS effect on HR, contractility, preload, afterload, and CO
- HR increases
- contractility increases
- preload increases
- afterload decreases
- CO increases
preload
volume coming into ventricles (end diastolic pressure)
afterload
resistance-left ventricle must overcome to circulate blood
give examples of neurohormonal imbalances that can cause progressive heart disease by causes cardiac remodeling and decline in heart function
- overactivation of the renin-angiotensin-aldosterone system
- sympathetic nervous system
what is HFrEF
- Heart failure with a reduced ejection fraction, also known as systolic heart failure
Signs of HFrEF
- increased LV volumes
- reduced LVEF (< or = 40%)
- usually progressive chamber dilation and eccentric remodeling
causes of HFrEF
- impaired contractility
- CAD
- cardiomyopathy
- high afterload
- HTN
HFpEF
Heart failure with preserved EF; also called diastolic heart failure
- Diastolic dysfunction
- abnormal mechanical properties of the ventricle
- normal LVEF (> or = 50%)
differentiate between concentric and eccentric remodeling
- concentric: walls are thicker
- eccentric: walls are thinner
LV diastolic pressure
determined by volume of blood in ventricle and distensibility or compliance of ventricle
an elevated LV diastolic pressure will have what effect on pulmonary venous pressure
pulmonary venous pressure will increase causing
- dyspnea
- exercise intolerance
- pulmonary congestion
- may lead to RHF
what are the two most common causes of HFpEF
- ischemia
- left ventricular hypertrophy
most common caues of right heart failure
left heart failure
- Rt heart does not tolerate increases in afterload
signs of Rt heart failure
- increased pressurein veins, capillaries
- increased formation of tissue fluid (peripheral edema and ascites)
risk factors of heart failure
- coronary heart disease
- smoking
- HTN
- obese
- DM
- valvular heart disease
what is the most common cause of heart failure
coronary artery disease
clinical presentation
- dyspnea that becomes worse over time
- DOE -> orthopnea -> PND -> dyspnea at rest
- fatigue, weakness
- dependent edema
- weight gain
heart failure
what physical exam findings would you expect to see with heart failure
- edema
- elevated JVD
- rales at bases
- displaced PMI (laterally)
- hepatomegaly
- S3/S4 gallop
modified framingham clinical criteria lists major and minor criteria for the diagnosis of heart failure. what is needed to diagnose HF
at least 2 major symptoms or 1 major and 2 minor
left heart failure has what impact of CO? what are the effects?
decreased CO
- activity intolerance, fatigue
- signs of decreased tissue perfusion (confusion)
left heart failure causes pulmonary congestion. what are some signs and symptoms you would expect
- impaired gas exchange
- signs of hypoxia
- pulmonary edema
- cough with frothy sputum
- orthopnea
these signs lead to what diagnosis
- dependent edema
- ascites
- increased JVD
- GI tract congestion
- hepatic congestion
- weight gain
right heart failure
signs and symptoms point toward what disease
- dyspnea
- diaphoresis
- tachypnea
- tachycardia
- rales
- S3 or S4
left side heart failure
patients with suspected HF should recieve the following diagnostic studies
- ECG
- echocardiography
- chest radiograph
a normal ECG makes which heart failure highly unlikely
systolic dysfunction
what information can echocardiogram tell us regarding HF
- ejection fraction > 50% is normal
- systolic HF: signs/symptoms of HF + EF < or = 40%
- diastolic HF: signs/symptoms of HF + normal EF
- size of left ventricle
- systolic HF: dilated LV
- diastolic HF: LVH
function of chest radiograph in diagnosis HF
- evaluate CM
- rule out pulmonary etiology
- findings suggestive of HF
- CM
- cephalization of pulmonary vessels
- Kerley B lines (interstitial edema)
- pleural effusion
when is a exercise ECG stress test contraindicated in HF
acute HF
what labs would you get for suspected HF
- cardiac enzymes
- CBC
- anemia/infection can exacerbate pre-existing HF
- CMP
- electrolytes
- glucose: detect underlying DM
- renal function
- liver function tests to see if hepatic congestion is present
- UA
- lipid panel
- thyroid panel: hypothyroidism can exacerbate HF
- iron studies
what lab is the marker for HF
brain type natriuretic peptide (BNP)
- released in response to stretching of ventricular wall
- elevated levels -> HF
- higher level of BNP -> poorer the prognosis
stages of heart failure
- stage A: high risk but without structural changes or symptoms
- stage B: structural heart disease but without signs or symptoms
- stage C: structural heart disease with signs or symptoms
- stage D: refractory heart failure including specialized interventions
NYHA functional classification
class I-IV: used to classify patients in stages C and D of heart failure based on their symptoms
goals of heart failure therapy
- reduce preload -> diminish congestive symptoms
- reduce afterload -> improve cardiac function
recommended initial therapy for ALL patients with HF
- ACE inhibitor
- Diuretics
preferred diuretic in treatment of HF. Goal of diuretic
- Loop diuretic preferred
- Lasix
- goal: reduce fluid overload
- relieve dyspnea and peripheral edema
what must you monitor when you place a patient on a diuretic
renal function
- lasix causes hypokalemia and patient may require KCl supplement
what must you monitor when you place a patient on a ACE inhibitors
- BP
- renal function
- causes hyperkalemia
- electrolytes
benefit of ACE inhibitors
shown to reduce morbidity and mortality in both symptomatic and asymptomatic patients
what medication can you give to patients in HF who can not tolerate ACE inhibitors
angiotensin II receptor blockers (ARBs)
what must you monitor when you place a patient on a angiotensin II receptor blocker
- BP
- renal function
- hyperkalemia
- electrolytes
when would you administer beta blockers to a patient with HF?
- start ACE inhibitors first, wait until stable
- administer only if patient is clinically stable
main side effect of beta blockers
bradycardia
what is mineralocorticoid receptor antagonist
- aldosterone antagonist
- potassium-sparing diuretic
indications of mineralocorticoid receptor antagonist
- patients with rest dyspnea withint past 6 months; post MI with systolic dysfunction
- may result in hyperkalemia
When is Digoxin given
- use in patients with concomitant atrial fib
- enhances exercise tolerance
loss of what predicts a higher mortality rate
ADL: activities of daily living
where do statins fall in treatment of HF
- statins are not helpful
- but if already on one for another indication, continue
prognosis of HF
- 30-40% die within 1 year
- 60-70% die within 5 years
what are the most common causes of death in a HF patient
- progressive pump failure (decompensation)
- malignant arrhythmias
list some triggers for decompensation
- uncontrolled HTN
- A-Fib
- ischemia
- renal dysfunction
- PE
- infection
name some drugs that can worsens heart failure
- NSAIDs
- metformin
- PDE-5 inhibitors (Viagra)
- Antiarrhythmics
acute decompensated heart failure
elevated left sided filling pressures and dyspnea with or without pulmonary edema
clinical presentation
- dyspnea
- productive cough
- diaphoresis
- rales, wheezes, rhonchi
cardiogrenic pulmonary edema
- most often a result of acute decompensated HF
what will CXR reveal in cardiogrenic pulmonary edema
- Kerley B lines
- edema
- CM
cardiogrenic pulmonary edema effect on pulmonary capillary wedge pressure
typically elevated ( > 25 mmHg)
clinical presentation
- cough
- dyspnea
- fatigue
- peripheral edema
- HTN
- JVD
- crackles
- S3, S4 gallop
- new murmur
acute decompensated HF
managment of acute decompensated HF
- O2: keep sat > 90%
- diuretics
- nitroglycerin: reduce preload and capillary wedge pressure
- morphine: reduce anxiety and work of breathing
the most common cause of heart failure
left ventricular systolic dysfunction
