Heart Failure Flashcards
systolic dysfunction
Impaired contractility that leads to a decreased ejection fraction
Diastolic dysfunction
Impaired ventricular filling during diastole due to either impaired relaxation or increased stiffness of the ventricle or both
“High Output” HF
Increase in CO is needed for the requirements of peripheral tissues for oxygen
Pathologic S3 (ventricular gallop)
Sound of Rapid filling phase into a non-compliant LV
*among most specific signs of CHF
Heard best at apex with bell
S3 follows S2 “Ken-tuck-Y”
S4 Gallop
Sound of atrial systole as blood ejected into a non-compliant or stiff LV
Heard best a left sternal border
s4 precedes s1 “TEN-nes-see”
Increased intensity of pulmonic component of second heart sound indicates……
Pulmonary Hypertension
Heard over left upper sternal border
NYHA Class I
Symptoms only occur with vigorous activity (like playing a sport)
NYHA Class II
Symptoms with prolonged or moderate exertion (like climbing stairs)
Slight limitations of activities
NYHA Class III
Symptoms occur with usual activities of daily living (Walking across a room)
Markedly limiting
NYHA Class IV
Symptoms occur at rest
Incapacitating
ACC/AHA HF Stage A
Risk factors present for HF, but have no structural heart disease or symptoms
ACC/AHA HF Stage B
Structural heart disease without HF
ACC/AHA HF Stage C
Structural heart disease with HF symptoms (prior or current)
ACC/AHA HF Stage D
Refractory HF requiring specialized interventions
Signs and symptoms of left-sided HF
“Lung Symptoms”
Dyspnea Orthopnea Paroxysmal Nocturnal Dyspnea Nocturnal Cough Pulmonary Hpertension S3 and S4 sounds present Crackles/rales
Signs and symptoms of Right-sided HF
“Backed up veins” Symptoms
Peripheral pitting edema Nocturia JVD Hepatomegaly Hepatojugular Reflex Ascites RV Heave
Tests to order for new patient with CHF
CXR (pulmonary edema, cardiomegaly, r/o COPD)
ECG
Cardiac Enzymes (r/o MI)
Echocardiography (estimate EF, r/o pericardial effusion)
Paroxysmal nocturnal dyspnea
Awakening after 1-2 hours of sleep due to SOB
Nocturnal cough is worse in what position?
Recumbent (same pathophysiology as orthopnea)
From where and why is brain natriuretic protein (BNP) released?
Released from ventricles in response to ventricular volume expansion and pressure overload
What BNP levels correlate strongly with presence of decompensated CHF?
levels >150 pg/mL, but remember you must compare this to the patient’s baseline or usual BNP levels, because they may be consistently elevated in CHF
Though not used to diagnose CHF, why can BNP be useful?
Can help differentiate between dyspnea caused by CHF and COPD
What NT-proBNP value virtually excludes diagnosis of CHF?
Compare potency of diuretics used in CHF patients
Loop diuretics (furosemide) most potent
Thiazide diuretics (hycrochlorothiazide) modestly potent
What CHF stages is spironolactone effective in?
Advanced stages Classes III and IV
What is an alternative to spironolactone and when would it be used?
Eplerenone can be used if spironolactone causes gynecomastia
Contraindication of spironolactone
Renal Failure
Standard treatment of CHF includes
Loop diuretic
ACE inhibitor
Beta Blocker
All patients with systolic dysfunction even if asymptomatic should be on….
ACE Inhibitor
If ACE inhibitor can not be tolerated what are some alternatives?
Angiotensin II Receptor Blockers (ARBs)
Hydralazine and Isosorbide dinitrates
Common side effect of the ACE inhibitors
Cough (non-productive)
Beta blockers should be given to what kind of CHF patients?
Must be STABLE (class I, II, III)
Which beta blockers have evidence for efficacy in CHF?
Carvedilol (shown to be most effective)
Metoprolol
Bisoprolol
What is the most common cause of death in CHF?
Sudden death from ventricular arrhythmia
Ischemia can provoke these
Digoxin is useful in patients with….
EF
Hydralazine and isosorbide dinitrates have been shown to improve mortality in which selected patient population?
African Americans
Medications contraindicated in CHF
Metformin: may cause lethal lactic acidosis
Thiazolidinediones: cause fluid retention
NSAIDs: increase risk of CHF exacerbation
Some antirhythmics with negative inotropy
Medications shown to decrease mortality in systolic HF
ACE inhibitors and ARBs
Beta Blocers
Aldosterone antagonists (spironolactone/eplerenon)
Hydralazine + nitrate
Medications that do not decrease mortality in HF but provide symptomatic relief
Digoxin
Diuretics
What are signs of Digoxin toxicity
GI: N/V, anorexia
Cardiac: Ectopic (ventricular) beats, AV block, AFib
CNS: visual disturbances, disorientation
which devices have been proven to decrease mortality in CHF patients?
Implantable Cardioverter Defibrillator and Cardiac Resynchronization therapy (biventricular pacemaker)
Treatment of Diastolic Dysfunction
Treated symptomatically
No meds have been proven to have mortality benefit
Use beta blockers and diuretics
Which meds should NOT be used in diastolic dysfunction
Digoxin
Spironolactone
What is acute decompensated HF?
Acute dyspnea associated with increased left-sided filling pressures with or without pulmonary edema
What is decompensated HF most commonly due to?
Dietary indiscretion
“Flash Pulmonary Edema”
Severe form of HF with rapid accumulation of fluid in the lungs
What is the most important intervention in acute decompensated HF?
Diuretics to treat volume overload and congestive symptoms
Why is digoxin not indicated in acute decompensated HF?
Because it takes several weeks to work
Which implantable device should be used in CHF NYHA class II-III?
Implantable Cardiac Defibrillator
Which implantable device should be used in CHF NYHA class III-IV with QRS >120 ms?
Cardiac Resynchronization Therapy
