Heart Failure

Question 1

What is the mortality rate of class III and class IV HF pts

Answer 1

III 40%, IV 50%

Question 2

What are the primary etiologies of Heart failure?

Answer 2

60-75% CAD
18% idiopathic
12% valvular heart disease
10% HTN

Question 3

What are some basic causes of Heart Failure?

Answer 3

RV infarct, constrictive pericarditis, mitral stenosis, atrial myxoma, Thyrotoxicosis, A-V fistula Beri Beri

Question 4

What are the Stages of heart failure?

Answer 4

ABCD

Question 5

Walk through the different stages of “evolution of heart failure”

Answer 5

A-Risk factors no heart disease; no symptoms
B- Heart disease w/o sx
C- Prior or current HF symptoms, reduced exercise capacity
D- Refractory HF symptoms

Question 6

Identify risk factors in Grade A staging of Heart failure

Answer 6

CAD, HT, DM, obesity, METABOLIC SYNDROME, excess EtOh

Question 7

Discuss in greater depth Stage B, including structural changes, symptoms, or etiology

Answer 7

Has LVH, or impaired LV function, previous MI, valvular disease, structural heart disease; hemodynamically stable
Mortality rate is 15%

Question 8

What are the different NYHA functional classification of Clinical Stages

Answer 8

Class I-IV

Question 9

Discuss class I NYHA functional classifications

Answer 9

No limitations to physical activity

No sx with ordinary exertion

Question 10

Discuss Class II NYHA Functional Classification. Include the one year mortality

Answer 10

Slight limitation of physical activity
Ordinary activity causes sx
One year mortality is 15-30%

Question 11

Discuss class III NYHA Functional classification

Answer 11

Marked limitation of physical activity
Less that ordinary activity causes symptoms
Asymptomatic at rest
15-30% 1 yr mortality

Question 12

Discuss Class IV NYHA functional classification

Answer 12

Inability to carry out physical activity w/o discomfort
Sx at rest
One year mortality 50-60%

Question 13

What are the different pathogenesis of heart failure (pathobiology)

Answer 13

Impaired systolic (contractile) function
Impaired diastolic function
Mechanical abnormalities
Disorders of Rate/Rhythm
Pulmonary heart disease
High output states

Question 14

What are the different forms of heart disease you are able to see on Echo

Answer 14

Hypertensive heart disease
Ischemic heart disease
Hypertrophic heart disease
Infiltrative heart disease
Primary valvular heart disease

Question 15

Discuss Hypertensive heart disease on CXR and echo

Answer 15

LVH, bigger cardiac silhouette on echo

Question 16

Discuss the findings on echo for ischemic heart disease

Answer 16

No change in wall size, a less compliant wall

Question 17

How many degrees does the heart rate go up for every 1 degree F

Answer 17

10 bpm

Question 18

Discuss the findings on echo for hypertrophic heart disease

Answer 18

Circumferential expansion of the heart including the septum

Question 19

At what value of hemoglobin should you consider dialysis

Answer 19

<10

Question 20

Infiltrative Heart disease

Answer 20

You see specks on the Echo

Question 21

Discuss the findings on echo for Primary valvular heart disease

Answer 21

Bad valves

Question 22

What are the different classifications (types) of heart failure

Answer 22

Systolic/Diastolic
High/Low
Acute/Chronic
Right/Left
Forward/Backwards

Question 23

Discuss systolic heart failure including EF, symptoms, pathogenesis, occurrence (in relationship to diastolic), associated diseases

Answer 23

More likely to be a systolic dysfunction but diastolic is increasing in number
Systolic- decreased SV, Increased ventricular filling pressure.
EF is less than 40%, hypoperfusion with impaired ventricular filling
Weak, fatigued, reduced exercise tolerance
DOE, orthopena, PND

Question 24

Discuss high type of heart failure, including disease associated, pathogenesis

Answer 24

High- pumping very hard but not pumping out a lot of volume
Hyperthyroidism, anemia, pregnancy, A-V fistula, beriberi, Paget’s
High CO, but low EF

Question 25

Discuss diastolic heart failure, including symptomology, pathogenesis, EF, associated diseases

Answer 25

``` NORMAL EF SOB, DOE, pulmonary edema Inability for the LV to relax/fill, decreased ventricular diastolic capacity Restrictive/constrictive pericarditis Hypertensive/hypertrophic cardiomyopathy Impaired Vent relax Acute ischemia Myocardial fibrosis Amyloidosis ```

Question 26

Discuss associated diseases with low output type of heart failure

Answer 26

Ischemic heart disease, HTN | Dilated cardiomyopathy, valvular and pericardial disease

Question 27

Discuss associated diseases with right sided Heart failure

Answer 27

Affects RV Pulmonary HTN due to pulmonary embolus Edema, hepatomegaly venous distension

Question 28

Discuss associated diseases with left sided heart failure

Answer 28

LV is overloaded, AS, MI | Dyspnea, orthopnea, due to pul congestion

Question 29

Discuss the Compensatory mechanisms of heart failure- Neurohormonal Responses

Answer 29

SNS, RAAS, cytokine activation, Altered renal physiology, LV remodeling

Question 30

What is the RAAS mechanism of Heart failure?

Answer 30

Decreased renal perfusion, increased renin, angiotensinogen, A1, A1 ACEA11 increases BP by vasoconstriction, stimulates adrenal gland release aldosterone. Na and H2O retention (increase preload, congestive symptoms and volume (expansions) A11- vasoconstrictor, PVR (increase afterload)

Question 31

Discuss the effects of Arginine Vasopressin- AVP or ADH

Answer 31

Stimulation of thirst leads to increase TBW and hyponatremia (dilutional) Increases preload (salt and water retention)

Question 32

What are some precipitating causes of heart failure (pt 1)

Answer 32

``` Underlying progression of heart disease Non-compliance with diet 25--50% (+ Na, calories, stimulants) Non-compliance with medications 25-50% (costly, side effects, worsening HF) CCB, Beta blockers, NSAIDS, antiarrhythmics ```

Question 33

Is unilateral edema suggestive of heart failure?

Answer 33

Nah

Question 34

List other causes of heart failure (minor causes)

Answer 34

``` Infection 20%, (look at the temp slide above) Anemia Increase O2 needs of tissues Increased CO Thyrotoxicosis/pregnancy High CO state Arrhythmias 20-30% Tachyarrhythmias- decrease diastolic filling time, leading to ischemia, bradycardia ```

Question 35

What are S/S of Heart Failure?

Answer 35

Decreased arterial perfusion to organs and venous congestion DYSPNEA Exercise interolance, orthopnea, PND, nocturnal angina (pul congestion) PND increases likelihood of heart failure of 2x Weakness Pulmonary Edema Transudation of fluid from pulmonary capillaries into alveolar spaces and interstitium

Question 36

S/S of Heart failure continued (think liver)

Answer 36

Hepatomegalia- passive congestion with increased LFTs, altered coagulation studies, ascites, increased abdominal girth, peripheral and sacral edema JVD- volume overload, cardiac tamponade and COPD

Question 37

S/S of Heart failure | cont (think heart)

Answer 37

S3, S4 (s3 x11 likelihood of failure) LV failure Orthopnea, PND Tachypnea, wheezing, crackles, decreased breath sounds Dullness to percussion over pleural effusions

Question 38

S/S of heart failure cont (what about Right ventricular failure)

Answer 38

Peripheral sacral edema Hepatomegalia Ascites Increased HVD, HJR

Question 39

What are tests you can do to help dx HF

Answer 39

No single test but consider CXR Shows cardiomegaly, pulmonary Edema with central peripheral infiltrates Increased size

Question 40

What can Echo show you?

Answer 40

``` Practical useful test Mobile, bedside/ICU /ED Chamber sizes, clots, tumors Wall motion (ischemic), muscle thickness Pericardial effusions Valvular disease Systolic/Diastolic heart failure-EF ```

Question 41

What will ECG show?

Answer 41

Ischemia, infarction, hypertrophy, Rhythm disturbances, Tachycardia/brady/blocks

Question 42

Discuss Cardiac Enzymes and Creatine Kinase, when they increase/peak

Answer 42

``` Troponin T and I Released from myocytes when damaged Increase in 3-12 hours from onset of CP Peak 24-48 hours' return to baseline in 5-14 days Creatinine kinase Increase 3-12 hours from onset of chest pain Peak 24 hours; baseline 1-3 days Sensitivity ```

Question 43

What other labs can you get to help with dx

Answer 43

``` CBC Anemia 2nd degree to chronic disease Anemia may aggravate HF CMP Electrolyte imbalance- Low Na,K Pre-renal azotemia- high BUN to creatine UA Protein in urine ```

Question 44

Labs continue (think outside of the cardiac system)

Answer 44

``` Thyroid If >65 y/o with a fib YOU MUST CHECK Free T4, TSH ABG May have hypoxia, metabolic acidosis from lactic acidosis ```

Question 45

Labs continued (what would help with diuresis of fluid)

Answer 45

BNP (neurohormone made in ventricles) Lower EF, higher BNP if less than 100 pg/ml there is a 97% chance of no HF Increase BNP in heart failure, AMI, PE, renal failure, old age

Question 46

What is your DDx of HF

Answer 46

``` Pulmonary PE Asthma Pneumonia Cirrhosis Ascites Edema Renal- edema Venous insufficiency edema ```