Heart Failure Flashcards
What is the mortality rate of class III and class IV HF pts
III 40%, IV 50%
What are the primary etiologies of Heart failure?
60-75% CAD
18% idiopathic
12% valvular heart disease
10% HTN
What are some basic causes of Heart Failure?
RV infarct, constrictive pericarditis, mitral stenosis, atrial myxoma, Thyrotoxicosis, A-V fistula Beri Beri
What are the Stages of heart failure?
ABCD
Walk through the different stages of “evolution of heart failure”
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
Identify risk factors in Grade A staging of Heart failure
CAD, HT, DM, obesity, METABOLIC SYNDROME, excess EtOh
Discuss in greater depth Stage B, including structural changes, symptoms, or etiology
Has LVH, or impaired LV function, previous MI, valvular disease, structural heart disease; hemodynamically stable
Mortality rate is 15%
What are the different NYHA functional classification of Clinical Stages
Class I-IV
Discuss class I NYHA functional classifications
No limitations to physical activity
No sx with ordinary exertion
Discuss Class II NYHA Functional Classification. Include the one year mortality
Slight limitation of physical activity
Ordinary activity causes sx
One year mortality is 15-30%
Discuss class III NYHA Functional classification
Marked limitation of physical activity
Less that ordinary activity causes symptoms
Asymptomatic at rest
15-30% 1 yr mortality
Discuss Class IV NYHA functional classification
Inability to carry out physical activity w/o discomfort
Sx at rest
One year mortality 50-60%
What are the different pathogenesis of heart failure (pathobiology)
Impaired systolic (contractile) function Impaired diastolic function Mechanical abnormalities Disorders of Rate/Rhythm Pulmonary heart disease High output states
What are the different forms of heart disease you are able to see on Echo
Hypertensive heart disease Ischemic heart disease Hypertrophic heart disease Infiltrative heart disease Primary valvular heart disease
Discuss Hypertensive heart disease on CXR and echo
LVH, bigger cardiac silhouette on echo
Discuss the findings on echo for ischemic heart disease
No change in wall size, a less compliant wall
How many degrees does the heart rate go up for every 1 degree F
10 bpm
Discuss the findings on echo for hypertrophic heart disease
Circumferential expansion of the heart including the septum
At what value of hemoglobin should you consider dialysis
<10
Infiltrative Heart disease
You see specks on the Echo
Discuss the findings on echo for Primary valvular heart disease
Bad valves
What are the different classifications (types) of heart failure
Systolic/Diastolic High/Low Acute/Chronic Right/Left Forward/Backwards
Discuss systolic heart failure including EF, symptoms, pathogenesis, occurrence (in relationship to diastolic), associated diseases
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
Discuss high type of heart failure, including disease associated, pathogenesis
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
Discuss diastolic heart failure, including symptomology, pathogenesis, EF, associated diseases
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
Discuss associated diseases with low output type of heart failure
Ischemic heart disease, HTN
Dilated cardiomyopathy, valvular and pericardial disease
Discuss associated diseases with right sided Heart failure
Affects RV
Pulmonary HTN due to pulmonary embolus
Edema, hepatomegaly venous distension
Discuss associated diseases with left sided heart failure
LV is overloaded, AS, MI
Dyspnea, orthopnea, due to pul congestion
Discuss the Compensatory mechanisms of heart failure- Neurohormonal Responses
SNS, RAAS, cytokine activation, Altered renal physiology, LV remodeling
What is the RAAS mechanism of Heart failure?
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)
Discuss the effects of Arginine Vasopressin- AVP or ADH
Stimulation of thirst leads to increase TBW and hyponatremia (dilutional) Increases preload (salt and water retention)
What are some precipitating causes of heart failure (pt 1)
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
Is unilateral edema suggestive of heart failure?
Nah
List other causes of heart failure (minor causes)
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
What are S/S of Heart Failure?
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
S/S of Heart failure continued (think liver)
Hepatomegalia- passive congestion with increased LFTs, altered coagulation studies, ascites, increased abdominal girth, peripheral and sacral edema
JVD- volume overload, cardiac tamponade and COPD
S/S of Heart failure
cont (think heart)
S3, S4 (s3 x11 likelihood of failure)
LV failure
Orthopnea, PND
Tachypnea, wheezing, crackles, decreased breath sounds
Dullness to percussion over pleural effusions
S/S of heart failure cont (what about Right ventricular failure)
Peripheral sacral edema
Hepatomegalia
Ascites
Increased HVD, HJR
What are tests you can do to help dx HF
No single test but consider
CXR
Shows cardiomegaly, pulmonary Edema with central peripheral infiltrates
Increased size
What can Echo show you?
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
What will ECG show?
Ischemia, infarction, hypertrophy, Rhythm disturbances, Tachycardia/brady/blocks
Discuss Cardiac Enzymes and Creatine Kinase, when they increase/peak
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
What other labs can you get to help with dx
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
Labs continue (think outside of the cardiac system)
Thyroid If >65 y/o with a fib YOU MUST CHECK Free T4, TSH ABG May have hypoxia, metabolic acidosis from lactic acidosis
Labs continued (what would help with diuresis of fluid)
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
What is your DDx of HF
Pulmonary PE Asthma Pneumonia Cirrhosis Ascites Edema Renal- edema Venous insufficiency edema
