Heart Failure Flashcards
define as a complex clinical syndrome that results from structural or functional impairment of ventricular filling or ejection of blood, which in turn leads to the cardinal clinical symptoms of dyspnea and fatigue and signs of HF, namely edema and rales.
Heart failure
The overall prevalence of HF in the adult population in developed countries is
2%
HF prevalence
follows an exponential pattern, rising with age, and affects
6–10% of people over age 65.
True or false:
Although the relative incidence of HF is lower in women than in men, women constitute at least one-half the cases of HF because of their longer life expectancy.
True
In industrialized countries, _____ has become the predominant cause in men and women and is responsible for 60–75% of cases of HF.
coronary artery disease (CAD)
Hypertension contributes to the development of HF in how many percent of patients, including most patients with CAD.
75%
Etiology of heart failure with depressed ejection fraction <40%
CAD HTN Obstructive Valvular disease Regurgitation valvular disease Intracardiac shunting Extracardiac shunting Col pulmonale Pulmonary vascular disorder Non-ischemic dilated cardiomyopathy Toxic/drug induced damage Chaga's disease Chronic bradycardia or tachycardia
Preserved ejection fraction causes of HF
Secondary Hypertension Hypertrophic cardiomyopathy Restrictive cardiomyopathy Amyloidoisis Sarcoidosis Hemochromatosis fibrosis Endomyocardial disorders Aging
High output states causes of HF
Thyrotoxicosis (metabolic d/o)
Nutritional d/o (beriberi)
Excessive blood flow requirement
(Chronic anemia and systemic AV shunting)
____ emerging as the single most common cause of HF.
CAD
Community-based studies indicate that _____ of patients die within 1 year of diagnosis and ____ die within 5 years, mainly from worsening HF or as a sudden event (probably because of a ventricular arrhythmia).
- 30–40%
2. 60–70%
patients with symptoms at rest (New York Heart Association [NYHA] class IV) have a _____ annual mortality rate, whereas patients with symptoms with moderate activity (NYHA class II) have an annual mortality rate of ____
- 30–70%
2. 5–10%
Major determinant of Preload or VEDV
VENTRICULAR END DIASTOLIC VOLUME
Total blood volume
Distribution of blood volume
Atrial contraction
Major determinants
of AFTERLOAD
Systemic vascular resistance
Elasticity of arterial tree
Arterial blood volume
Ventricular wall tension
MECHANISM OF HFPEF
Diastolic dysfunction
Increased vascular stiffness
Impaired renal function
Cardinal symptoms of HF
Fatigue
And
Shortness of breath
Most important mechanism of HF
Pulmonary congestion which activates juxtacapillary J receptors that stimulates a rapid shallow breathing (cardiac dyspnea)
Etiologies of heart failure with preserved ejection fraction (>40-50%):
Hypertrophic CM Hypertension Restrictive cardiomyopathy Infiltrative d/o (amyloidosis, sarcoidosis) Storage diseases (hemochromatosis) Fibrosis, endomyocardial disorders Aging
Etiologies of heart failure with high output states:
Metabolic disorders: thyrotoxicosis
Nutritional disorders: BERI BERI
Excessive Blood flow requirements: systemic AV shunting, chronic anemia
Major cause of HF in AFRICA AND ASIA esp in the young
RHD
Known causes of DILATED CMP
Prior viral infection Toxin exposure (ALCOHOL, CHEMO) Genetic defect in cytoskeleton, muscular dystrophy
Most forms of familial dilated CMP
Autosomal dominant inheritance
Mechanisms that explains dyspnea in heart failure :
Pulmonary congestion Decreased pulmonary compliance Increased airway resistance Respiratory muscle or diaphragm fatigue Anemia
Mechanism: redistribution of fluid from the splanchnic circulation and lower extremities INTO the central circulation during recumbency => increased PCWP
Orthopnea
Mechanism: increased pressure in the bronchial arteries leading to airway compression + interstitial pulmonary edema causing increased airway resistance
PND
usually 1-3hrs after retiring
Periodic respiration or cyclic respiration sec to increased sensitivity of the respiratory center to arterial PCO2 and increased circulatory time
Cheyne stokes respiration
“Routine” lab test for new onset HF or chronic heart failure:
CBC ELECTROLYTES BUN CREA HEPATIC ENZYMES UA
Gold standard for assessing LV mass and volume
MRI
accurate evaluation of LV structure and causes of HF (amyloidosis,hemochromatosis, CMP - HRPEF)
Most useful index of LV dysfunction
Ejection fraction (Normal >/=50%)
Increased levels of PRO BNP
Increased AGE Renal impairment Women Right heart failure from any cause Use of ARNI
Pulmary heart disease,
altered “RV” structure and or function in chronic lung disease and triggered by PULMONARY HYPERTENSION
Col pulmonale
Common mechanism of col pulmonale
Pulmonary hypertension
Inc right ventricular AFTERLOAD
RV DILATION AND HYPERTROPHY
ALTERED RV FX
Signs of CHRONIC COL PULMONALE
TR MURMUR
S3 gallop
RV HEAVE
ECG in severe pulmonary hypertension
P pulmonale
RAD
RVH
Confirms diagnosis of pulmonary hypertension
Right heart catherization
Parameters associated with worse prognosis
Bun > 43mg/dL
SBP <115 mmHg
CREA > 2.75mg/dL
ELEVATED TROPONIN
Stabilizing hemodynamics using PULMONARY ARTERY CATHETER is NOT recommended unless
Hypotension
Poor response to DIURETICS
SSX of LOW CO
Management for typical ADHF that is hypertensive
VASODILATORS
Management for typical ADHF that is NORMOTENSIVE (volume overload)
DIURETICS
Cornerstone therapy for HFREF
Acei and BB
Benefit of ACE-I and BB extends to NYHA Class
Class IIIB - IV
Treatment for PULMONARY EDEMA ADHF
Opiates
VASODILATORS
DIURETICS
O2 and Noninvasive ventilation
Inotropic therapy for ADHF which increased CAMP and cytoplasmic calcium
Dobutamine (b1 agonist)
Milrinone (PDE INHIBITOR)
Indication for Inotropic therapy for ADHF
As bridge therapy ( to LV assist device support or transplant)
Palliation in end stage HF
Beta blockers dose dependent improvement and reduction in mortality and hospitalization is restricted to
CBM
Carvedilol
Bisoprolol
Metoprolol succinate
Mineralocorticoid antagonist that is selective for NYHA II and post MI HF
Eplerenone
Mineralocorticoid antagonist that is non-selective, NYHA III-IV
SPIRONOLACTONE
Neurohormonal escape Strategy is ACEI + BB, ARB + BB or ACEI + ARBS if BB INTOLERANT, HOWEVER IF SYMPTOMATIC NYHA II -IV May add
Aldosterone antagonist
Substitute to acei and ARBs if intolerable (hyperkalemia and renal insufficiency) combined arterial dilator and about dilator, with benefits for African Americans
Hydralazine and nitrates
Trial for sacubitril - Valsartan (ARNI improves survival compared to ACEI alone)
PARADIGM HF TRIAL
Inhibitor of funny channels If in the SA NODE which slows HR WITHOUT a negative inotropic effect (SHIFT TRIAL)
Indicated in symptomatic px despite Acei, bb and aldo ant with residual hr>70bpm
IVABRADINE
True or false
In DIG trial: there is decreased HF HOSPITALIZATION but no reduction in mortality , no improvement in QOL AND INCREASED mortality rate and hospitalization in W>M
TRUE
Use as initial treatment of HF to achieve volume control prior to neurohormonal therapy
Oral diuretics
Use to DECREASE BP in HF
Second generation CCB AMLODIPINE AND FELODIPINE
DO NOT USE 1st gen and NON DHP (diltiazem and verapamil)
Treatment of anemia in HF sec to iron deficient, dysregulation of iron metabolism and occult gi bleeding
IV IRON ( iron sucrose and carboxymaltose)
Treatment of AF in HF
AMIODARONE
DOFETILIDE
Dm therapy that DECREASES CV MORTALITYand hospitalization in HF
EMPAGLIFLOZIN (SGLT2 inhibitor)
Surgical therapy for px with ischemic cm with multi vessel CAD in HF
CABG
Alterations in Left Ventricular Chamber Geometry
Left ventricular (LV) dilation
Increased LV sphericity
LV wall thinning
Mitral valve incompetence
