Heart Failure Flashcards
what is the definition of heart failure
progressive structural or functional disorder of the myocardium, endocardium or pericardium which results in heart muscle mass enlargement due to compensatory mechanisms of increased heart rate to increase cardiac output, narrowing of coronary vessels to sustain blood pressure, with decreased blood flow to the kidneys, heart and brain. compensatory mechanism may take years until fatigue, shortness of breath and edema develop left sided heart failure occurs before right sided heart failure. heart failure can involve the hearts left, right or both sides.
what are some heart failure statistics
75% of those with HF have HTN the lifetime risk of HF is doubled for patients with HTN 160/90 vs those with BP < 140.90
what is expected cost of HF in 2015
22.5 billion 63% attributable to direct medical costs
what is future projection of HF cost?
2030 total cost will increase by 84% to 41.5 billion, from 2015.
what is the simplified pathophysiology of HF
what are the 2 key features of pathophysiology of HF
- impaired cardiac output (perfusion) 2. increased cardiac filling pressures (volume)
what are the factors impairing cardiac output
stage A HF
at high risk for HF but without structural heart disease or symptoms of HF
Patients with: HTN, atherosclerostic disease, DM, obesity, metabolic syndrome or patients using cardiotoins, with family history of cardiomyopathy
therapy
Goals:
- heart health lifestyle
- prevent vascular, coronary disease
- prevent LV structural abnormalities
Drugs:
- ACEI or ARB in appropriate patients for vascuarl disease or DM
- statins as appropraite
stage b HF
structural heart disease but without signs or symptoms of HF
patients with: previous MI, LV remodeling including LVH & low EF, asymptomatic valvular disease
THERAPY
Goals:
- prevent HF symptoms
- prevent further cardiac remodeling
drugs:
- ACEI or ARB as appropriate
- beta blockers as appropriate
in selected patients
- ICD
- revascularization or vasular surgery as appropriate
stage C HF
structural heart disease with prior or current symptoms of HF
patients with: known structural heart disease and HF signs and symptoms
HFpEF Therapy
Goals
- control symptoms
- improve HRQOL
- prevent hospitalization
- prevent mortality
Strategies - idenfification of comorbidities
Treatment
- diuresis to relieve symptoms of congeiton
- follow guideline driving indications for comorbidities (HTN, AF, CAD, DM)
HFrEF Therapy
Goals:
- control symptoms
- patient education
- prevent hospitalization
- prevent mortality
Drugs for routine use
- diurtics for fluid retention
- ACEI or ARB
- beta blocker
- aldosteone antagonists
drugs for use in selected patients
- hydralazine/ISDN
- ACEI and ARB
- digitalis
in selected patients
- CRT
- ICD
- revsacularization or vascular surgery as appropriate
stage D HF
refractory HF
Patients w/ marked HF symptoms at rest
recurrent hospitalizations despite GDMT
Therapy
- control symptoms
- improve HRQOL
- reduce hospital readmissions
- establish pareitn end of life goals
Options
- advanced care measures
- heart transplant
- chronic inotropes
- temporary or permanent MCS
- experimental surgery or drugs
- palliative care and hospice
- ICD deactivation
what are the 2 types of left sided heart failure
- heart failure with reduced ejection fraction (HFrEF) AKA systolic failure - heart gets tired of beating -left ventricle loses its ability to contract normally. heart can’t pump with enough force to push enough blood into circulation 2. heart failure with preserved EF (HFpEF) AKA diastolic failure/dysfunction -has S3/gallop -left ventricle loses its ability to relax normally b/c muscle has become stiff -heart can’t properly fill with blood during the rest period between each beat
information on right sided HF
-right ventricular dysfunction is most commonly caused by either hypoxic pulmonary disease of LV dysfunction -when right ventricle is unable to fill or eject adequate amounts of blood, it leads to an elevated right atrial pressure -this contributes to increased pressure in the vena cava and impaired venous drainage from the liver, GI tract, lower extremities, resulting in hepatomegaly, abdominal pain and peripheral edema
what are clinical recommendations for HF
-initial evaluation of patients with suspected heart failure should include a history & physical examination, lab assessment, CXR, and electrocardiography. echocardiography can help confirm the diagnosis
what are good predictors to rule in the diagnosis of heart failure
displaced cardiac apex, third heart sound, CXR findings of pulmonary venous congestion or interstitial edema.
how can you rule out systolic heart failure
systolic heart failure can be effectively ruled out with a normal B type natriuretic peptide or N-terminal pro-BNP natriuretic peptide level
what is another way to rue out heart failure
systolic heart failure can be effectively ruled out when the Framinham criteria are not et.
what will give you the exact EF?
a mugga scan
what do you need to rule in heart failure using the Framingham definition of HF
2 major or 1 major + 2 minor criteria
what are the major criteria of the Framingham definition
-paroxysmal nocturnal dyspnea -orthopnea -elevated Jugular venous pressure -pulmonary rales -third heart sound -cardiomegaly on chest radiograph -pulmonary edema on chest radiograph
what are the minor criteria of the Framingham definition
-peripheral edema -night cough -dyspnea on exertion -hepatomegaly -pleural effusion -heart rate > 120 -weight loss > 4.5 kg in 5 days.
what are the 3 categories of heart failure
- HFpEF 2. HFrEF 3. HFmrEF
what is HFpEF
patients with symptoms +/- signs of heart failure, but a normal left ventricular ejection fraction (LVEF > 50%)
what is HFrEF
patients with symptoms +/- signs of heart failure and a reduced left ventricular ejection fraction (LVEF < 40%)
what is HFmrEF
patients with symptoms +/- signs of heart failure and a ‘mid-range’ left ventricular ejection fraction (LVEF 40-49%)
what are vasodilators used to reduce BP in HTN acute HF
nitrates nitroprusside infusion nesiritide morphine sulfate hydralazine
what are diuretics/loop diuretics used to reduce BP in HTN acute HF
-furosemide, torsemide, or bumetanide -initial dose should equal or exceed chronic dose -subsequent dose may be required and/or addition of a second diuretic (such as a thiazide diuretic)
when should you consider advanced therapies, what are signs of pos prognosis?
-hyponatremia (<125) -high diuretic requirements (>1.5 mg/kg furosemide) -intolerant to guideline based medications (ACE/BB) -worsening renal insufficiency -recurrent hospitalizations -low systolic blood pressure (<90) -use of inotropic medications -high biomarker or risk score
when should you use inotropes?
-inotropic support is not for routine use in heart failure patients, especially those warm & wet -increase mortality in the long run -use only if cold and wet or palliative care -use only with systolic heart fialure
what is acute treatment for HFpEF
-stiff heart is dependent on preload for filling -aggressive preload reduction can lead to hypotension -cautious use of preload reducers -reducing BP (after load) in a HTN patient can reduce LVEDP -consider short acting drips that can be turned off quickly (nitroprusside)
what is acute treatment for advanced HFpEF
-since there is normal EF no role for inotropic therapy -may benefit from ultrafiltration if unable to achieve volume loss
acute management take home points for HF
-determine if warm/wet/dry/cold -generally continue chronic HF medication but no rush to start new chronic HF medication -IV diuretics with a goal of achieving euvolemia -ultrafiltration only in very refractory cases -vasodilators before inotropes if BP allows -inotropes only in the ‘cold’ patient (look for signs of end order perfusion - urine output, rising creatinine, lactic acidosis, mental status) -no clear role for nesiritide or renal dosed dopamine.
hospital management for HF
-once stabilized identify type, etiology (if new onset) or precipitating factors (if prior history) -correct any reversible causes -optimize volume status -echoardiogram to evaluate LV function -transition to chronic therapy medications
what are some precipitating factors?
-ischemia -noncompliance with medications -excessive fluid/salt intake -thyroid dysfunction (TSH, free T4 & free T3) arrhythmias (a-fib, ventricular tachycardia) -anemia -malignant HTN -drug interactions (including negative inotropic drugs and those that increase salt retention NSAIDs)
what are medications the patient should have at discharge
-ACEI/ARB -beta blocker (once euvolumic) - titrate slowly -aldosterone antagonist (if K+ and renal function are ok and can monitor potassium) -hydralazine/ISDN (if black) -sacubitril/valsartan (Entresto) instead of ACE/ARB -diuretic if CAD ASA +/- statin
HFpEF treatment
treat underlying condition -HTN: control SBP & DBP -no benefit of particular drugs over others in contrast to HFrEF (systolic HF); CCB will sometimes cause foot/ankle edema -ischemia: consider revascularization: ASA, statin, ACEI, beta blocker -if tachyardic (a-fib) control heart rate -use diuretics for symptomatic improvement
drugs to avoid with HF
-most antiarrhythmics (except amiodarone, does not improve mortality & deofetilie) non-dihydropyridine calcium channel blockers (verapamil, diltiazem) negative inotropes NSAIDs long term inotropes unless used for palliation nutritional supplements and hormonal therapies are not indicated unless repleting deficiencies ACD+ARB+aldosterone antagonist combination is contraindicated
load dependency of measurement of LV function
stroke volume: preload / after load dependent cardiac output: preload / after load / heart rate ejection fraction: preload / after load dependent
what is stroke volume
quantity of blood ejected with each heart beat mL
what is cardiac output
quantity of blood delivered to the systemic circulation per unit time (L/min) (stroke volume * HR)
what type of non-invasive cardiac imaging is recommended?
- patients w/ suspected acute or new onset HF should undergo a CXR 2. 2D echocardiogram with doppler should be performed for initial evaluation of HF 3. repeat measurement of EF is useful in patients w/ HF who have had a significant change in clinical status or received treatment that might affect cardiac function or for consideration of device therapy.
recommendations for invasive evaluation
monitoring with a pulmonary artery catheter should be performed in patients with respiratory distress or impaired system perfusion when clinical assessment is inadequate.
recommendations for inotropic support, MCS, and cardiac transplantation?
- HF patients hospitalized with fluid overload should be treated with IV diuretics 2. HF patients receiving loop diuretic therapy should receive an initial parental dose greater than or equal to their chronic oral daily dose, the dose should be serially adjusted 3. HFrEF patients requiring HF hospitalization on GDMT should continue GDMT except in cases of hemodynamic instability or where contraindicated 4. initiation of beta-blocker therapy at a low dose is recommended after optimization of volume status and discontinuation of IV agents. 5. thrombosis/thromboembolism prophylaxis is recommended for patients hospitalized with HF 6. serum electrolyte, BUN, creatinine should be measured during titration of HF medications, including diuretics
recommendations for treatment of HFpEF
systolic & diastolic BP should be controlled according to published clinical practice guidelines diuretics should be used for relief of symptoms due to volume overload.
recommendations for pharmacologic therapy for management of stage C HFrEF
- diuretics are recommended in patients with HFrEF with fluid retention 2. ACEI are recommended for all patients with HFrEF 3. ARBs are recommended in patients with HFrEF who are ACEI intolerant 4. use of 1 of the 3 beta blocker (bisoprolol, carvedilol, or metoprolol) proven to reduce mortality is recommended for all stable patients 5. aldosterone receptor antagonists are recommended in patients with NYHA class II-IV who have LVEF 35% 6. aldosterone receptor antagonists (aldactone) are recommended in patients following an acute MI who have LVEF < 40% with symptoms of HF or DM 7. the combination of hydrazine and ISDN is recommended for blacks with NYHA class III-IV HFrEF on GDMT 8. patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardio-embolic stroke should receive chronic anticoagulation therapy 9. the selection of an anticoagulation agent should be individualized
recommendations for treatment of stage B HF
- in patients with a history of MI and reduced EF, ACEI or ARBs should be used to prevent HF 2. in patients with MI and reduced EF, evidence based beta blockers should be used to prevent HF 3. in patients with MI, statins should be used to prevent HF 4. blood pressure should be controlled to prevent symptomatic HF 5. ACEI should be used in all patients with a reduced EF to prevent HF 6. beta blockers should be used in all patients with a reduced EF to prevent HF
recommendations for biomarkers in HF
- natriuretic peptides: diagnosis or exclusion of HF & prognosis of HF. both ambulatory & acute 2. biomarkers of myocardial injury, additive risk stratification. acute & ambulatory
