Heart Failure Flashcards
What is HF?
Inability to pump blood forward due to dec CO or inc intra-cardaic pressures
Factors controlling CO
Preload - PCWP…EDV
Contractility - EF…ability to develop force independent of preload and afterload
Afterload - SVR…blood at which ventricle has to work against to eject
HR and rhythm
HFpEF
HFrEF
HFpEF…inability to fill due to still ventricel…dec compliacne or relaxation…EF preserved
HFrEF - inability to contract or empty…EF under 40.
Progression
WIth Excpetion of transplant or mech support, txs dec morbidity and delay mortality
Compensatory mechs help inc CO but worsen underlying dz
Compensatory mechs
Intial fall in LV and wall stres…activate RAAS and SNS which
1) fibrosis, apoptosis, hypertrophyh, myotoxicty
2) inc HR and LV remodeling
3) AT2 inc SVR and leads to edema
Sx of HF
Low output - renal faiure, cool extremities, lethargy
Inc cogenstion - DOE< orthopnea, PND
Sx of RV failure - nausea, ab distension and bloating, LE edema
Acute deompensated HF
No cong, low perfusion - warm and dry…PCWP and CI normal
Congested and low perfusion - Warm and wet…PCWP elevated and CI normal
Low perfusion but no congestion - Cold and dry PCWP low/normla and CI decreased
Congestion and low persuon - COld and wet PCWP elevated, CI dec
CI cutoff 2, PCWP 18
Adjunct testing
CXR for edema and congestion of pulmonary
ECG - look for chamber abnormlities, arrhythmias, ischemi/infarction
Lab testing - NT-pro BNP, sodium
Echo
LF signs and sx
Dyspnea Orthopnea Cough PND Pulm edema Pleural effusion Bibasilar rales S3 gallop
RF signs and sx
Peripoheral edema JVD Hepato/splenomegaly Ascites Nausea/anorexia Hepatojugular reflux
Fxns classes
1 - no limitation
2 - slight on exertion
3 - marked (act of daily living)
4 - at rest
Tx
Short term - tx underlying etiology and improve hemodynamics
LT - lifestyle mods, ACEI, B blocker, aldosterone antags, defib
Acute meds
Dec preload - diuretics
Improve contractility - inotropic agents and mech circulatory support
Dec afterload
Non pharm approahc to chonic HF
Reduce salt intake Fluid restriction Weight loss if obese Exercise Defib
INhibition of hypertrophic growht response and cardiac remodeling
Beta blockers
ACEIs/ARB
Aldosterone antags
ACE inhibs
LVEF under 40%
Afterload and preload reduction with RAAS inhibiton
IMprove sx and reduce remodeling
Angiotensin antags
ACEIs should be used first
If chronic cough move to ARBs
If angioedema with ACEIs, do not use ARBs
PReg contraindication
Beta blocker - general
Dec in HR without inc in stroke volume is NOT good
Inhbit SNS Reduce afterload and inc EF Reduce remodeling Reduce hospitalization Reduce mortality
Beta blocker indication
LVEF under 40% Not a class effect
Carvedilo, metoprolol, bisoprolo
Beta blocker pearls
Start on stable pts
Low and slow
May havbe to inc diuretic to inc BB
Aldosterone antags
LFEV under 35 or under 40 post MI
Already on ACEI and BB
Class effect - epleronone and spironlacton
Conta if renal failure (Cr over 2) and hyperklaemia (K over 5)
Diuretics
Hydralazine and isosorbide
Ivabradine
Sx of congestion
Motrality benefit in African americnas
HR over 75 on max BB
Digoxin
Improves sx but narrow therpaeutic index
ICD
Implantable cardiac defibrillator
MOst effective tx of vent arrhytmias
Who qualifies for ICD
LVEF below 35
At least 40 days post MI
Good med therapy
High risk of sudden cardiac death
Contraind for ICD
VT from reversible cause
Unlikely to survive 1 year
Incessant VT
Psychiatric illness
Biventricular pacing
Cardiac resynchronization
Dyssynchroy - diff in timing of the contractions of the 2 ventricles or the septal or lateral wall of left ventricle
Goes through coronary sinus
Who gets biventriclar pacing
Low LVEF (under 35) Wide QRS (over 150 msec) Class 3 or 4
Biventricular pacing benefits
6 minute walk test better
Dec hospitalizing
Reduction in mortality
