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Internal Medicine (IM platinum) > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

Etionpathogenesis of Heart failure

A

clinical syndrome charcterized by clincal symptoms (dyspnea and fatigue) and signs (edema, rales, elevated JVP) that lead to frewquent hospitalizations, poor quality of life and shortened life expectancy

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2
Q

Etiologies of Heart Failure

A
  • Coronary artery disease (CAD) : most common cause of HF in industrialized countries (60-75%)
  • Hypertension: cause of HFin 75% of patients
  • Cardiomyopathy: dilated cardiomyopathy, restrictive cardiomyopathy, hypertrophic cardiomyopathy
  • Pulmonary heart disease: cor pulmonale, pulmonary vascular disorders
  • High output states: thyrotoxicosis, nutritional disorders (beriberi), excessive blood flow requirements, chronic anemia
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3
Q

Classification and Statges of Heart Failure

(Based on LV function/Ejection Fraction)

A
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4
Q

American College of Cardiology/American Heart Association Stages (compared with NYFC)

STAGES OF HEART FAILURE

A
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5
Q

Fatigue and dyspnea

A
  • Cardinal symptoms of heart failure
  • Due to pulmonary congestion → activated juxtacapillary J-receptors → cardiac dyspnea
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6
Q

Orthopnea/ Nocturnal cough

A
  • Dyspnea in the recumbent position
  • Redistribution of fluid from splanchnic circulation and lower extremities into the central circulation on recumbency
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7
Q

Trepopnea

A
  • Dyspnea in lateral decubitus position
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8
Q

Paroxysmal Noctural Dyspnea

A
  • Severe dyspnea that awakens patientent from sleep 1-3 hours after patient retires
  • Increased pressure in the bronchial arteries
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9
Q

Cheyne-Stokes Respiration

A
  • Periodic/cyclic respiration respiration: series of apnea, hyperventilation, and hypocapnia
  • Caused by an increased sensitivity of the respiratory center to arterial pCO2
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10
Q

Other Symptoms of Heart Failure

A
  • GI:
    • anorexia
    • nausea
    • early satiety
    • abdominal fullness (congested liver and/or bowels)
  • CNS:
    • confusion
    • disorientation
    • sleep
    • mood disturbance
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11
Q

General and Vital signs of patients with HF

A
  • Uncomfortable when lying flat, labored breathing
  • Normal or low BP
  • cardiac cachexia
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12
Q

Cardiovascular signs in patients with HF

A
  • Elevated jugular venous pressure (JVP)
  • Sinus tachycardia due to increased adrenergic activity
  • Point of maximal impulse displaced due to cardiomegaly
  • Regirgitant murmurs: MR and TR
  • S3 (protodiastolic gallop) at apex: usually in volume overloaded patients
  • S4: usually in diastolic dysfunction from LV hypertrophy
  • Pulsus alterans and narrow pulse pressure or thready pulse in severe disease
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13
Q

Pulmonary signs of Heart Failure

A
  • Crackels/rales: transudation of fluid from intravascular space to alveoli
  • Expiratory wheezes: cardiac wheezing caused by peribronchial cuffing from congestion
  • Pleural effusions: often bilateral; if unilateral, more often on the right
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14
Q

Abdominal signs of patients with heart failure

A
  • Hepatomegaly with pulsation (if with significant TR)
  • Ascites: increased pressure in the heaptic veins
  • Jaundice: impairment of hepatic function due to congestion
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15
Q

Extremities (Signs) of patients with Heart failure

A
  • peripheral edema: ankles and pre-tibial region (usually pitting)
  • Indurated and pigmented skin: longstanding edema
  • Peripheral vasoconstriction: cool extremities in late stages
  • Chronic venous stasis change (hyperpigmentation, venous ulcers, etc)
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16
Q

Framingham Diagnostic Criteria for HF

A
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17
Q
  • most useful test for evaluation of ejection fraction (EF) or LV function
  • Semi-quantitative assessmet of LV size, function, wall motion abnormalities, valvular defects
A

2D Echocardiography with doppler

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18
Q
  • Gold standard for emasurements of volumes, mass, and EF of both RV and LV
  • High quality imaging of heart obtained in tomographic planes
  • Can characterize myocardial tissue/ structure and Assess myocardial viability
A

Cardiac MRI

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19
Q
  • Assess cardiac rhythm, LV hypertrophy, prior MI
A

12-Lead ECG

  • A normal ECG virtually excludes LV systolic dysfunction
  • An abnormal ECG increases likelihood of HF, but has low specific
20
Q
  • Assess the cardiac size and shape and state of pulmonary vasculature
A

Chest Radiography

  • Kerley B lines:
    • thin, horizontal linear opacities extending to the pleural surface due to fluid in the interstitial space
  • Other Findings:
    • peribronchial cuffing
    • prominent upper lobe basculature (cephalization)
21
Q

Cardiac biomarkers

A
  • Includes B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NTp-proBNP)
    • upper limits in chronic HF: BNP 35 pg/ml and NT-proBNP 125 pg/ml
    • upper limits in acute HF: BNP 100 pg/ml and NT-proBNP 300 pg/ml
  • Relatively sensitive markers for the presence of heart failure
  • Increase with age and renal impairment
  • May be falsely low in obese patients
22
Q

Complete Blood count (HF)

A
  • Look for anemia
  • signs of infection
  • bleeding

Which may precipitate/worsen HF

23
Q

Serum electrolytes, BUN, Creatinine, AST, ALT

(HF)

A
  • Assess for electrolyte disturbances or beginning cardiorenal syndrome, ischemic hepatitis or chronic passive congestion of the liver
24
Q

Other Labs for Heart Failure

A
  • FBS, OGTT: assess for diabetes
  • Lipid profile: assess for dyslipidemia
  • FT4, TSH: assess for thyroid hormone abnormalities
25
Q

Non pharmacologic manangement of HRrEF

A
  • Sodium restriction: limit Na intake to 2-3 g/day in all patients with HF; and to <2g/day in patients with moderate to severe HF
  • Fluid restriction: generally unnecessary unless with hyponatremia (less than 130 mEq/L) and volume overload
  • Caloric supplementation: for those with cachexia
26
Q

ACE-Inhibitors for Heart Failure

A
  • Cornerstone of modern HF treatent
  • Interferes with RAAS by inhibiting conversion of angiotensin-I to angiotensin II
  • Inhibits kininase which increases bradykinin (causes ACE-I induced cough)

Captopril 6.25 to 50 mg TID

Enalapril 2.5-20 mg BID

Ramipril 2.5-10 mg OD

Lisinopril 5–20 mg OD

27
Q

Angiotensin Receptor Blockers (ARBs) for Heart Failure

A
  • Used if ACEI intolerant (i.e cough, angioedema)

Valsartan 40-160 mg BID

Candesartan 4-32 mg OD

Losartan 25-100 mg OD

28
Q

Beta Blockers for heart Failure

A
  • Another cornerstone of modern HF therapy
  • Interferes with sustained activation of the adrenergic nervous system, particularly the deleterious effects of B1 activation
  • Three BB effective in reducing risk of death in chronic HF:
    • Carvedilol
    • Bisoprolol
    • Metoprolol succinate

Carvedilol 3.125-25 mg BID

Bispoprolol 1.25-10 mg OD

Metoprolol succinate 25-200mg OD

Nebivolol 1.25-10 mg OD

29
Q

Aldosterone Antagonist for Heart Failure

A
  • Inhibits action of aldosterone on the collecting duct
  • May also be used for fluid retention (diuretic)

Spironolactone 25-50 mg OD

Eplerenone 25-50 mg OF

30
Q

Digoxin for Heart Failure

A
  • Inhibits Na-K-ATPase pump, increasing intracellular Ca, which leads to increased cardiac contractility
  • For symptomatic LV dysfunction with concomitant atrial fibrillation
  • Add-on standard therapy

Digoxin 0.125-0.375 mg OD

31
Q

Ivabradine for Heart Failure

A
  • Reduces heart rate by inhibition of the “funny channel” (If) in the SA node
  • Primarily used for symptomatic chronic stable angina
  • May be used on top of BB for HF with systolic dysfunction in patients with sinus rhythm and heart rate >=70 bpm

Ivabradine 5-7.5 mg BID

32
Q

Angiotensin Receptor Neprilysin Inhibitor (ARNI): LCZ696 (Sacubitril + Valsartan)

A
  • Combines an ARB(valsartan) and a neprilysin inhibitor (sacubitrl)
  • Recommended to replace ACE-inhibitors in ambulatory HFrEF patients who remain symptomatic despite optimal therapy (but require discontinuation of the prior ACE-inhibitor at least 36 hours before starting ARNI)

Sacubitril/Valsartan

49/51 - 97/103 mg BID

33
Q

Management if Fluid Retention in Chronic Heart Failure

34
Q

Indications for Use of Drugs in HF

35
Q

Devices used in Heart Failure

A
  • Cardiac resynchronization Therapy (CRT) or Biventricular Pacing:
    • device used to restore synchronized contraction of the left and right ventricles in patients with heart failure in sinus rhythm and widened QRS complex
  • Implantable ardioverter-Defibrillator (ICD):
    • device to treat tachyarrhytmias (VF or VT) for primary/secondary prophylaxis against sudden cardiac death
36
Q

Classification of Diastolic Dysfunction by Echocardiography

37
Q

Therapy for HFpEF

A
  • Evidence is lacking for the management of HFpEF
  • No treatment has been shown to redue orbidity or mortality in HFpEF
  • Practical clinical approach:
    • Manage individual risk factors (HPN, DM, CAD, etc.)
    • Reduce symptoms (diuretics may be used to relieve volume overload)
    • Prevent acute decompensation
    • Improve exercise tolerance
38
Q

Refers to rapid onset or worsening of symptoms/signs of HF

A

Acute Decompensated Heart Failure

  • Life threatening and requires urgent treatment
39
Q

Acute Decompensation of Chronic HF

A
  • Typical Triggers
    • Patient with chronic compesated HF who gradually decompensates due to non-compliance to meds, ischemia, or infections
  • SSx
    • Peripheral edema
    • Orthopnea
    • Dyspnea on exertion
    • Usually no/minimal volume overload
  • Clinical Assessment
    • ​SBP: generally in the normal range
    • CXR: often clear despite elevated filling pressures
    • Echo: preserved or reduced EF
40
Q

Acute Hypertensive HF

A
  • TYPICAL TRIGGERS
    • Patient with no heart failure suddenly decompensates
    • Possible causes:
      • Hypertensive emergency
      • Arrythmias
      • ACS
  • SSx
    • Dyspnea
    • Tachypnea
    • Tachycardia
    • Frank pulmonary edema
  • CLINICAL ASSESSMENT
    • ​SBP >140 mmHg in most
    • CXR: pulmonary edema
    • Echo: preserved EF in most patients
    • Hypoxemia common
41
Q

Cadiogenic Shock

A
  • TYPICAL TRIGGERS
    • Patient with progression of advanced HF or a patient who develops a major mayocardial insult (large AMI, acute myocarditis)
  • SSx
    • End organ hypoperfusion
    • Oliguria
    • Confusion
    • Cool Extremities
  • CLINICAL ASSESSMENT
    • ​SBP: low or low normal
    • Echo: severely depressed EF
    • Evidence of end-organ dysfunction (renal, hepatic)
42
Q

Parenteral Therapy for Acute Decompensated HF

43
Q

Simplified Management Based on Clinical Profile

44
Q

Signs of hypoperfusion (“cold”)

A
  • Cold extremities
  • Confusion
  • narrow pulse pressure
45
Q

Signs of Congestion (“wet”)

A
  • rales
  • jugular venous distention
  • PND
  • edema

Internal Medicine (IM platinum) (14 decks)

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