Heart Failure

Question 1

Etiologies of heart failure

Answer 1

CAD - IHD

Idiopathic, dilated cardiomyopathy

Valvular heart disease

Hypertensive heart disease (congenital, viral myocarditis, toxins, endocrine, nutritional)

Restriction/obstruction to ventricular filling (RV infarct, constrictive pericarditis, mitral stenosis, atrial myxoma)

Others: thyrotoxicosis, AV fistula, beri beri

Question 2

Most common cause of LV systolic dysfunction

Answer 2

Ischemic heart disease

Question 3

Define stage A HF

Answer 3

Patients at high risk for heart failure WITHOUT structural heart disease or symptoms of heart failure

[ex: HTN, DM, obesity, CAD, PVD, FH, exposure to toxins]

Question 4

Define stage B HF

Answer 4

Patients with structural heart disease but WITHOUT signs/symptoms of heart failure

[ex: prior MI, LVH, reduced LVEF, asymptomatic valvular dz]

Question 5

Define stage C HF

Answer 5

Pts with structural heart disease with prior or current symptoms of heart failure

[ex: known structural heart disease and dyspnea, fatigue, reduced exercise tolerance]

Question 6

Define stage D heart failure

Answer 6

Pts with refractory heart failure requiring specialized interventions

[ex: marked sx at rest despite maximal medical therapy, with recurrent hospitalizations]

Question 7

The NYHA functional classification of clinical stages of HF are based on what 2 parameters?

Answer 7

Exercise capacity

Symptomatic status of disease

Question 8

Compare differences of the 4 functional classes of HF from NYHA

Answer 8

Class I = asymptomatic

Class II = no sx at rest, exertional sx with ordinary activity

Class III = no sx at rest, sx with minimal activity

Class IV = sx at rest; inability to carry out activity without discomfort

Question 9

What diagnostic tool is essential in evaluation of heart disease, and is necessary to distinguish systolic HF from diastolic HF?

Answer 9

Echocardiogram

Question 10

What type of heart failure is associated with CAD, VHD, HT, myocarditis, and more; and is associated with decreased SV and increased ventricular filling pressure?

Answer 10

Systolic heart failure (HFrEF)

Question 11

What type of heart failure is associated with restrictive/constrictive pericarditis, hypertensive/hypertrophic cardiomyopathy, and a preserved EF (HFpEF)?

Answer 11

Diastolic HF

Question 12

Causes of high output heart failure (High CO, low EF)

Answer 12

Hyperthyroid
Anemia
Pregnancy
AV fistula
Beriberi
Paget’s

Question 13

Causes of low output HF

Answer 13

Ischemic heart disease
HTN

[dilated cardiomyopathy, valvular and pericardial dz]

Question 14

______-sided HF is associated with edema, hepatomegaly, and venous distention

Answer 14

Right

Question 15

_____sided HF is associated with aortic stenosis and mitral insufficiency with sx of dyspnea and orthopnea d/t pulmonary congestion

Answer 15

Left

Question 16

General compensatory mechanisms in HF

Answer 16

SNS
RAAS
Cytokine activation
Altered renal physiology
LV remodeling

Question 17

One compensatory response in HF is activation of RAAS due to reduced renal perfusion. This leads to increased renin and angiotensinogen. What causes the associated increases in preload and afterload?

Answer 17

Angiotensin II increases BP by vasoconstriction —> adrenal gland release of aldosterone —> Na and H2O retention —> increased preload (volume expansion)

Angiotensin II vasoconstriction also increases PVR —> increased afterload

Question 18

Stimulation of thirst by _____ also increases TBW and dilutional hyponatremia, thus increasing _____

Answer 18

Arginine vasopressin (AVP or ADH); preload

Question 19

What are some medications that can worsen HF?

Answer 19

CCBs
Beta blockers (high doses)
NSAIDs
Antiarrhythmics

Question 20

Presence of what on PE increases likelihood of heart failure 11-fold?

Answer 20

S3 gallop

Question 21

Signs/symptoms of RV failure

Answer 21

Peripheral/sacral edema
Hepatomegaly
Ascites
Increased JVD/HJR

Question 22

Is heart failure typically associated with unilateral or bilateral LE edema?

Answer 22

Bilateral

Question 23

Signs of heart failure on CXR

Answer 23

Cardiomegaly
Pulmonary edema with central peripheral infiltrates
Increased size of vessels in upper lungs
Pleural effusions

Question 24

Signs of HF on ECG

Answer 24

May have ischemia, infarct, hypertrophy

Rhythm disturbances (atrial, junctional, ventricular)

Tachycardia/bradycardia/heart blocks

Question 25

What’s something you always want to look for on CBC in HF pts, because it may aggravate their condition?

Answer 25

Anemia

Question 26

If a patient is in heart failure, greater than 65 years old, and presenting with atrial fibrillation, what must you always check?

Answer 26

Thyroid function [free T4; TSH]

Question 27

What changes in ABGs might be present in pts with HF?

Answer 27

Hypoxia induced metabolic acidosis due to lactic acid

Question 28

Neurohormone sensitive to ventricle stretch and volume overload stimulated by increased preload/afterload, and used as sensitive marker for HF

Answer 28

BNP [if value is <100, there is 97% of no HF]

Question 29

What increases BNP other than HF?

Answer 29

AMI PE Renal failure Old age

Question 30

Indications for admission to hospital for management of HF

Answer 30

``` Acute myocardial ischemia Severe respiratory distress Hypoxia Hypotension Cardiogenic shock Anasarca Syncope HF refractory to oral meds ```

Question 31

Nonpharmacologic tx for HF

Answer 31

Quit smoking Decrease caloric and sodium intake AHA diet Fluid restriction if Na<126 Avoid isometric activity (increase SVR and afterload) Encourage isotonic activity - walking/hiking/golf Avoid alcohol

Question 32

What medication class is useful for all NYHA functional classifications with systolic heart failure but must be used cautiously in pts with renal insufficiency or K>5?

Answer 32

ACE-I

Question 33

Drug class comparable to the ACE-I but not MORE effective

Answer 33

ARBs

Question 34

What drug class shows benefits in decreasing HR, treating arrhythmias, anti-ischemic, blunts SNS effects, and reverses remodeling, BUT cannot be used in unstable HF pts (class IV)?

Answer 34

Beta blockers [these are recommended for all stable pts with sx of HF, reduced EF]

Question 35

Inotropic agent that improves quality of life associated with HF but no demonstratable effect on survival; useful in HFrEF and afib for rate control

Answer 35

Digitalis

Question 36

Drug used in addition to standard care for HF that may decrease mortality and hospitalizations due to antagonistic effect on aldosterone

Answer 36

Spironolactone (or eplerenone)

Question 37

Inotropic agent that stimulates beta 1 and beta 2 receptors

Answer 37

Dobutamine

Question 38

Inotropic vasodilator that inhibits phosphodiesterase

Answer 38

Milrinone

Question 39

Inotropic agent that stimulates beta 1 receptors, but at high doses also stimulates alpha receptors; useful short term

Answer 39

Dopamine

Question 40

Arterial vasodilator that reduces afterload and SVR, sometimes paired with isosorbide dinitrate

Answer 40

Hydralazine [better response to hydralazine and isosorbide in african americans than in whites; use if intolerant to ACE/ARB]

Question 41

When hydralazine + _______ are added to diuretics and dig, may reduce mortality, increase EF, and increase exercise tolerance

Answer 41

Nitrates

Question 42

What drug class shows no benefit and is not recommended routinely to tx HF patients, however may be used to tx in those with reduced EF

Answer 42

CCBs

Question 43

OMM applications in HF

Answer 43

Lymphatics: thoracic inlet, rib raising, doming the diaphragm, effleurage/petrissage, cervical stroking