Heart Failure Flashcards
Etiologies of heart failure
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
Most common cause of LV systolic dysfunction
Ischemic heart disease
Define stage A HF
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]
Define stage B HF
Patients with structural heart disease but WITHOUT signs/symptoms of heart failure
[ex: prior MI, LVH, reduced LVEF, asymptomatic valvular dz]
Define stage C HF
Pts with structural heart disease with prior or current symptoms of heart failure
[ex: known structural heart disease and dyspnea, fatigue, reduced exercise tolerance]
Define stage D heart failure
Pts with refractory heart failure requiring specialized interventions
[ex: marked sx at rest despite maximal medical therapy, with recurrent hospitalizations]
The NYHA functional classification of clinical stages of HF are based on what 2 parameters?
Exercise capacity
Symptomatic status of disease
Compare differences of the 4 functional classes of HF from NYHA
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
What diagnostic tool is essential in evaluation of heart disease, and is necessary to distinguish systolic HF from diastolic HF?
Echocardiogram
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?
Systolic heart failure (HFrEF)
What type of heart failure is associated with restrictive/constrictive pericarditis, hypertensive/hypertrophic cardiomyopathy, and a preserved EF (HFpEF)?
Diastolic HF
Causes of high output heart failure (High CO, low EF)
Hyperthyroid Anemia Pregnancy AV fistula Beriberi Paget’s
Causes of low output HF
Ischemic heart disease
HTN
[dilated cardiomyopathy, valvular and pericardial dz]
______-sided HF is associated with edema, hepatomegaly, and venous distention
Right
_____sided HF is associated with aortic stenosis and mitral insufficiency with sx of dyspnea and orthopnea d/t pulmonary congestion
Left
General compensatory mechanisms in HF
SNS RAAS Cytokine activation Altered renal physiology LV remodeling
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?
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
Stimulation of thirst by _____ also increases TBW and dilutional hyponatremia, thus increasing _____
Arginine vasopressin (AVP or ADH); preload
What are some medications that can worsen HF?
CCBs
Beta blockers (high doses)
NSAIDs
Antiarrhythmics
Presence of what on PE increases likelihood of heart failure 11-fold?
S3 gallop
Signs/symptoms of RV failure
Peripheral/sacral edema
Hepatomegaly
Ascites
Increased JVD/HJR
Is heart failure typically associated with unilateral or bilateral LE edema?
Bilateral
Signs of heart failure on CXR
Cardiomegaly
Pulmonary edema with central peripheral infiltrates
Increased size of vessels in upper lungs
Pleural effusions
Signs of HF on ECG
May have ischemia, infarct, hypertrophy
Rhythm disturbances (atrial, junctional, ventricular)
Tachycardia/bradycardia/heart blocks
What’s something you always want to look for on CBC in HF pts, because it may aggravate their condition?
Anemia
If a patient is in heart failure, greater than 65 years old, and presenting with atrial fibrillation, what must you always check?
Thyroid function
[free T4; TSH]
What changes in ABGs might be present in pts with HF?
Hypoxia induced metabolic acidosis due to lactic acid
Neurohormone sensitive to ventricle stretch and volume overload stimulated by increased preload/afterload, and used as sensitive marker for HF
BNP
[if value is <100, there is 97% of no HF]
What increases BNP other than HF?
AMI
PE
Renal failure
Old age
Indications for admission to hospital for management of HF
Acute myocardial ischemia Severe respiratory distress Hypoxia Hypotension Cardiogenic shock Anasarca Syncope HF refractory to oral meds
Nonpharmacologic tx for HF
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
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?
ACE-I
Drug class comparable to the ACE-I but not MORE effective
ARBs
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)?
Beta blockers
[these are recommended for all stable pts with sx of HF, reduced EF]
Inotropic agent that improves quality of life associated with HF but no demonstratable effect on survival; useful in HFrEF and afib for rate control
Digitalis
Drug used in addition to standard care for HF that may decrease mortality and hospitalizations due to antagonistic effect on aldosterone
Spironolactone (or eplerenone)
Inotropic agent that stimulates beta 1 and beta 2 receptors
Dobutamine
Inotropic vasodilator that inhibits phosphodiesterase
Milrinone
Inotropic agent that stimulates beta 1 receptors, but at high doses also stimulates alpha receptors; useful short term
Dopamine
Arterial vasodilator that reduces afterload and SVR, sometimes paired with isosorbide dinitrate
Hydralazine
[better response to hydralazine and isosorbide in african americans than in whites; use if intolerant to ACE/ARB]
When hydralazine + _______ are added to diuretics and dig, may reduce mortality, increase EF, and increase exercise tolerance
Nitrates
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
CCBs
OMM applications in HF
Lymphatics: thoracic inlet, rib raising, doming the diaphragm, effleurage/petrissage, cervical stroking
