Heart Failure Flashcards
What is the definition of heart failure?
Complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood
What is the difference between heart failure and dysfunction?
Dysfunction is asymptomatic
What is the difference between systolic and diastolic dysfunction?
Systolic is impaired cardiac contractile function and diastolic is abnormal cardiac relaxation, stiffness or filling
What if left heart failure characterized by?
Elevated LV filling pressures
How do you increase preload?
Increase venous return, filling time, ventricular compliance and filling pressure
How do you increase afterload?
Increase PVR and aortic pressure and decrease arterial wall compliance
What is the progression of heart failure?
Myocardial disease
Impaired ventricular performance/ventricular arrhythmias
Neurohormonal stimulation
Vasoconstriction/sodium retention
Increased impedance/ventricular dilation (then goes back to the second one)
What is HFrEF?
HF with reduced EF
Clinical signs/sxs of HF, systolic dysfunction (EF<40%) and increased LV volumes
How does the left ventricle change in HFrEF?
Progressive chamber dilation (cardiomyocytes elongate) and eccentric remodeling due to volume overload
What are causes of HFrEF?
Impaired contractility (CAD/cardiomyopathy) or high afterload from HTN
What is HFpEF?
HF with preserved EF
Clinical signs and sxs of HF and diastolic dysfunction seen on an echo (abnormal mechanical properties of ventricle like impaired relaxation of decreased compliance)
How do the ventricles change in HFpEF?
Concentric remodeling or hypertrophy due to a pressure overload
What happens when LV diastolic pressure is increased?
Increases pulmonary venous pressure (see dyspnea, exercise intolerance and pulm congestion)
What are big contributors of HFpEF?
Hypertension/LVH, aging, CAD, DM, sleep disordered breathing, obesity, kidney disease
What causes overlap between HFrEF and HFpEF?
Older age, HTN, CAD and DM
Pts with HFpEF tend to be…
Older, frequently with HTN, overweight, more often women
What is the most common cause of right heart failure?
Left heart failure (because it is a low pressure, high compliance system and doesn’t tolerate increases in afterload)
Risk factors of HF
CAD, smoking, HTN, overweight, DM, valvular heart disease
What is the most common cause of heart failure?
Coronary artery disease
What sxs will the patient report with HF?
Dyspnea, nocturnal/nonproductive cough, fatigue/weakness, dependent edema, weight gain (may have ascites, RUQ discomfort or nocturia)
What will be seen on the physical exam?
Edema, elevated JVD, crackles at the bases, displaced PMI, S3/S4 gallop, hepatomegaly, hepatojugular reflux
What survey is useful for the diagnosis of heart failure?
Modified Framingham Clinical Criteria
What is the progression of left heart failure?
Decreased CO and pulmonary congestion
What is the progression of right heart failure?
Congestion of peripheral tissues
Differences in clinical presenation between left and right HF?
Left: dyspnea, diaphoresis, tachypnea, tachycardia, rales, S3/S4
Right: peripheral edema, RUQ pain, JVD, ascites
What are some ddx for HF?
MI, peripheral vascular disease, pulmonary diseae, GI disease, sleep apnea, depression
What lab studies must all pts with heart failure get?
ECG, echo and CXR
What is the normal EF?
> 50-55%
Difference on an echo for systolic vs diastolic dysfunction
Systolic is a dilated left ventricle and diastolic is LVH
What is cardiomegaly on CXR?
Cardiac to thoracic width ratio >50%
What findings are suggestive of HF on a CXR?
Cardiomegaly, cephalization of the pulmonary vessels (becomes more prominent at apex of lungs), Kerley B-lines (interstitial edema), pleural effusions
What does cardiac catheterization eval for?
Active CAD
What labs are used in HF?
Cardiac enyzymes (rule out acute ischemia) CBC (anemia/infection) CMP Brain-natiuretic peptide UA Lipid panel Thyroid panel Iron studies (hemochromatosis)
What is brain-type natriuretic peptide?
Marker for HF (at high levels) because released in response to stretching of the ventricular wall
Used to differentiate pulmonary from cardiac diseases in pts with dyspnea or inconclusive exam
What is the relationship between level of BNP and prognosis of HF?
Inverse (higher level of BNP means poorer prognosis)
What levels of BNP can you rule in or rule out HF?
Rule out <100 and rule in >400
Stages of HF
A: at high risk for HF but without structural changes or sxs
B: structural heart disease without sxs/signs of HF
C: structural heart disease with prior or current sxs of heart failure
D: refractory HF including specialized interventions
How is the tx of HFpEF driven?
By ID of the comorbidities
Functional classification of HF
I: no limitation of physical activity
II: slight limitation of physical activity while ordinary activity results in undue breathlessness, fatigue or palpitations
III: marked limitation of physical activity with less than ordinary physical activity resulting in same
IV: unable to carry on any physical activity without discomfort, can have sxs at rest
What are the principles of tx of HF?
Manage underlying cause
Manage precipitating cause
Control sxs of failure (reduce cardiac workload, control salt/water retention, enhance contractility)
Review meds
What is the initial therapy for HFrEF?
ACE-i or diuretics
What is the tx for HFpEF?
ID and tx of comorbidities, diuretics for symptomatic relief
What type of diuretics is preferred?
Loops (thiazide can be added for synergism)
Start with 20-40 mg furosemide
Goal of diuretics
Reduce fluid overload (mostly to relieve sxs like dyspena or peripheral edema)
Why do you monitor renal function with diuretics or ACE-i?
Watch for hypokalemia with diuretics and hyperkalemia with ACE-i
What is the theme for most HF meds?
Start low, go slow (when they titrate to the maximum/ target dose)
Benefit of ACE-i
Reduce morbidity and mortality in both symptomatic and asymptomatic pts
Side effect of ACE-i
Cough (breaking down bradykinin)
When do you use ARBs (AT II receptor blockers)?
If ACE-i are not tolerated (especially pt persistently symptomatic like cough)
*will not produce the cough
Benefit of beta blockers
Decrease morbidity and mortality and lead to event free survival
Why do you start ACE first before beta blockers?
To stabilize the pt-they have a rapid hemodynamic benefit and won’t exacerbate the HF (never BB during acute decompensation)
Major side effect of beta blockers
Bradycardia
When would you use mineralocorticoid receptor antagonist?
For pts who still have sxs after trying the other classes
Aldosterone antagonist and K-sparing diuretic
What is digoxin?
Inotropic agent to increase contractility of the heart
Enhances exercise tolerance
When is digoxin very useful?
Pts with concomitant Afib
General non-pharm measures to treat HF
Smoking cessation, restrict alcohol, sodium restriction, activity, daily weight measurements, flu vaccine, pneumococcal vaccine
When do you do follow-ups?
Every 1-3 mos
What is a predictor of a higher mortality rate?
Loss of ADLS (bathing, dressing, walking, eating etc)
What pts are candidates for cardiac rehab?
Stable pts with HF, angina, post MI, post CABG, pacemaker, transplant candidate, PAD
Use of statins in HF?
Shown to not be helpful but if they are already on it when develop HF, then continue it
Most common causes of death in HF
Progressive pump failure (decompensation) and malignant arrhythmias
Examples of drugs that can worsen HF
NSAIDs, metformin (DM), antiarrhythmics etc
What is acute decompensated heart failure?
New or exacerbation of chronic disease (emergent!)
Elevated left-sides filling pressures and dyspnea, maybe pulmonary edema
Cardiogenic pulmonary edema
Can cause acute respiratory distress and is most often a result of ADHF (acute MI, ischemia, mitral stenosis)
“flash” edema is just more dramatic development of sxs
Presentation of cardiogenic pulmonary edema
Dyspnea, productive cough and diaphoresis
Crackles/rales, wheezes and rhonchi
Frothy sputum
Physical exam of cardiogenic pulmonary edema
Kerley B lines, edema, cardiomegaly on CXR
Pulmonary capillary wedge pressure elevated
What is classic to see on CXR for pulmonary edema?
Butterfly pattern
Presentation of ADHF
Cough, dyspnea, fatigue, peripheral edema (same sxs but different severity)
First line tx for ADHF
Hospital admission
Can then do O2, diuretics, nitro
*watch for changes in potassium!!
