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X Clin Med II Exam 1 > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What is the definition of heart failure?

A

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

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2
Q

What is the difference between heart failure and dysfunction?

A

Dysfunction is asymptomatic

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3
Q

What is the difference between systolic and diastolic dysfunction?

A

Systolic is impaired cardiac contractile function and diastolic is abnormal cardiac relaxation, stiffness or filling

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4
Q

What if left heart failure characterized by?

A

Elevated LV filling pressures

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5
Q

How do you increase preload?

A

Increase venous return, filling time, ventricular compliance and filling pressure

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6
Q

How do you increase afterload?

A

Increase PVR and aortic pressure and decrease arterial wall compliance

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7
Q

What is the progression of heart failure?

A

Myocardial disease
Impaired ventricular performance/ventricular arrhythmias
Neurohormonal stimulation
Vasoconstriction/sodium retention
Increased impedance/ventricular dilation (then goes back to the second one)

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8
Q

What is HFrEF?

A

HF with reduced EF

Clinical signs/sxs of HF, systolic dysfunction (EF<40%) and increased LV volumes

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9
Q

How does the left ventricle change in HFrEF?

A

Progressive chamber dilation (cardiomyocytes elongate) and eccentric remodeling due to volume overload

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10
Q

What are causes of HFrEF?

A

Impaired contractility (CAD/cardiomyopathy) or high afterload from HTN

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11
Q

What is HFpEF?

A

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)

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12
Q

How do the ventricles change in HFpEF?

A

Concentric remodeling or hypertrophy due to a pressure overload

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13
Q

What happens when LV diastolic pressure is increased?

A

Increases pulmonary venous pressure (see dyspnea, exercise intolerance and pulm congestion)

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14
Q

What are big contributors of HFpEF?

A

Hypertension/LVH, aging, CAD, DM, sleep disordered breathing, obesity, kidney disease

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15
Q

What causes overlap between HFrEF and HFpEF?

A

Older age, HTN, CAD and DM

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16
Q

Pts with HFpEF tend to be…

A

Older, frequently with HTN, overweight, more often women

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17
Q

What is the most common cause of right heart failure?

A

Left heart failure (because it is a low pressure, high compliance system and doesn’t tolerate increases in afterload)

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18
Q

Risk factors of HF

A

CAD, smoking, HTN, overweight, DM, valvular heart disease

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19
Q

What is the most common cause of heart failure?

A

Coronary artery disease

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20
Q

What sxs will the patient report with HF?

A

Dyspnea, nocturnal/nonproductive cough, fatigue/weakness, dependent edema, weight gain (may have ascites, RUQ discomfort or nocturia)

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21
Q

What will be seen on the physical exam?

A

Edema, elevated JVD, crackles at the bases, displaced PMI, S3/S4 gallop, hepatomegaly, hepatojugular reflux

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22
Q

What survey is useful for the diagnosis of heart failure?

A

Modified Framingham Clinical Criteria

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23
Q

What is the progression of left heart failure?

A

Decreased CO and pulmonary congestion

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24
Q

What is the progression of right heart failure?

A

Congestion of peripheral tissues

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25
Q

Differences in clinical presenation between left and right HF?

A

Left: dyspnea, diaphoresis, tachypnea, tachycardia, rales, S3/S4
Right: peripheral edema, RUQ pain, JVD, ascites

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26
Q

What are some ddx for HF?

A

MI, peripheral vascular disease, pulmonary diseae, GI disease, sleep apnea, depression

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27
Q

What lab studies must all pts with heart failure get?

A

ECG, echo and CXR

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28
Q

What is the normal EF?

A

> 50-55%

29
Q

Difference on an echo for systolic vs diastolic dysfunction

A

Systolic is a dilated left ventricle and diastolic is LVH

30
Q

What is cardiomegaly on CXR?

A

Cardiac to thoracic width ratio >50%

31
Q

What findings are suggestive of HF on a CXR?

A

Cardiomegaly, cephalization of the pulmonary vessels (becomes more prominent at apex of lungs), Kerley B-lines (interstitial edema), pleural effusions

32
Q

What does cardiac catheterization eval for?

A

Active CAD

33
Q

What labs are used in HF?

A 
Cardiac enyzymes (rule out acute ischemia)
CBC (anemia/infection)
CMP
Brain-natiuretic peptide
UA
Lipid panel
Thyroid panel
Iron studies (hemochromatosis)
34
Q

What is brain-type natriuretic peptide?

A

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

35
Q

What is the relationship between level of BNP and prognosis of HF?

A

Inverse (higher level of BNP means poorer prognosis)

36
Q

What levels of BNP can you rule in or rule out HF?

A

Rule out <100 and rule in >400

37
Q

Stages of HF

A

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

38
Q

How is the tx of HFpEF driven?

A

By ID of the comorbidities

39
Q

Functional classification of HF

A

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

40
Q

What are the principles of tx of HF?

A

Manage underlying cause
Manage precipitating cause
Control sxs of failure (reduce cardiac workload, control salt/water retention, enhance contractility)
Review meds

41
Q

What is the initial therapy for HFrEF?

A

ACE-i or diuretics

42
Q

What is the tx for HFpEF?

A

ID and tx of comorbidities, diuretics for symptomatic relief

43
Q

What type of diuretics is preferred?

A

Loops (thiazide can be added for synergism)

Start with 20-40 mg furosemide

44
Q

Goal of diuretics

A

Reduce fluid overload (mostly to relieve sxs like dyspena or peripheral edema)

45
Q

Why do you monitor renal function with diuretics or ACE-i?

A

Watch for hypokalemia with diuretics and hyperkalemia with ACE-i

46
Q

What is the theme for most HF meds?

A

Start low, go slow (when they titrate to the maximum/ target dose)

47
Q

Benefit of ACE-i

A

Reduce morbidity and mortality in both symptomatic and asymptomatic pts

48
Q

Side effect of ACE-i

A

Cough (breaking down bradykinin)

49
Q

When do you use ARBs (AT II receptor blockers)?

A

If ACE-i are not tolerated (especially pt persistently symptomatic like cough)
*will not produce the cough

50
Q

Benefit of beta blockers

A

Decrease morbidity and mortality and lead to event free survival

51
Q

Why do you start ACE first before beta blockers?

A

To stabilize the pt-they have a rapid hemodynamic benefit and won’t exacerbate the HF (never BB during acute decompensation)

52
Q

Major side effect of beta blockers

A

Bradycardia

53
Q

When would you use mineralocorticoid receptor antagonist?

A

For pts who still have sxs after trying the other classes

Aldosterone antagonist and K-sparing diuretic

54
Q

What is digoxin?

A

Inotropic agent to increase contractility of the heart

Enhances exercise tolerance

55
Q

When is digoxin very useful?

A

Pts with concomitant Afib

56
Q

General non-pharm measures to treat HF

A

Smoking cessation, restrict alcohol, sodium restriction, activity, daily weight measurements, flu vaccine, pneumococcal vaccine

57
Q

When do you do follow-ups?

A

Every 1-3 mos

58
Q

What is a predictor of a higher mortality rate?

A

Loss of ADLS (bathing, dressing, walking, eating etc)

59
Q

What pts are candidates for cardiac rehab?

A

Stable pts with HF, angina, post MI, post CABG, pacemaker, transplant candidate, PAD

60
Q

Use of statins in HF?

A

Shown to not be helpful but if they are already on it when develop HF, then continue it

61
Q

Most common causes of death in HF

A

Progressive pump failure (decompensation) and malignant arrhythmias

62
Q

Examples of drugs that can worsen HF

A

NSAIDs, metformin (DM), antiarrhythmics etc

63
Q

What is acute decompensated heart failure?

A

New or exacerbation of chronic disease (emergent!)

Elevated left-sides filling pressures and dyspnea, maybe pulmonary edema

64
Q

Cardiogenic pulmonary edema

A

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

65
Q

Presentation of cardiogenic pulmonary edema

A

Dyspnea, productive cough and diaphoresis
Crackles/rales, wheezes and rhonchi
Frothy sputum

66
Q

Physical exam of cardiogenic pulmonary edema

A

Kerley B lines, edema, cardiomegaly on CXR

Pulmonary capillary wedge pressure elevated

67
Q

What is classic to see on CXR for pulmonary edema?

A

Butterfly pattern

68
Q

Presentation of ADHF

A

Cough, dyspnea, fatigue, peripheral edema (same sxs but different severity)

69
Q

First line tx for ADHF

A

Hospital admission
Can then do O2, diuretics, nitro
*watch for changes in potassium!!

X Clin Med II Exam 1 (7 decks)

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