Heart Failure Flashcards
State Sterling’s Law
The force of contraction depends on the length of muscle fibers of the heart wall. Supplement. The greater the stretch of cardiac muscle, the greater the force of contraction.
MAP formula
Cardiac Output (Stroke Volume x Heart Rate) x Total Peripheral Resistance
What is the #1 risk factor for HF in women with heart disease
Diabetes (atrial fibrillation close 2nd)
Explain the sympathetic activation in heart failure
There is an increase in cardiac sympathetic activity which affects the Beta 1, Beta 2 and alpha 1 receptors which triggers myocardial toxicity and increased arrhythmias. In 2. Increased sympathetic activities to the kidneys affects the peripheral vasculature. Activation of Beta 1 and alpha 1 causes activation of RAS. Activation of RAS results in decreased renal perfusion. Activation of alpha 1 along with activation of RAS results in vasoconstriction and sodium retention which leads to disease progression of heart failure
What are the NYHA functional classifications of heart failure I-IV
I. no pain with ordinary activity II. slight limitation of activity a) pain at > 2 blocks b) pain at 1 flight of stairs III. Marked limitation a) pain < 2 blocks b) pain during 1 flight of stairs IV. Pain with any activity or at rest
What are ACCF/ AHA stages of HF - Compare to NY classification scale
A) At high risk for HF but No structural heart disease or symptoms of HF (no correlation to NY classification) (lifesytle Mod maybe BB) B) Structural heart disease /No signs of HF (Class I- NY) C) Structural disease with + HF symptoms (Class I-III NY) (EF < 40%) D) Structural Disease with Refractory HF symptoms (Class IV NY) (heart transplant 30% die each year)
Name Typical Signs and symptoms of heart failure
Typical symptoms 1. Breathlessness 2. Orthopnea (SOB when lying flat prop self on pillows) 3. PND 4. Reduced exercise tolerance 5. Fatigue 6. Ankle swelling Signs 1. Elevated jugular venous pressure 2. Hepatojugular reflux (press liver and jugular veins pop out) 3. 3rd Heart Sound (S3) (gallop rhythm) S3 is fluid overload - heard in L or R HF 4. Laterally displaced apical pulse (PMI normal in 5th intercoastal pace) (No apical pulse is in axilla) 5. Cardiac murmur 6. “Distant heart sound” Heart sound does not sound muffled but “distant” like you are listening and it is in another room.
Diagnosis of HF depends on 3 for 4 conditions depending on whether you have reduced ejection fraction or preserved ejection fraction.
3 conditions if reduced EF 1. Symptoms of HF (nausea, Lack of appetite, impaired thinking/confusion, fatigue/lightheaded, elevated HR) 2. Signs of HF (shortness of breath, cough or wheezing, bilateral LE edema) 3. Reduced LVEF. 4. If LVEF is preserved or only mildly reduced then need to see relevant structural heart disease (LV hypertrophy, LA enlargement) and or diastolic dysfunction.
Name Less Typical Signs and symptoms of heart failure
Less typical Symptoms 1. Nocturnal cough 2. Wheezing 3. Weight gain > 2 kg/week 4. Weight loss (in advanced heart failure) 5. Bloated feeling 6. Loss of appetite 7. Confusion (esp in elderly) 8. Depresssion 9. Palpitations 10. Syncope Less typical signs 1. Peripheral edema (ankle, sacral, scrotal) 2. Pulmonary crepitations 3. Reduced air entry or dullness to percussion at lung bases (pleural effusion) 4. Tachycardia 5. Irregular pulse 6. Tachypnea (>16 breaths /min) 7. Hepatosplenomegaly 8. Ascites 9. Tissue wasting (cachexia)
Algorithm for HF Acute Onset
Suspected HF (acute -acute onset) 1. ECG and CXR 2. If ECG and CXR positive then get Echo to confirm. 3. If ECG is normal AND NT-proBNP < 300 pg/mL OR BNP < 100 then HF is unlikely. 4. If ECG is abnormal ORproBNP >= 300 pg/mL OR BNP >= 100 pg/mL proceed to Echo
Algorithm for HF NON-Acute Onset
Suspected HF (acute -non-acute onset) 1. ECG and CXR (+/- if non-acute onset) 2. If ECG and CXR positive then get Echo to confirm. 3. If ECG is normal AND NT-proBNP < 125 pg/mL OR BNP < 35 then HF is unlikely. 4. If ECG is abnormal OR proBNP >= 125 pg/mL OR BNP >= 35 pg/mL proceed to Echo
Treatment algorithm for pts with chronic symptomatic systolic HF
- Add diuretics to relieve symptoms/signs of congestion 2. ACE inhibitor (or ARB if not tolerated) 3. ADD a beta blocker If pt is no longer symptomatic (as classified by NYHA class II-IV) then no furhter treatment necessary
What if pt with chronic symptomatic systolic HF is still symptomatic while on diuretic, ACE (or ARB) and BB? List 3 examples:
Add MRA (mineralcorticoid receptor antagonist) or aldosterone receptor antagonist. Aldosterone is responsible for increasing sodium reabsorption by the kidneys, salivary glands, sweat glands and colon. At the same time it increases excretion of hydrogen and potassium ions. If you block aldosterone then you promote water loss. This is given to all pts with symptoms of heart failure or with a history of hospitalization for heart failure Examples: 1) eplerenone (Inspra)(Pro) 2) spironolactone (Aldactone)(Pro) (CaroSpir)
What is normal LV EF
Normal 55-70%
What is the EF in systolic dysfunction?
< 40%
Systolic Heart Failure occurs when
your heart is not contracting properly (blood pumped out of the heart is less than normal)
Diastolic Heart Failure occurs when
your heart is not relaxing the way it should (affects mainly LV - to does not relax properly therefore there is impairment in filling with blood)
How to systolic heart failure treatments differ from diastolic heart failure
- Systolic HF- pharmacologic treatment algorithm 2. Diastolic HF- tends to involve identifying and treating the condition or conditions behind the heart problem (HTN, diabetes, CKD, CAD, obesity, atherosclerosis, valve disease, A-fib, OSA, smoking, EtOH)
Symptomatic systolic HF pt with EF < 35% and sinus rhythm HR >= 70 beats/min
Already on BB, ACE (or Arb), spironolactone. Consider isosorbide dinitrate-hydralazine. (symptomatic HF pts who are african-american)
What medications are used prn for systolic HF
- Diuretics- to maintain proper fluid balance Potassium sparing diuretics: A) spironolactone B) eplerenone 2. Digoxin- for pts who remain symptomatic on diuretics, ACE, BB- OR for those in A-Fib needing rate control 3. Aspirin/ clopidogrel- keeps platelets from sticking together
Labs in HF
- CBC (hyponatremia- too much fluid on board- does NOT need more sodium) 2. Chemistry (Na, K, Ca, Mg, BUN, Cr) 3. ABG? 4. LFTs (congestive hepatomegaly) 5. TSH
HF with rEF (systolic dysfunction) causes
- MI (most common overall) 2. ischemic heart disease 3. Dilated cardiac myopathy and volume overload 4. Valve regurgitation 5. Acute PE
HF with pEF (diastolic dysfunction) causes
- Hypertension (second most common cause of heart failure overall) 2. Valve stenosis 3. Hypertrophic and restrictive cardiomyopathy 4. COPD & Pulmonary HTN
How does OSA affect the heart
Releases catecholamine which can result in 1st, 2nd, 3rd degree AV block
Surgical options for systolic HF
- Coronary revascularization 2. Valve surgery
Loop diuretics MOA
Work in the ascending loop of Henley. Greatest fluid excretion. 1. Furosemide 2. Buteminide
List Meds for different stages of HF
When is BB contraindicated for HF
Not recommended for COPD because it could cause vasospasm
Name BB
- metoprolol succinate
- carvedilol
- Bisprolol
When to use isosorbid dinitrate & hydrolazine
Use on african-american pts who cannot tolerate BB
You should never give this medication in if the pt is in acute decompensated HF
Never give BB b/c you do not want to drop heart rate, in this case you need an ionotrope
Name 6 ionotropes
Ionotropes
- Digoxin
- Dobutamine
- Norepinephrine
- Milrinone
- levosimendan
- omecamtiv mecarbil
Treatment options in Stage C Systolic HF
- Warfarin (EF < 35%) A-fib, PE, Stroke
- Avoid anti-arrhythmics for prevention
- Digoxin: LVEF < 40% and symptoms while on standard therapy
- Implantable defibrillator: LVEF < 35%, hx of arrest, unstable VT and life expectancy > 1 year
- Bi-ventricular pacing LBBB , QRS > 150 ms, bradycardia
