Heart Failure Flashcards
Heart failure is an impaired ability of the heart to either _______ or _______.
relax or pump blood
impaired LV contractile function is known clinically as…
systolic dysfunction
abnormal LV cardiac relaxation, stiffness or impaired filling is known clinically as…
diastolic dysfunction
T or F
Systolic dysfunction causes diastolic dysfunction.
F. one doesn’t cause the other
can systolic and diastolic dysfunction coexist?
yes
Generally, isolated right heart pathology suggests an issue with what system?
pulmonary
pulmonary hypertension can contribute to what type of cardiac dysfunction?
right ventricle
LHF, HFrEF is systolic or diastolic?
systolic
LHF HFpEF is systolic or diastolic?
diastolic
what does ejection fraction measure?
ability of ventricles to eject blood/ventricular function
The below factors have a positive impact on what factor of stroke volume? Preload, Afterload, Contractility or HR?
Increased venous return
increased filling time
increased ventricular compliance
increased filling pressure
increased preload
The below factors have a positive impact on what factor of stroke volume? Preload, Afterload, Contractility or HR?
increased peripheral vascular resistance
increased aortic pressure
decreased arterial wall compliance
increased afterload
The below factors have a positive impact on what factor of stroke volume? Preload, Afterload, Contractility or HR?
SNS stimulation leading to inotropy
increased contractility
The below factors have a positive impact on what factor of stroke volume? Preload, Afterload, Contractility or HR?
SNS stimulation leading to chronotropy
HR
Abrupt damage to myocardium can occur in what condition?
MI
What two factors cause gradual damage to the myocardium leading to HF?
Increased pressure
Increased volume
Progressive damage to myocardium causes what two changes to the heart?
cardiac remodeling
declining heart function
Decreased perfusion to the kidneys leads to what two physiologic changes which lead to CHF?
overactive RAAS system
SNS stimulation
The progression of heart disease can be visualized as a cycle. What are the steps of this cycle?
heart disease
LEADING TO
decreased CO
LEADING TO
neurohormonal stimulation
LEADING TO
vasoconstriction and sodium retention
LEADING TO
increased resistance and ventricular dilation
A pt. presents with the following findings. What type of HF do you suspect?
- clinical S/S of HF
- reduced LVEF (40% or less)
- increased LV ESV/EDV
HFrEF
HFrEF is also known as…
systolic heart failure
In HFrEF, _______ overload leads to ________ dilation and _________ remodeling
volume overload
chamber dilation
eccentric remodeling
HFrEF is caused by impaired contractility and high afterload. What conditions impair contractility and increase afterload?
Contractility: CAD, cardiomyopathy
Afterload: HTN
What is the normal range for LVEF?
50-55%
HFpEF is systolic or diastolic dysfunction?
Diastolic Dysfunction
Impaired LV relaxation and decreased LV compliance lead to…
diastolic dysfunction
What happens to the LVEF and EDV in HFpEF?
normal
When the LV increases its dependence on atrial contraction for filling, what results?
left atrial enlargement
HFrEF is a ______ overload, while HFpEF is a ________ overload
rEF: volume overload
pEF: pressure overload
what type of cardiac remodeling is seen in HFpEF?
concentric remodeling/hypertrophy
What risk factors do HFpEF and HFrEF have in common?
old age
HTN
CAD
DM
Patients with HFpEF compared to HFrEF tend to…
be older
have HTN
overweight
women
What is the most common cause of right heart failure?
LHF
The right heart is a low pressure, high compliance system, meaning it does not tolerate increases in ______
afterload
What conditions cause increased afterload in the right heart?
PE
chronic pulmonary disease
What is the MC cause of heart failure?
CAD
A patient with CAD presents with the following sxs. What should you immediately suspect?
dyspnea
fatigue/weakness
dependent edema
weight gain
nocturnal, nonproductive cough
nocturia
heart failure
What is the progression of dyspnea as heart failure worsens?
DOE
to
orthopnea
to
PND
to
dyspnea at rest
HF has many of the normal cardiovascular risk factors like CAD, PVD, DM, HTN, and obesity.
What endocrine disorders contribute to HF?
pheochromocytoma
thyroid abnormality
What is an early finding in decompensation in patients with HF?
S3/S4 gallop
What findings should you expect to see on cardiac physical exam of patients with HF?
elevated JVD
Displaced PMI
S3/S4 gallop
What findings should you expect to see on skin physical exam of patients with HF?
edema
What findings should you expect to see on pulmonary physical exam of patients with HF?
Crackles at the bases
What findings should you expect to see on abdominal physical exam of patients with HF?
hepatomegaly
hepatojugular reflux
LHF can present with the following S/S that are caused by…
activity intolerance
fatigue
altered mental status
decreased CO
LHF can present with the following S/S that are caused by…
cyanosis/hypoxia
cough with frothy sputum
orthopnea
PND
pulmonary congestion
RHF can present with the following S/S that are caused by…
dependent edema
ascites
JVD
anorexia
GI distress
Hepatomegaly
congestion of peripheral tissues
A 70 year old smoker with a 20 pack year hx an DM presents with the following sxs. What should you immediately include in your DDx?
- dysnea on exertion
- diaphoresis
- tachypnea
- tachycardia
- rales/crackles
- S3 or S4
LHF
You are seeing a patient who has LHF. They report new onset of the following sxs. What should you immediately suspect?
- edema
- RUQ pain
- JVD
- Ascites
RHF
A patient presents with risk factors for heart disease and a CC of fatigue and weight gain.
PE findings are as follows:
Lungs: crackles at base, dyspnea, dry cough
Cardiac: tachycardia,
Skin: diaphoresis, edema.
What diagnostic studies do you want to order?
ECG
Echo
CXR
In patients suspected of HF, EKG evaluates for…
ischemia, arrhythmias
You suspect a pt. has HF. You order an EKG, which comes back normal. This finding makes what cardiac condition unlikely?
systolic dysfunction
What can assist in evaluating for arrhythmia in patients suspected of HF?
holter monitor
What makes echo the most important diagnostic in evaluation of HF?
EF evaluation
On echo, systolic dysfunction can be suspected when what is visualized?
dilated left ventricle
On echo, diastolic dysfunction can be suspected when what is visualized?
left ventricular hypertrophy
What findings on CXR are suggestive of HF?
cardiomegaly
cephalization of pulmonary vessels
kerley b-lines
pleural effusion
In patients with HF, exercise EKG is helpful in evaluating what?
degree of functional impairment
ID of ischemic disease
Is cardiac catheterization routine in evaluation of HF?
no
What labs can be ordered to help evaluate HF?
cardiac enzymes
CBC
CMP (electrolytes, renal fxn, glucose, liver fxn)
BNP
NT-proBNP
cardiac enzymes are ordered for what reason?
evaluate for acute ischemia
why is a CBC useful in HF evaluation?
anemia, infx can exacerbate HF
What are BNP and NT-proBNP useful for?
diagnosing HF
Risk stratification
guiding Tx
Who should have natriuretic peptide biomarkers measured, according to 2017 ACC/AHA/HFSA guidelines
pts w/ dyspnea to support HF dx
chronic HF on admission to hospital
Why would iron studies be useful in HF?
evaluate hemochromatosis as underlying cause
What could a thyroid panel tell you that is helpful for HF?
hypothyroidism can present as and exacerbate HF
what foods can help moderate risk for heart failure?
breakfast cereals
fruits/veggies
How much exercise will moderate risk for HF?
5+ times per week
how much EtOH consumption is acceptable to lower risk of HF?
5-14 drinks/week
What is the recommended initial therapy for HFrEF?
ACE-I
Diuretics
What is the recommended initial therapy for HFpEF?
ID and Tx of comorbid conditions
diuretics for sx releif
What type of dysfunction is more common in elderly females with HTN/DM
diastolic dysfunction
DOC diuretic for HF?
furosemide (lasix)
Diuretic therapy in HF has a goal of what?
reducing dyspnea, edema, fluid overload
What must be monitored with diuretic therapy?
renal function, electrolytes.
hypokalemia can occur
What drug is shown to reduce morbidity and mortality in symptomatic and asymptomatic HF?
ACE-I
What is the approach to dosing with ACE-I in HF?
titrate… start low, go slow
ACE-Is and ARBs have what effect that is beneficial for treating HF?
reduce afterload
If an ACE-I isn’t tolerated due to cough, what can be substituted?
ARBs
What should be monitored with ACEs and ARBs?
BP, renal fxn, electrolytes
Which beta blockers improve morbidity and mortality for class II and III HF?
carvedilol, bisoprolol, metoprolol
Describe the dosing regimen for beta blockers…
dose slowly and only if clinically stable. start with ACE-I first.
What is the main side effect of beta blockers?
bradycardia
patients with chronic symptomatic HFrEF Class II or III who tolerate an ACE-I or ARB should replace with…
ARNI (entresto)
patients with at-rest dyspnea w/in last 6 months, or post-MI with systolic dysfunction can be treated with what drug?
Mineralcorticoid receptor antagonist (aldosterone antagonist + potassium-sparing diuretic)
What needs to be monitored when prescribing an MRA?
electrolytes, fluid balance, renal function
A patient with HF cannot take an ACE, ARB, or ARNI. What can be prescribed?
hydralazine plus isosorbide dinitrate
Hydralazine does what?
Isosorbide does what?
Hydralazine: vasodilation
Isosorbide dinitrate: decreased O2 demand, decreased preload
This drug can be used in patients with accompanying atrial fibrillation
Digoxin
Digoxin is what glass of drugs?
Inotropic agent
Which drug enhances exercise tolerance?
digoxin
How should digoxin dosing be approached and what serum levels must be maintained?
low dose, titrate.
serum .5-.8ng/mL
are statins helpful in tx for HF?
no
When can you continue statin therapy with HF?
if already on for a different indication
What is a major predictor of high mortality in HF?
loss of ADLs
Education on heart failure should be direct at whom?
patient and family
Where should HF pts be treated?
specific heart failure clinic
What are the most common causes of death in heart failure patients
decompensation/pump failure and arrhythmia
cardiogenic pulmonary edema is most often a result of…
ADHF (MI, ischemia, mitral stenosis)
A patient presents with:
dyspnea
productive cough with pink frothy sputum
diaphoresis
abnormal breath sounds
What do you suspect?
cardiogenic pulmonary edema
On CXR with cardiogenic pulmonary edema, what do you expect to find?
kerley b lines
edema
cardiomegaly
What is typically elevated in cardiogenic edema?
pulmonary capillary wedge
A patient presents to the clinic with the following sxs…what are these concerning for?
cough
dyspnea
fatigue
rapid peripheral edema
orthopnea/PND
Acute decompensated heart failure
A PE of a patient reveals the following… what is this immediately concerning for?
HTN
JVD
Tachypnea
Accessory muscle use
crackles
Tachycardia
S3/S4
New murmur
LE edema
acute decompensated heart failure
What is the workup for ADHF>
ECG CXR pulseox ABGs CBC electrolytes renal/liver function cardiac enzymes BNP Echo
How is ADHF treated?
hospital admission with telemetry
supp O2, sats >90%
diuretics
nitro
what electrolyte should be monitored in ADHF?
potassium
