Heart Failure Flashcards
What is heart failure
Any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood
What are the 2 types of dysfunction of the left ventricle
- systolic dysfunction: impaired cardiac CONTRACTILE function
- diastolic dysfunction: abnormal cardiac RELAXATION stiffness or filling
Right ventricle dysfunction
Pulmonary hypertension (left heart disease, lung disease, congenital heart disease)
Types of left sided heart failure (LHF)
HFrEF: HF with REDUCED ejection fraction (systolic)
HFpEF: Hf with PRESERVED ejection fraction (diastolic)
What shows the progression of heart failure
Damage to myocardium
Progressive (contribute to cardiac remodeling and decline in heart function)
-neurohormonal imbalance activated by decrease of perfusion of kidneys
Overactivation of renin angiotensin aldosterone system RAAS
Sympathetic nervous system
HFrEF REDUCED clinical signs and symptoms
Systolic dysfunction
-reduced LVEF (<=40%)
Increased LV volumes (ESV and EDV) end systolic and end diastolic
“Systolic heart failure”
Causes of HFrEF
Coronary artery disease
Cardiomyopathy
High after load
-HTN
HFpEF clinical signs and symptoms PRESERVED
Diastolic dysfunction (seen on echo) -abnormal mechanical properties of the ventricle (impaired LV relaxation, decrease LV compliance)
Normal LVEF (>=50%)
Normal/ decrease LV end-diastolic volume (increase pressure)
Left atrial enlargement (>65% of patients)
-reflect degree of chronically elevated LV pressure over time
“Diastolic heart failure”
Pathophysiology of HFpEF
LV diastolic pressure
-determined by volume of blood in ventricle and distensibility or compliance of ventricle
When elevated will increase pulmonary venous pressure
-dyspnea, exercise intolerance and pulmonary congestion
Causes of HFpEF
Hypertension with or without left ventricular hypertrophy Aging Coronary artery disease DM Sleep disordered breathing Obesity Kidney disease
Pathophysiology of right heart failure
MOST COMMON CAUSE IS LEFT HEART FAILURE Low pressure, high compliance system -does not tolerate increases in afterload Pulmonary embolism Chronic pulmonary disease
Elevated pressure in right atrium, increased pressure in veins and capillaries, increased formation of tissue fluid (peripheral edema, and ascites)
Risk factors for heart failure
CAD (more common) Smoking HTN Overweight DM Valvular heart disease
Predisposing underlying causes of heart failure
Most common is CAD
Dilated cardiomyopathy Valvular heart disease HTN Left ventricular hypertrophy Others
Symptoms of heart failure
DYSPNEA Cough FATIGUE/WEAKNESS DEPENDENT EDEMA WEIGHT GAIN Ascites RUQ discomfort/early satiety Nocturia
Signs of heart failure
Edema Elevated JVD Crackles at bases Displaced PMI S3/S4 gallop Hepatomegaly Hepatojugular reflex
Left heart failure
Decreased cardiac output
- activity intolerance
- signs of decreased tissue perfusion (confusion)
Pulmonary congestion
- impaired gas exchange (cyanosis, signs of hypoxia)
- pulmonary edema (cough with frothy sputum, orthopnea, PND)
Right heart failure
Dependent edema (wt gain) Ascites Increased venous pressure (JVD) GI tract congestion Hepatic congestion (hepatomegaly, impaired liver function)
What diagnostic studies for suspected HF
ECG
Echocardiography
Chest radiography
What to evaluate for ECG heart failure
Ischemia, arrhythmia
Normal EKG makes systolic dysfunction highly unlikely
Echocardiogram ejection fraction percent considered normal and systolic vs. diastolic
Normal ejection fraction >50-55%
Systolic vs. diastolic
SYSTOLIC HF + EF <= 40%
DIASTOLIC HF + normal EF, and DIASTOLIC DYSFUNCTION
Echo systolic vs diastolic dysfunction
Systolic- dilated left ventricle
Diastolic dysfunction- left ventricle hypertrophy
What does chest radiography evaluate for and what findings are suggestive of HF
Evaluate for cardiomegaly (cardiac to thoracic width ratio >50%
Cardiomegaly
Cephalization of the pulmonary vessels
Kerley B-lines (interstitial edema)
Pleural effusions
Labs for heart failure
Cardiac enzymes CBC CMP (electrolytes) Renal function (cr) Glucose Liver function tests Natriuretic peptide biomarkers
What are the two natriuretic peptide biomarkers and what is. It useful for
Brain-type natriuretic peptide (BNP)
N-terminal pro-brain natriuretic peptide (NT-proBNP)
Useful in:
Diagnosing HF
Risk stratification
Guiding treatment of patients with HF
When should you measure natriuretic peptide biomarkers
In patients presenting with dyspnea to support a diagnosis of HF
In patients with chronic HF, on admission to the hospital to establish prognosis in acutely decompensated HF
Heart failure classes 1-4
Class 1- no limitation of physical activity
Class 2- slight limitation of physical activity
Class 3- marked limitation of physical activity
Class 4- unable to carry on any physical activity without discomfort. Symptom at rest can be present
Prevention strategies of HF
Early detection and treatment of
- predisposing conditions (HTN, CAD, DM, obesity)
- high risk candidates
Risk factor modification -normal body weight Not smoking Regular exercise Moderate alcohol intake Consumption of breakfast cereals Consumption of fruits and vegetables
Goals of therapy of HF
Reduce morbidity and mortality
- reduce preload -> diminish congestive symptoms
- reduce afterload -> improve cardiac function
Recommended initial therapy for HFrEF
ACE inhibitor
Diuretics
Treatment of HFpEF
Identification and treatment of co-morbidities
Diuretics for symptomatic relief
Goal and important points about diuretics
Goal: reduce fluid overload
-relieve dyspnea, peripheral edema
Loop diuretics are preferred
-thiazide diuretics added for synergistic effect
Monitor renal function, electrolytes
-hypokalemia
Start yet with 20-40 mg furosemide (lasix)
- some respond better to bumetanide or torsemide
- reasonable response: 1 kg/day weight loss
Maintenance dose to prevent recurrent edema
ACE inhibitors (ACE-I)
Shown to reduce morbidity and mortality in both symptomatic and asymptomatic HF patients
Reduce severity and number of symptoms
Reduce hospitalizations
Hyperkalemia
SE: cough
Angiotensin 2 receptor blockers
Improve morbidity and mortality
Use if ACE inhibitors are not tolerated (via cough)
Monitor BP, renal function, electrolytes
-hyperkalemia
Decrease afterload
RAAS blockade
Beta-blockers
Certain beta blockers improve overall event free survival in patients
Carvedilol (Coreg), bisoprolol (zebeta), and metoprolol succionarte (toparol XL)
Start ACE inhibitors first, until stable
Administer only if pt clinically stable
Main side effect: bradycardia
Angiotensin receptor-neprilysin inhibitor (ARNI)
Reduce risk of cardiovascular death and. Hospitalization for HF
Sacubitril-valsartan (entresto)
In patients with chronic symptomatic HFrEF NYHA class 2 or 3 who tolerate an ACE-1 or ARB replacement with sacubitril/valsartan is recommended
Allow 36 hour washout period when switching
Mineralocorticoid receptor antagonist (MRA)
Aldosterone antagonist
Potassium-sparing diuretic
Spironolactone, eplerenone
-indicated in patients with at rest dyspnea within past 6 months; post-MI with systolic dysfunction
-lowers mortality rate in patients who meet the prescribing criteria
-monitor electrolytes fluid balance, renal function
May result in hyperkalemia
What drug do you use for patients that cannot take ACE inhibitor, ARB, or ARNI
Hydralazine plus is oso ride dinitrate (Bidil)
Add-on to optimal guideline-directed medical therapy (GDMT) for African-American pts
Ivabradine (Corlanor)
Chronic HFrEF, LVEF <= 35% in sinus rhythm, resting HR >= 70
Digoxin
Inotropic agents used to improve symptoms and decrease hospitalization rates in symptomatic heart failure
Of use in pts with concomitant atrial fibrillation
Enhances exercise tolerance
Monitor serum levels (between 0.5-0.8 no/ml
General nonpharm treatments
Smoking cessation Restriction of alcohol consumption Sodium restriction Physical activity [daily weight measurements Annual influenza vaccine Pneumococcal vaccine PPSV23 Close follow-up with provider to ensure compliance
Heart failure prognosis
30-40% die within 1 year
60-70% within 5
Acute decompensated Heart failure (ADHF)
- requires prompt recognition and management
- new or exacerbation of chronic disease
- elevated. Left-sided filling pressures and dyspnea with or without pulmonary edema
Cardiogenic pulmonary edema
Potential fatal cause of acute respiratory distress
Most often a result of ADHF acute decompensated heart failure
Clinical presentation of cardiogenic pulmonary edema
Pt presents with dyspnea, productive cough and diaphoresis
Pulmonary exam reveals crackles/rales, wheezes, and rhonchi
Cardiogenic pulmonary edema X-ray
CXR reveals kerley B lines, edema, cardiomegaly
Pulmonary capillary wedge pressure typically elevated (>25mmhg)
Acute decompensated heart failure (ADHF) clinical presentation and physical exam
Clin:
Cough, dyspnea, fatigue and or peripheral edema which rapidly became more severe
Physical:
HTN, JVD, tachypneic and accessory muscle use, crackles, tachycardia, S3 or S4 gallop, new murmur, LE edema
Acute decompensated heart failure ADHF management
Hospital admission:
Close monitoring of vitals, o2 says, daily wt, I and O, electo, renal function, telemetry at least 24-48 hrs
Management
-O2 -> goal is to keep arterial oxygen saturation >90%
-diuretics ->fluid reduction and decreased pulmonary congestion
Nitroglycerin -> reduce preload and capillary wedge pressure
