Heart Failure

Question 1

What is heart failure

Answer 1

Any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood

Question 2

What are the 2 types of dysfunction of the left ventricle

Answer 2

• systolic dysfunction: impaired cardiac CONTRACTILE function
• diastolic dysfunction: abnormal cardiac RELAXATION stiffness or filling

Question 3

Right ventricle dysfunction

Answer 3

Pulmonary hypertension (left heart disease, lung disease, congenital heart disease)

Question 4

Types of left sided heart failure (LHF)

Answer 4

HFrEF: HF with REDUCED ejection fraction (systolic)
HFpEF: Hf with PRESERVED ejection fraction (diastolic)

Question 5

What shows the progression of heart failure

Answer 5

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

Question 6

HFrEF REDUCED clinical signs and symptoms

Answer 6

Systolic dysfunction
-reduced LVEF (<=40%)

Increased LV volumes (ESV and EDV) end systolic and end diastolic

“Systolic heart failure”

Question 7

Causes of HFrEF

Answer 7

Coronary artery disease
Cardiomyopathy

High after load
-HTN

Question 8

HFpEF clinical signs and symptoms PRESERVED

Answer 8

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”

Question 9

Pathophysiology of HFpEF

Answer 9

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

Question 10

Causes of HFpEF

Answer 10

Hypertension with or without left ventricular hypertrophy
Aging
Coronary artery disease
DM
Sleep disordered breathing
Obesity
Kidney disease

Question 11

Pathophysiology of right heart failure

Answer 11

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)

Question 12

Risk factors for heart failure

Answer 12

CAD (more common)
Smoking
HTN
Overweight
DM
Valvular heart disease

Question 13

Predisposing underlying causes of heart failure

Answer 13

Most common is CAD

Dilated cardiomyopathy 
Valvular heart disease
HTN
Left ventricular hypertrophy
Others

Question 14

Symptoms of heart failure

Answer 14

DYSPNEA
Cough
FATIGUE/WEAKNESS
DEPENDENT EDEMA
WEIGHT GAIN
Ascites
RUQ discomfort/early satiety  
Nocturia

Question 15

Signs of heart failure

Answer 15

Edema
Elevated JVD
Crackles at bases
Displaced PMI
S3/S4 gallop
Hepatomegaly
Hepatojugular reflex

Question 16

Left heart failure

Answer 16

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)

Question 17

Right heart failure

Answer 17

Dependent edema (wt gain)
Ascites
Increased venous pressure (JVD)
GI tract congestion
Hepatic congestion (hepatomegaly, impaired liver function)

Question 18

What diagnostic studies for suspected HF

Answer 18

ECG
Echocardiography
Chest radiography

Question 19

What to evaluate for ECG heart failure

Answer 19

Ischemia, arrhythmia

Normal EKG makes systolic dysfunction highly unlikely

Question 20

Echocardiogram ejection fraction percent considered normal and systolic vs. diastolic

Answer 20

Normal ejection fraction >50-55%

Systolic vs. diastolic
SYSTOLIC HF + EF <= 40%
DIASTOLIC HF + normal EF, and DIASTOLIC DYSFUNCTION

Question 21

Echo systolic vs diastolic dysfunction

Answer 21

Systolic- dilated left ventricle

Diastolic dysfunction- left ventricle hypertrophy

Question 22

What does chest radiography evaluate for and what findings are suggestive of HF

Answer 22

Evaluate for cardiomegaly (cardiac to thoracic width ratio >50%

Cardiomegaly
Cephalization of the pulmonary vessels
Kerley B-lines (interstitial edema)
Pleural effusions

Question 23

Labs for heart failure

Answer 23

Cardiac enzymes
CBC
CMP (electrolytes)
Renal function (cr)
Glucose
Liver function tests
Natriuretic peptide biomarkers

Question 24

What are the two natriuretic peptide biomarkers and what is. It useful for

Answer 24

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

Question 25

When should you measure natriuretic peptide biomarkers

Answer 25

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

Question 26

Heart failure classes 1-4

Answer 26

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

Question 27

Prevention strategies of HF

Answer 27

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 ```

Question 28

Goals of therapy of HF

Answer 28

Reduce morbidity and mortality - reduce preload -> diminish congestive symptoms - reduce afterload -> improve cardiac function

Question 29

Recommended initial therapy for HFrEF

Answer 29

ACE inhibitor | Diuretics

Question 30

Treatment of HFpEF

Answer 30

Identification and treatment of co-morbidities | Diuretics for symptomatic relief

Question 31

Goal and important points about diuretics

Answer 31

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

Question 32

ACE inhibitors (ACE-I)

Answer 32

Shown to reduce morbidity and mortality in both symptomatic and asymptomatic HF patients Reduce severity and number of symptoms Reduce hospitalizations Hyperkalemia SE: cough

Question 33

Angiotensin 2 receptor blockers

Answer 33

Improve morbidity and mortality Use if ACE inhibitors are not tolerated (via cough) Monitor BP, renal function, electrolytes -hyperkalemia Decrease afterload RAAS blockade

Question 34

Beta-blockers

Answer 34

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

Question 35

Angiotensin receptor-neprilysin inhibitor (ARNI)

Answer 35

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

Question 36

Mineralocorticoid receptor antagonist (MRA)

Answer 36

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

Question 37

What drug do you use for patients that cannot take ACE inhibitor, ARB, or ARNI

Answer 37

Hydralazine plus is oso ride dinitrate (Bidil) Add-on to optimal guideline-directed medical therapy (GDMT) for African-American pts

Question 38

Ivabradine (Corlanor)

Answer 38

Chronic HFrEF, LVEF <= 35% in sinus rhythm, resting HR >= 70

Question 39

Digoxin

Answer 39

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

Question 40

General nonpharm treatments

Answer 40

``` 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 ```

Question 41

Heart failure prognosis

Answer 41

30-40% die within 1 year | 60-70% within 5

Question 42

Acute decompensated Heart failure (ADHF)

Answer 42

- requires prompt recognition and management - new or exacerbation of chronic disease - elevated. Left-sided filling pressures and dyspnea with or without pulmonary edema

Question 43

Cardiogenic pulmonary edema

Answer 43

Potential fatal cause of acute respiratory distress | Most often a result of ADHF acute decompensated heart failure

Question 44

Clinical presentation of cardiogenic pulmonary edema

Answer 44

Pt presents with dyspnea, productive cough and diaphoresis Pulmonary exam reveals crackles/rales, wheezes, and rhonchi

Question 45

Cardiogenic pulmonary edema X-ray

Answer 45

CXR reveals kerley B lines, edema, cardiomegaly | Pulmonary capillary wedge pressure typically elevated (>25mmhg)

Question 46

Acute decompensated heart failure (ADHF) clinical presentation and physical exam

Answer 46

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

Question 47

Acute decompensated heart failure ADHF management

Answer 47

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