Heart Failure Flashcards
Symptom of heart failure with highest sensitivity?
Highest specificity?
Highest sensitivity: Dyspnea on exertion (84%)
Highest specificity: Orthopnea, PND, and edema (77-84%)
Define “Hypertensive acute Heart Failure”
Signs and symptoms of Heart Failure, SBP >140 mmHg, CXR with pulm edema, symptom onset <48 hours
(This was per Tintanelli’s handbook)
Mortality rate after initial diagnosis of Heart Failure?
50% within 5 years of initial diagnosis
Define Acute-on-chronic Heart Failure
Per Tintanelli’s handbook:
Signs and symptoms of acute HF, mild-moderate, usually onset over days-weeks
Do not meet criteria for Pulmonary edema, Cardiogenic shock, or Hypertensive HF. SBP is <140 and >90
What are the classic Chest X-ray findings for CHF?
Describe specificity and sensitivity of these findings.
Cardiomegaly - 70% of cases Vascular congestion (cephalization of vessels) —> Interstitial edema (Kerry B lines, haziness) —> Alveolar infiltrates Pleural effusions
HIGH specificity (71-99%) LOW sensitivity (10-64%)
Also note: CXR may lag behind clinical findings
These BNP and N-t-proBNP levels make Heart Failure highly unlikely
These BNP and N-t-proBNP levels make Heart Failure very likely
Unlikely:
- BNP <100 pg/mL and proBNP <300 pg/mL
Likely:
- BNP >1,000 pg.mL and proBNP >30,000 pg/mL
If noninvasive positive pressure ventilation is needed for Acute Heart Failure, what are the settings?
Start with CPAP (EPAP set at 5 cmH2O and titrations up to 15 cm H2O)
Add IPAP as needed. Or start with BIPAP at 10/5 cm H2O
What are the 4 basic tenets of treating acute heart failure?
1) Improve gas exchange and arterial O2 saturation (supplemental O2 and possibly NIPPV)
2) REDUCE preload and afterload
3) Address excess sodium and water
4) improve contractility
Describe the use and dosing of Nitroglycerin for acute Heart Failure
Use this to decrease preload and afterload
Dose: low doses reduce preload (10-20 mcg/min) and higher doses (100 mcg/min and up) reduce afterload too
- EM:RAP advocates starting at a high dose: 400 mcg/min and titrations down to control BP
- Could also start at 100-200 mcg/min IV and titrations up as needed
- Could start with low dose (10-20 mcg/min) and titrations up too (to make nursing less nervous)
NOTE: If starting with these high doses, the physician should stay by the bedside while titrating.
I think the BP goal is <140 SBP
Use this medicine as an adjunct to nitroglycerin to help reduce BP if needed (include dose)
Single dose of ACEi:
PO or sublingual Captopril: 12.5 - 25 mg
IV Enalaprialat: 1.25 mg IV
Contraindications for the use of Nitroglycerin
Concurrent use of PDE5 inhibitor (sildenafil and tidalafil)
Severe Aortic Stenosis
RV infarction
Avoid in Hypotension
While using nitroglycerin drip for acute Heart Failure what should you do if hypotension occurs?
Stop or decrease the dose.
The hypotension is usually transient.
SBP goal in hypertensive acute heart failure?
SBP <140
Note: I never actually saw this written specifically as a goal anywhere, it was just the number given in Tintanelli’s as when hypertensive heart failure started and there was also a note saying that pulmonary edema can occur at as low as SBP of 150, so I just kind of went with it.
How does Nitroprusside differ from Nitroglycerin and when might you use it instead for acute Heart Failure?
Has a more balanced venodilation and arteriodilation effects (Nitroglycerin is only venodilation at low doses and arteriodilation at high doses).
Switch to nitroprusside if not achieving good results with nitroglycerin (BP not responding)
When should diuretics be used to help treat acute heart failure?
After initial stabilization of BP and pulmonary edema, etc.
AND only if they have total-body volume overload (it is possible that they could have pulmonary edema and be euvolemic or hypovolemic - ask about their dry weight to help determine this, if weight gain then likely volume overloaded and will need diuretic)
