Heart Failure Flashcards
What are the 3 most common causes of HF?
- CAD - ischemic heart disease
- Idiopathic, dilated cardiomyopathy
- Valvular heart disease
What are 4 causes of restriction/obstruction to ventricular filling which can lead to HF?
- RV infarct
- Constrictive pericarditis
- Mitral stenosis
- Atrial myxoma
Using the AHA/ACC heart failure staging guidelines, what does stage A represent?
Pts at high risk for HF but WITHOUT structural heart disease or sx’s of HF
Using the AHA/ACC heart failure staging guidelines, what does stage B represent?
Asymptomatic pts WITH structural heart disease (i.e., LVH and/or impaired LV function (low EF), valvular dz, but hemodynamically stable
Using the AHA/ACC heart failure staging guidelines, what does stage C represent?
Pts WITH current or prior sx’s of HF WITH structural heart disease; SOB, fatigure, reduced exercise tolerance
Using the AHA/ACC heart failure staging guidelines, what does stage D represent?
Pts w/ refractory HF requiring specialized treatment/interventions
Using the NYHA functional classification for HF, what does class I-class IV represent?
- Class I = asymptomatic; no physical activity limitations
- Class II = no sx’s at rest; exertional sx’s w/ ordinary activity
- Class III = no sx’s at rest; sx’s with minimal activity
- Class IV = sx’s AT rest
Which imaging modality is essential in the evaluation of heart disease and for distinguishing systolic HF from diastolic HF?
Echocardiogram
List 5 causes of acute HF
- Acute MI
- Ruptured papillary muscle
- MR
- AI
- Toxins
What are some distinguishing sx’s of systolic HF vs. diastolic HF?
- Systolic HF = DOE, orthopnea, paroxysmal nocturnal dyspnea
- Diastolic HF = SOB, DOE, and pulmonary edema
Which type of HF (diastolic/systolic) is associated with HTN, obesity, DM, CAD, and aging?
Diastolic HF
What are 3 common underlying causes of imparired ventricular relaxation leading to diastolic HF?
- Acute ischemia
- Myocardial fibrosis
- Amyloidosis
List 6 causes of high-output HF?
- Hyperthyroidisim
- Anemia
- Pregnancy
- A-V fistula
- Beriberi
- Paget’s
What are the CO and EF like in high output HF?
- High CO
- Low EF
Which hormones released as a compensatory mechanism for HF causes an increased preload and which causes inceased afterload?
- Aldosterone —> Na and H2O retention = ↑ preload, congestive sx’s and volume expansion
- Angiotensin II –> vasoconstrictor –> ↑PVR (↑ afterload)
What is the effect of increased ADH released during compensatory phase of HF?
- Stimulates thirst –> ↑ TBW and hyponatremia (dilutional)
- ↑ preload (Na and H2O retention)
What are 2 major non-compliance issues which precipitate HF?
- Non-compliance with diet = too much Na+, too many kcals, too many stimulants
- Non-complance with meds = AE’s and cost
What are 4 medication classes which can worsen/precipitate HF?
- Antiarrhythmics
- Beta-blockers
- CCBs
- NSAIDs
How can anemia precipitate HF?
↑ O2 needs of tissues –> ↑ CO
By which mechanism do tachyarrhythmias lead to ischemia?
↓ diastolic filling time
What is the most common sx of HF?
Dyspnea –> ↓ arterial perfusion to organs and venous congestion
Presence of which sx ↑ the likelihood of HF by 2-fold?
Paroxysmal nocturnal dyspnea
Which PE of the lung is common with HF?
Crackles in lung due to pulmonary edema; may wheeze or cough (frothy- pink fluid)
What are 4 signs/sx’s of RV failure?
- Peripheral/sacral edema
- Hepatomegalia
- Ascites
- ↑ JVD, hepatojugular reflex
When measuring JVP, how many cm’s is considered above normal?
- >3 cm above the sternal angle
- 8-9 cm in total distance above the RA
What are findings on a CXR associated with HF?
- Cardiomgalia
- Pulmonary edema w/ central peripheral infiltrates
- ↑ size of vessels in upper portions of lungs
- Pleural effusions
What is the usefulness of ordering a CBC, CMP, and UA when assessing possible HF?
- CBC looking for anemia 2’ to chronic disease
- CMP looking for electrolyte imbalance; pre-renal azotemia (BUN:Cr)
- UA looking for protein in urine
Which lab must always be ordered in pt with HF who is >65 yo with Afib?
Thyroid
What is the significance of a BNP <100 pg/mL in terms of HF?
97% chance of NO HF
BNP is a neurohormone made in the ventricle that is sensitive to what (i.e., what are the stimuli)?
- Sensitive to ventricle stretching and volume overload.
- Preload/afterload are the stimuli
What are pulmonary and liver problems which may mimic HF?
- Pulmonary = PE, asthma, and pneumonia
- Liver = cirrhosis –> ascites + edema
What is a non-pharmacologic approach to tx of HF if pt’s Na+ is <126 mEq/L?
Fluid restriction to <2 L/day
Which type of activity should be avoided in HF and what should be encouraged?
- AVOID isometric acivity which ↑ SVR and afterload
- ENCOURAGE isotonic activity - walking, hiking, golf
Why is enoxaparin (subcut lovenox) given to someone with HF?
Prophylaxis for DVT’s
What does a class II recommendation mean in evidence based medicine?
Conflicting evidence and/or divergence of opinion
What does a grade of A-C represent in levels of evidence for evidence based recommendations?
- A = data from meta-analysis or multiple RCT’s; multiple populations evaluated
- B = data from single RCT or non-randomized studies; limited population evaluated
- C = only consensus opinion of experts, case studies, or standard of care, very limited populations evaluated
Which drug class is useful for all NYHA functional classification with systolic HF?
ACE inhibitors
ACE-I should be used cautiously in pt’s with what 2 underlying conditions?
- Renal insufficiency
- K+ >5 mEq/L
You should not give an ARB to a pt that had what AE from an ACE-I?
Angioedema
There is a survival benefit with using beta-blockers with what 2 underlying heart conditions?
- Chronic systolic HF
- Dilated cardiomyopathy
Which NYHA functional classes of HF are beta-blockers recommended in?
Class II and III
The US Carvedilol HF program showed improvement in what 2 pt parameters?
- Improved LVEF
- Improved well being
Beta-blockers should never be used in pt’s who are in what classification of HF?
Unstable (Class IV)
Which level of evidence exists for the use of beta-blockers in all stable pt’s with sx’s of HF and reduced EF, unless contraindicated?
Level A
Diuretics are able to relieve congestive (pulmonary) sx’s by decreasing what?
Preload
Which inotropic agent is useful in HFrEF and A.fib for ventricular rate control?
Digitalis
Which level of evidence exists for the use of Spironolactone in decreasing mortaility and decreasing HF hospitalization?
Level B
Which drug used in HF is an inotropic vasodilator?
Milrinone = PDE inhibitor
Which inotropic agent used in HF stimulates beta-1 receptors and is useful short-term?
Dopamine
Which drug given for HF is an arterial vasodilator, which reduced afterload and SVR?
Hydralazine
When is hydralazine plus isosorbide dinitrate used for HF?
- Better response in African Americans
- Can be used in general if intolerant to ACE-I/ARB
