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Clin Med - Cardiology > Heart Failure and Evaluation of Dyspnea > Flashcards

Heart Failure and Evaluation of Dyspnea Flashcards

1
Q

What is heart failure?

A
  • Inability of heart to pump at sufficient rate to meet needs without abnormally high filling pressure
  • Abnormality of cardiac function and neurohormonal regulation
  • Effort intolerance, fluid retention and reduced longevity
  • Impairment of ventricles to fill with or to eject blood
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2
Q

How common is heart failure?

A

Prevalence: 1% of those 50-59, 10% of those 80+ in US

Incidence: 550K per year in US

Most common caudse of hospitalization in those 65+

(1/3 are readmitted in 6 mos, 24% in 1 mo)

50% 5-year mortality

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3
Q

What are some diseases that are risk factors for heart failure?

A

HTN, DM, Ischemia, CAD (most common), Valve Disease, Toxins (ETOH, chemo)

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4
Q

What are the three key problems

with heart failure and what causes each one?

A
  1. Myocardial (pump) failure: myocardial loss, increased pressure/work load, increased volume load
  2. LV inflow obstruction (filling problem): mitral stenosis, decrease LV compliance (eg concentric hypertrophy)
  3. Increased cardiac output: due to acute (transfusions) or chronic (eg: anemia) volume overload
  4. Other: thryrotoxicosis, arrhythmias
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5
Q

What are some ways of classifying heart failure?

A

Right vs Left Side

Systolic vs Diastolic

Acute vs Chronic

Compensated vs Decompensated

Dilated vs Hypertrophic vs Restrictive

High Output vs Low Output

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6
Q

What are the three key mechanisms of heart failure and what is their result?

A
  1. Increased Preload (blood volume)
  2. Increased Afterload (resistance)
  3. Decreased Contractility

Leading to increased stroke volume

leading to cardiac remodeling.

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7
Q

What causes Increased Afterload?

A

Resistance in the arterial tree that the ventricle must overcome.

AKA: Systemic Vascular Resistance

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8
Q

What causes increased preload?

A

Total blood volume

Skeletal Muscle exercise (venous return)

Venous Tone (volume storage)

Intrapericardial pressure

Body Position

Intrathoracic pressure

Atrial Function (CHF, HTN, Aortic Stenosis)

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9
Q

What affects Contractility?

A

Increased by: # of cardiomyocytes, strength of stimulation (Ca++), Sympathetic impulses, Circulating catecholamines, Inotropic Agents (digoxin)

Decreased by: Cardiomyopathy (-), MI, Anoxia, Acidosis, Hypercapnia, Medications

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10
Q

How are the four classes of heart failure patients?

A

I: No Sx

II. Sx during ordinary activity

III. Sx during sligh activity

IV: Sx at rest

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11
Q

What are the four stages of heart failure?

A

A. Risk factors but not Sx

B. Structural changes but no Sx

C. Structural changes with Sx

D. Decompensated, end stage

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12
Q

What are the goals of treatment for heart failure?

A

Decrease Symptoms

Prevent/Slow disease progression

Increase survival

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13
Q

What are Hemodynamic Profiles?

A

A simple way of classifying patients

in order to guide treatment options.

Based on level of perfusion and level of congestion/pressure:

I. Normal (Dry and Warm)

II. Congestion (Wet and Warm)

III. Hypoperfusion (Dry and Cool)

IV. Hypoperfusion and Congestion (Wet and Cool)

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14
Q

What is Left Ventricular Failure?

A

When the left ventricle fails and fluid backs up into the lungs

Sx: SOB, DOE, tachypnea, rales, pulmonary edema,

orthopnea, paroxysmal noctural dyspnea,

S3, Mitral Regurgitation, fatigue

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15
Q

What is Right Ventricular Heart Failure?

A

When the right ventricle fails and fluid backs up into the veins/body.

Signs/Sx: increased JVP (FIRST SIGN!!),

pitting, dependent edema (legs, ankles, sacrum), ascites,

hepatomegaly and hepatojugular reflex sign

parasternal heave

nocturia

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16
Q

What causes Right Side Heart Failure?

A
  1. Left Side Heart Failure

or

  1. Pulmonary HTN or Pulm Stenosis –> Cor Pulmonale
17
Q

What are the two kinds of Left Ventricular Heart Failure?

A
  1. Systolic (aka Heart Failure reduced Ejection Fraction - HFrEF)
  2. Diastolic: (aka Heart Failure preserved Ejection Fraction HFpEF)
18
Q

What is HFrEF?

A

Systolic Heart Failure = pump failure

More common in men

Signs: large, dilated heart, low ejection fraction, S3, Normal or low BP

Tx: Well established

19
Q

What is HFpEF

A

Diastolic Heart Failure = filling problem

More common in post-menopausal women

Signs: Concentric LV hypertrophy leading to small LV cavity, HTN, normal/increased ejection fraction, S4

Tx: not well established

20
Q

What is Acute Decompensated Heart Failure?

A

When a heart failure patient gets rapidly worse due to:

Medications that worsen HF: CCBs, BBs, NSAIDs, Antiarrhythmics, Anti-TNF antibodies,

Other Changes that worsen HF: Pregnancy, alcohol, increased HTN, acute valvular insufficiency, MI, ischemia, arrhythmia, infection (pneumonia), anemia, stopping HF Tx

NOTE: the point is that HF patients are very fragile

and can easily go downhill rapidly!

21
Q

How do you diagnose Heart Failure?

A

Signs/Sx: elevated JVP, edema, rales, S3

2D Echo with Doppler: decreased LV ejection fraction, LV structural problems, other structural abnormalities (valves, pericardium, RV)

CXR: cardiomegaly (2/3 thoracic cage), pleural effusion, enlarged pulmonary artery, engorged upper lobe veins

22
Q

What labs help with Heart Failure Dx?

A
  • Initial: CBC, UA, electrolytes (Ca++, Mg++), BUN, Creatinine, Glucose, Lipid Panel, Liver Function, TSH (treatable ETX!), ANP/BNP (best re R/O)
  • Serial Monitoring: Electrolytes and Renal

Also depending on your location and suspicion:

HIV, hemochromatosis, pheochromocytoma,

rheumatoid diseases, amyloidosis, Chagas

23
Q

What is Invasive Hemodynamic Monitoring

and when is it used?

A

Threading a catheter up to the mitral valve to measure pressure.

Used for: respiratory distress, impaired perfusion, decreased systolic pressure, decreased renal function,

persistent Sx despite Tx

Consideration for revascularization or transplant

24
Q

When is an endocardial biopsy called for?

A

If you suspect an inflammatory process

and it would change treatment.

(this is invasive)

25
Q

What is the pharmacological Tx for Heart Failure?

A

For Sx, but do not decrease mortality:

  • Inotropics: (to increase contractility): digoxin, sympathomimetics, phosphodiesterase inhibs

To decrease mortality:

  • Vasodilators (decrease afterload): Nitro, ACEi, ARBs, Nitro, Hydralazine,
  • Aldosterone inhibitors (spironolactone) (10%)
  • Beta Blockers (carvedilol): effective for severe HF (30%+)
  • Neprilysin Inhibitors (LCZ696) esp w ACEi (30%+)
  • Ivabradine re I(f) channels in pacemaker cells
26
Q

What are some nonpharmacologic treatments for HF?

A

Weight loss, exercise

biventricular pacemakers

ventricular assist devices as bridge to transplantation

heart transplant

hospice and palliative care

27
Q
A

Clin Med - Cardiology (17 decks)

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