Heart Failure and Evaluation of Dyspnea Flashcards
What is heart failure?
- 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
How common is heart failure?
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
What are some diseases that are risk factors for heart failure?
HTN, DM, Ischemia, CAD (most common), Valve Disease, Toxins (ETOH, chemo)
What are the three key problems
with heart failure and what causes each one?
- Myocardial (pump) failure: myocardial loss, increased pressure/work load, increased volume load
- LV inflow obstruction (filling problem): mitral stenosis, decrease LV compliance (eg concentric hypertrophy)
- Increased cardiac output: due to acute (transfusions) or chronic (eg: anemia) volume overload
- Other: thryrotoxicosis, arrhythmias
What are some ways of classifying heart failure?
Right vs Left Side
Systolic vs Diastolic
Acute vs Chronic
Compensated vs Decompensated
Dilated vs Hypertrophic vs Restrictive
High Output vs Low Output
What are the three key mechanisms of heart failure and what is their result?
- Increased Preload (blood volume)
- Increased Afterload (resistance)
- Decreased Contractility
Leading to increased stroke volume
leading to cardiac remodeling.
What causes Increased Afterload?
Resistance in the arterial tree that the ventricle must overcome.
AKA: Systemic Vascular Resistance
What causes increased preload?
Total blood volume
Skeletal Muscle exercise (venous return)
Venous Tone (volume storage)
Intrapericardial pressure
Body Position
Intrathoracic pressure
Atrial Function (CHF, HTN, Aortic Stenosis)
What affects Contractility?
Increased by: # of cardiomyocytes, strength of stimulation (Ca++), Sympathetic impulses, Circulating catecholamines, Inotropic Agents (digoxin)
Decreased by: Cardiomyopathy (-), MI, Anoxia, Acidosis, Hypercapnia, Medications
How are the four classes of heart failure patients?
I: No Sx
II. Sx during ordinary activity
III. Sx during sligh activity
IV: Sx at rest
What are the four stages of heart failure?
A. Risk factors but not Sx
B. Structural changes but no Sx
C. Structural changes with Sx
D. Decompensated, end stage
What are the goals of treatment for heart failure?
Decrease Symptoms
Prevent/Slow disease progression
Increase survival
What are Hemodynamic Profiles?
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)
What is Left Ventricular Failure?
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
What is Right Ventricular Heart Failure?
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
What causes Right Side Heart Failure?
- Left Side Heart Failure
or
- Pulmonary HTN or Pulm Stenosis –> Cor Pulmonale
What are the two kinds of Left Ventricular Heart Failure?
- Systolic (aka Heart Failure reduced Ejection Fraction - HFrEF)
- Diastolic: (aka Heart Failure preserved Ejection Fraction HFpEF)
What is HFrEF?
Systolic Heart Failure = pump failure
More common in men
Signs: large, dilated heart, low ejection fraction, S3, Normal or low BP
Tx: Well established
What is HFpEF
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
What is Acute Decompensated Heart Failure?
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!
How do you diagnose Heart Failure?
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
What labs help with Heart Failure Dx?
- 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
What is Invasive Hemodynamic Monitoring
and when is it used?
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
When is an endocardial biopsy called for?
If you suspect an inflammatory process
and it would change treatment.
(this is invasive)
What is the pharmacological Tx for Heart Failure?
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
What are some nonpharmacologic treatments for HF?
Weight loss, exercise
biventricular pacemakers
ventricular assist devices as bridge to transplantation
heart transplant
hospice and palliative care
