Heart Failure Clinical Aspects-Weinstein Flashcards
What is the 5 year survival of heart failure
50%
What is the most common mode of death of heart failure?
Sudden death
What is the increase in prevalence of HF from 50 to 89?
10x
What percentage of HF patients are over 65?
>75%
What is the most common hospital diagnosis in patients over 65?
Heart failure
What percentage of HF patients die suddenly?
40%
Definition of sudden death
Death within an hour of onset of symptoms. Usually caused by arrhytmias
What percentage of HF patients have ventricular arrhythmias?
90%, including PVCs (premature ventricular contractions), multiform PVCs and NSVT (nonsustained ventricular contractions)
Prognostic factors of heart failure
LV Dysfunction Coronary Artery Disease Arrhythmias Exercise Tolerance Plasma Noradrenaline ↓ Serum Sodium.
New York Heart Association Classification of Heart Failure
I-Asymptomatic, II-Mild, III-Moderate, IV-Severe
What is involved in class I NYHA?
Known to have dysfunction but asymptomatic during a reasonable amount of exercise.
What is involved in class II NYHA classification?
Can perform everyday activities but LV dysfunction prevents exertion above regular activities (can walk but not run). 2/3 die of sudden death, otherwise CHF/fluid retention, pulmonary edema, etc.
What is involved in class III NYHA classification?
Symptomatic in normal everyday activities. 1/2-2/3 sudden death, 1/4 CHF death.
What is involved in class IV NYHA classification?
Symptomatic even at rest. Ex: short of breath while sitting in chair. Over half of deaths are from CHF, only 1/3 sudden death.
Definition of heart failure?
Clinical syndrome with symptoms, signs AND objective evidence.
What are the symptoms typical of HF
Dyspnoea, fatigue, ankle swelling
What are the signs typical of HF
Tachycardia, tachypnoea, ↑JVP, oedema, hepatomegaly
What objective evidence needs to be shown of a structural or functional heart abnormality
Cardiomegaly, S3, murmur, abnormal echo, ↑BNP-all at rest.
Stages of LV dysfunction and HF classified by the AHA
Stage A: risk factors (normal healthy people, keep evaluating), Stage B: asymptomatic and structural heart disease (keep following up and treat risk factors, like NYHA class I), Stage C: symptomatic and structural heart disease (known to have HD but need aggressive treatment of risk factors, NYHA II), Stage D: severely symptomatic and structural heart disease (most patients either in HF and feeling good or potentially on their way to HF, tip of iceberg)
What is the difference between NYHA and AHA classificiation?
NYHA is a clinical assessment (already ill) and AHA looks at overall picture and how aggressively to treat, risk factor modification, etc.
Respiratory symptoms and signs of left heart failure
Exertional dyspnea, orthopnea (sit up to ease breathing), paroxysmal nocturnal dyspnea (PND), pulmonary congestiona nd edema (worst aspect, outpouring of fluid into lung tissue itself)
Systemic igns and symptoms of heart failure
Respiratory, fatigue (LV not perfusing skeletal muscle), weakness, nocturia, cerebral symptoms (rare)
Signs of physical exam in left heart failure
Rales (at lung bases like hair), pleural effusion, decreased pulse pressure, pulsus alternans, abnormal apical impulse (weak from LV dilation), muffled heart sounds, apical S3, mitral regurgitation (original insult or secondary)
What is Pulsus alternans?
LV destroyed and so weak that between one beat to next, doesn’t sufficently recover to perform adequate systole. Monitor might show 100bpm but may only have 50 functional beats on BP monitor. Extremely uncommon-“end of the road” sign.
Symptoms of extreme left heart failure
Pulmonary edema, unable to breathe, legs down to increase pooling (DIY preload reduction), steronomastoids and accessory muscles, tremendous sympathetic response, pouring with sweat, limbs cold and clammy.
Symptoms of right heart failure
Fatigue, weakness, GI (anorexia, abdominal pain-upper quadrant and distension, asciites), weight gain (d/t fluid retention, edema of intestinal walls/gastric walls, drops appetite, congestion of liver), peripheral edema (legs)
Signs of right heart failure on physical exam
Elevated jugular venous pressure, hepatojugular reflux, hepatomegaly, peripheral edema, pleural effusion, cyanosis, asciites, right sided S3, tricuspid regurgitation (from failing RV)
What is hepatojugular Reflux?
If JVD is not palpable, press area of liver, compression forces fluid into RA from portal vein, increases pressure in RV and makes jugular venous pressure increase.
Picture of signs of right heart failure
Cyanosis, engorgement of jugular veins, enlargement of liver, asciites, dependent edema in legs, elevated venous pressure (seen in monometer), not in distress.
Precipitating factors in chronic heart failure
Lack of compliance (diet and drugs), uncontrolled HTN, arrhythmias (Afib most common), environmental factors, inadequate therapy, pulmonary infection, Fluid overload (causing pulmonary edema or HF, ex: steroids/NSAIDS, negative inotropes), MI, thyrotoxicosis and other endocrine disorders, worsening of renal function
Aspects of HF management
- History (confirm diagnosis, lifestyle, NYHA class, underlying diseases, etc.), 2. Physical examination, 3. baseline investigations (ECG, CXR)
Baseline investigations/exams in HF
Blood chemistry (renal, thyroid, cardiac markers), ECG (sinus, old infarct, other underlying problems), Echocardiogram, IHD investigations (within clinical context: exercise test, thallium, catheterization), BNP, Holter
What aspects need to be treated in heart failure?
- Underlying condition, 2. Precipitating condition (ex: Afib from pulmonary infection give antibiotics) 3. Heart failure itself
What points are important to convey in patient education?
Why they are in HF, signs of deterioration, physical activity (mild if can’t strenuous), rehab, sexual dysfunction
What pharmacological therapy is used for heart failure (big list)?
ACE inhibitors, diuretics, Beta blockers, aldosterone antagonists, angiotensin antagonists, cardiac glycosides, vasodilator agents, positive inotropes, anticoagulation, antiarrhythmics, oxygen
Compiled list of device and surgery interventions for heart failure
Revascularization, pacemakers, ICDs, heart transplantation, ventricular assist devices, artificial heart, ultrafiltration/hemodialysis
When are ACE inhibitors used?
First line therapy in patients with reduced LVEF. Only drug to give to asymptomatic patients with LV dysfunction (use guidelines, not symptoms to treat).
What are the outcomes with ACE inhibitors?
Decrease development of symptoms and hospitalizations, delay onset of problems. Best benefit in most severe cases.
What are the restrictions of ACE inhibitors?
If side effects (cough) on ACE inhibitors, can give ARBs), moderate renal insufficiency but NOT contraindictations.
What are the absolute contraindications for ACE inhibitors
Bilateral renal artery stenosis, angioedema,
What are the pros and cons of ARBs?
Fewer side effects, efficacy may or may not be the same as ACE inhibitors. Given only when ACE inhibitor intolerance.
When are beta blockers recommended?
For symptomatic patients NYHA Class II and above, in addition to ACE inhibitors and diuretic.
What are the benefits of beta blockers?
Decreases symptoms of LV systolic dysfunction after MI, reduces: mortality when added to ACE inhibitors. total mortality cardiovascular mortality sudden death death due to progressive HF hospitalizations (all, HF, CV) FC II-IV Improves functional class I, A Less worsening of HF Independent of age, sex, FC, EF, etiology
What are the 4 currently recommended beta blockeres?
Carvedilol (blocks both alpha and beta), beta 1 selective: metoprolol succinate, bisoprolol, nebivolol
When are ICDs recommended (Implanted Cardiac Defibrillator)
Prior resuscitated cardiac arrest, demonstrated underlying propensity for life-threatening arrhythmias or severe MI complications, ischemic etiology and >40 days post MI or nonischemic etiology.
What does an ICD do?
Pacemaker type implanted under skin with electrode to RV gives internal shock when senses arrhythmia. Doesn’t pace patient, just waits for VF or VT to happen. During an atrial block will let pts own internal pacemaker system and when it doesn’t work gives its own pulse.
When is a CRT (Cardiac resynchronization therapy used?
- Significant HF: NYHA class III or IV and QRS extended over 120ms., 2. On max therapy, 3. Severe LV dysfunction
What does a CRT do?
Pacemaker. Fully takes over conduction as it sits on the right ventricle. Improves symptoms and decreases hospitalization, reduces mortality.
When is a CRTD (Cardiac resynchronization therapy defibrillator) used?
In patients candidates for CRT but underlying propensity to develop arrhythmias and need ICD. Paces by ICD electrode but also gives shocks.
