Heart Failure - Johnston

Question 1

What is the most common cause of HF?

Answer 1

ischemic heart disease

Question 2

What are the basic causes of HF?

Answer 2

• restrictive/obstruction to ventricular filling ( RV infarct, constrictive pericarditis, mitral stenosis, atrial myxoma)

Question 3

What are the stages of heart failure according to AHA?

Answer 3

A. AT risk people (CAD, HTN, DM) asymptomatic
B. has LVH or impaired LV function, low EF, previous MI, valvular disease, structural heart disease, hemodynamicaly stable. - asymptomatic
C. Symptomatic of HF with structural heart disease
D. Refractory HF; does not respond to conventional tx and needs specialized tx like mechanical support, transplant.

Question 4

what are the classes of HF according to NYHA?

Answer 4

1. Asymptomatic, no limitation of activity, or symp on exertion,
2. Slight limitation, ordinary activity causes symptoms
3. Exertional symptoms with minimal activity.
4. Inability to carry out physical activity without discomfort; symptoms at rest

Question 5

what are some symptoms of systolic HF?

Answer 5

• Decreased SV, increased vent filling pressure
• EF less than 40%
• weak, fatigued, reduced exercise tolerance, dyspnea, orthopnea, nocturnal dyspnea

Question 6

What are some symptoms of diastollic HF?

Answer 6

• SOB
• dyspnea
• pulmonary edema

Question 7

Differentiate between acute and chronic HF.

Answer 7

Acute: heart failure due to acute MI, ruptured papillary muscle, MR, AI, toxins

Chronic: (most common): Multivalvular disease of dilated cardiomyopathy, progresses slowly, edema, wt gain

Question 8

what are are causes of high output heart failure?

Answer 8

• hyperthyroidism, anemia, pregnancy, A-V fistula, beriberi, Paget’s
• High CO but low EF

Question 9

What are some causes of Low Output Heart failure?

Answer 9

More common than High output

- ischemic heart disease, HTN ( dilated cardiomyopahty, valvular and pericardial disease)

Question 10

what are signs of right sided HF

Answer 10

• edema
• pulmonary HTN
• hepatomegalia,
• venous distension
• increased JVD, HJR
• ascites

Question 11

What are signs of left sided HF

Answer 11

• LV is overloaded
• AS, MI
• dyspnea, orthopnea, due to pul congestion

Question 12

Due to heart failure, what neurohormonal responses are unregulated?

Answer 12

SNS
RAAS
ADH
cytokines

Question 13

What are three major symptoms of increased HF probability?

Answer 13

• new murmur
• S3 gallop
• Dyspnea

Question 14

what are some signs of RV failure?

Answer 14

• peripheral sacral edema

-

Question 15

On CXR what is seen that which are diagnostic of HR?

Answer 15

• cardiomegalia
• pulmonary edema with central peripheral infiltrates
• increased size of vessels in upper portion of lungs
• pleural effusions

Question 16

What is the timeline of levels of Troponin T and I?

Answer 16

increase 3-12 hrs from onset of chest pain

• peak at 24-48rs;
• return to baseline 5-14 days

Question 17

what is the timeline of levels of CkMB?

Answer 17

• increase 3-12 hrs from onset of chest pain
• peak 24 hrs; baseline 1-3 days
• sensitivity

Question 18

Explain how CBC, CMP, UA, Thyroid function, can help with diagnosis of HF

Answer 18

CBC: anemia secondary to chronic disease can aggregate HF
CMP: electrolyte imbalance - how Na, K ; Pre-renal azotemia
UA: protein in urine
Thyroid: function should be checked in HF pt greater than 65 with afib

Question 19

what are some differential diagnosis of HF?

Answer 19

• Pulmonary issues (PE, asthma, pneumonia)
• Cirrhosis (ascites, edema
• Renal - edema
• Venous insufficiency - edema

Question 20

What are some nonpharmacologic tx of hF?

Answer 20

• quit smoking
• lose weight
• Salt restriction (2g/day)
• Fluid restriction
• avoid isometric activity
• avoid alcohol

Question 21

When is ACEI indicated for HF?

Answer 21

• systolic HF in all stages - prevent further fluid retention
• preventing HF in high risk pts
• symptoms of HF unless contraindicated
  Be cautious in pts with renal insufficiency. Contrandicated if pt has angioedema, pregnant, or bilateral RAS

Question 22

when is BB indicated for HF? contraindicated?

Answer 22

Indicated: all stable pts with systolic HF and dilated cardiomyopathy
contracindicated: reduced EF, or class IV HF pts. 
Good to use in NYHA class II and III

Question 23

when is digitalis indicated?

Answer 23

Afib –> sl0w ventricular rate

Question 24

What positive inotrope is best to increase contractility and improve CO?

Answer 24

• dobutamine (beta 1 and beta 2 stimulation)

Question 25

How is hydrazine and nitrates/isosorbide used?

Answer 25

• in combo w/diuretics and digoxin to increase EF and exercise tolerance

Question 26

what patient population best responds to hydralzazine + isosorbide?

Answer 26

African americans

Question 27

when should a HF patient be admited to the hospital?

Answer 27

• acute myocardial ischemia
• severe resp distress
• hypoxia
• hypotension
• cardiogenic shock
• anasarca
• syncope
• heart failure refractory to oral meds

Question 28

in conventional tx of acute HF what is the goal with each of these:
A. Diuretics
B. Vasodilators
C. Inotropes

Answer 28

A. reduce fluid volume
B. decrease preload and/or afterload
C. augment contractility

Question 29

which class of evidence based meds (EBM) classification recommendation should we ideally follow to treat HF?

Answer 29

Class I. ACEI and ARB falls within this class

Question 30

CCB falls under what class of recommendation as tx of HF?

Answer 30

Class III. No benefit, not recommended as routine. it’s used for pts with HF associated with reduced EF.