Heart Failure Part 1 Flashcards
Complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. Characterized by signs and symptoms of reduced CO and volume overload
Heart Failure
Which patients have the highest risk of heart failure?
Black patients due to disparities in risk factors, socioeconomic status, and access to care
Which gender is more impacted by heart failure?
Men, slightly
What is the 5 year survival rate of heart failure?
50%
Severe disease, 1 year mortality may be as high as 40%
What is the MC cause of death for heart failure patients?
Progressive HF or sudden cardiac death
What 2 things related to morbidity and mortality are common with heart failure?
- Hospitalization (83% hospitalized at least once)
- Readmission
What are risk factors for heart failure?
- CAD/atherosclerosis
- DM
- HTN
- Metabolic syndrome/obesity
What are the most common risk factors for heart failure in men?
- Hypertension
- Myocardial infarction
- Valvular disease
What are the most common risk factors for heart failure in women?
- Hypertension
- Myocardial infarction
- Diabetes
How is heart failure classified?
- Acute vs chronic
- High vs low output
- HF with reduced left ventricular EF vs HF with preserved EF
- Left vs Right
What qualifies as acute heart failure?
- Symptoms within last few days to weeks
- Shortness of breath
- PND
- Orthopnea
- RUQ pain
What qualifies as chronic heart failure?
- Symptoms present for months
- Fatigue
- Anorexia
- Abdominal distention
- Edema
Possible to have acute exacerbation in a chronic state
What qualifies as high output heart failure?
- Heart unable to meet the demands of the peripheral needs
- D/t thyrotoxicosis, severe anemia, sepsis
- Symptoms of reduced cardiac output rather than volume overload
What qualifies as low output heart failure?
- Insufficient forward output
- Reduced EF, hypovolemia
What qualifies as HF with reduced left ventricular EF (HFrEF)?
- Systolic
- EF < or equal to 40%
What qualifies as HF with preserved EF (HFpEF)?
- Diastolic
- EF>50%
If falls between 40 and 50% EF, symptom management depending on patient case
This classification of HF is referred to as systolic. It is the type of HF that efficacious therapies have been demonstrated in
Heart failure with reduced ejection fraction (HFrEF)
Also referred to as diastolic HF. Challenging diagnosis because largely of excluding other noncardiac causes of symptoms suggestive of HF. To date, no efficacious therapies have been identified
HFpEF
EF% 41 to 49
HFpEF, borderline. Characteristics, treatment patterns, and oucomes are similar to HFpEF
Which side of the heart is affected in the majority of cardiomyopathies?
Left
What does left sided HF lead to?
- DOE
- PND
- Orthopnea
- Fatigue
d/t poor perfusion of the body and congestion of the lungs
What is the most common cause of right side HF?
Left sided HF
Can also be caused by lung disorders, CAD, pulmonary valvular disorders, ARVC, VSD with left to right shunting
How does right sided HF present?
- JVD
- Hepatic congestion
- Ascites
- Anorexia
- LE edema
due to R sided heart backing up into vena cava
What are all the symptoms of Left sided HF (based on picture)?
- PND
- Elevated pulmonary capillary wedge pressure
- Pulmonary congestion (cough, crackles, wheezes, blood-tinges sputum, tachypnea)
- Restlessness
- Confusion
- Orthopnea
- Tachycardia
- Exertional dyspnea
- Fatigue
- Cyanosis
only perfusing proximal
What are all the symptoms of R sided failure (based on picture)?
- Fatigue
- Increased peripheral venous pressure
- Ascites
- Enlarged liver and spleen
- JVD
- Anorexia and complaints of GI distress
- Weight gain
- Dependent edema
Cor pulmonale
What is NYHA classification used to quantify?
- Functional limitation in order to estimate severity of disease
- Assesses effort needed to elicit symptoms in HF patient
What are the NYHA classes?
I-IV
Is NYHA classification static or can it change?
It can change at any time
What does it mean if a patient has a NYHA classification of I?
- No limitation of physical activity
- Ordinary physical activity does not cause symptoms of HF (dyspnea, fatigue)
What does it mean if a patient has a NYHA classification of II?
- Slight limitation of physical activity
- Symptoms of HF develop with ordinary activity but not at rest
What does it mean if a patient is a NYHA classification of III?
- Marked limitation of physical activity
- Symptoms of HF with less than ordinary activity but not at rest
What does the American College of Cardiology Foundation/AHA staging describe?
- Evolution of heart failure
- Progressive stages that cannot change
How is ACCF/AHA classification helpful?
Helps define appropriate therapeutic approach and determine prognosis
What does it mean if a patient is a ACC/AHA stage A?
- At risk for HF but no structural heart disease or symptoms of HF
What does it mean if a patient is a ACC/AHA stage B?
- Structural heart disease but without signs or symptoms of HF
- Includes NYHA class I with no prior or current signs or symptoms of HF
What does it mean if a patient is a ACC/AHA stage C?
- Structural heart disease with prior or current symptoms of HF
- Patients in any NYHA functional class (including class I with prior symptoms)
What does it mean if a patient is an ACC/AHA stage D?
- Refractory HF requiring specialized interventions
- Includes patients in NYHA functional class IV with refractory symptoms
What is cardiac output the product of?
Heart rate and stroke volume
What impacts the heart rate (causing an effect on the cardiac output)?
- Increases with positive chronotropic agents –> atropine, beta agonists
- Decreases with negative chronotropic agents –> beta blockers, calcium channel blockers
- Inversely affects filling time
What impacts stroke volume?
- Inversely affected by afterload
- Afterload directly affects ESV
- ESV inversely affects stroke volume
- Stroke volume is directly affected by contractility and preload due to EDV
What impacts preload due to EDV (leading to direct impact on stroke volume)?
- directly affected by filling time
- Directly affected by venous return
What impacts contractility (directly affecting stroke volume)?
- Increases with positive inotropic agents
- decreases with negative inotropic agents
What impacts venous return (leading to direct impact on preload due to EDV and impact on SV)?
- directly affected by blood volume and venous pressure
- inversely affected by intrathoracic pressure
What are neurohumoral adaptations?
compensatory mechanisms used by the body in an attempt to adjust for a reduction in cardiac output
* maintain systemic pressure by vasoconstriction
* restores cardiac output by increasing myocardial contractility and heart rate
* occurs in both systolic and diastolic dysfunction
As cardiac output decreases, what does the body do to compensate?
- Increases sympathetic activity
- Vasoconstriction
- Releases renin in response to decreased renal blood flow leading to increased angiotensin II and increased aldosterone
What medications can be given for HF and where do they work?
- Beta blockers counteract increased sympathetic activity
- Arterial vasodilators counteract vasoconstriction
- ACEI/ARBs counteract conversion to angiotensin II
- Aldosterone antagonists counteract increased aldosterone release
What is one of the first response to low cardiac output?
- Activation of the SNS
- Resulting in increased release and decreased uptake of norepinephrine to increase ventricular contractility and heart rate
- Also leads to vasoconstriction and enhanced venous tone increasing preload
What does increased sympathetic nervous system activity in HF do to sodium and norepinephrine?
- Stimulates proximal tubular sodium reabsorption, contributing to sodium retention in HF
- Increased release and decreased reuptake results in increase of plasma NE concentration, which correlates to severity of HF and inversely with survival
What does HF do to the RAAS system?
- RAAS system stimulated by decreased glomerular filtration and increased beta-1 adrenergic activity
- Increases sodium reabsorption
- Induces systemic and renal vasoconstriction
- Can act directly on myocytes to promote pathologic remodeling via hypertrophy, apoptosis, necrosis
- Myocytes develop more AT2 receptors, which results in cell apoptosis
What happens to ADH in HF?
- Low cardiac output –> activation of carotid sinus and aortic arch baroreceptors –> release of ADH and stimulation of thirst
What does increased release of ADH lead to?
- Increase in systemic vascular resistance
- Water retention
- Reduced sodium level (due to dilution via water retention and thirst)
- Degree of hyponatemia parallels severity of HF
What is ANP?
- Atria natriuretic peptide
- Released from atria in response to volume expansion
How is ANP related to HF?
Rises early in HF
What is BNP?
- Brain natriuretic peptide
- Released from ventricles in response to high ventricular filling pressures
How is BNP related to HF?
- Present in chronic or advanced HF
- Reduces systemic vascular resistance and central venous pressure, while increasing natriuresis, which reduces afterload
What are maladaptive consequences of HF?
- Elevation in diastolic pressures are transmitted to the atria and pulmonary and systemic venous circulations –> pulmonary vascular congestion and peripheral edema
- Increased afterload can depress cardiac function and enhance deterioration
- Catecholamine-stimulated contractility and increased heart rate can worsen coronary ischemia
- Catecholamines and antiotensin II promote myocyte loss, resulting in cardiac remodeling
What are the 3 major determinants of the LV stroke volume?
- Preload
- Contractility
- Afterload
What impacts preload?
Venous return and end-diastolic volume
What is contractility?
The force generated at any given end-diastolic volume
What impacts afterload?
- Aortic impedance
- Vascular resistance
- Wall stress
- Small changes in failing heart can lead to large changes in SV
What happens to contractility in systolic dysfunction? What does this lead to?
- Reduction in myocardial contractility
- Reduction in SV and CO
- Which increases SNS, increasing contractility and HR
- Which promotes salt and water retention, leading to expansion of blood volume, therefore raising end-diastolic pressure and volume
What would patient complain of due to heart failure?
- Symptoms due to low CO and fluid accumulation
Cardinal symptoms:
* Dyspnea
* Fatigue
* Fluid retnetion: lower extremity edema
What should you include in ROS to identify source of HF?
- Chest pain, flu-like symptoms, alcohol use, hx of heart murmurs
- Family hx
- Changes in medications (chemo, calcium channel blockers, flecainide)
- PMH of autoimmune disorders, thyroid disease, DM, CAD, etc.
What can be present on vital signs and volume assessment physical exam of HF?
Vital signs:
* Resting sinus tachycardia
* Narrow pulse pressure
* Diaphoresis
* Peripheral vasoconstriction
Volume assessment:
* Pulmonary congestion: inspiratory rales or dull breath sounds at bases
* Peripheral edema: lower extremities, scrotum, ascites
* Elevated jugular venous pressure: present if edema is due to HF
How do you assess for LE edema?
Start at feet and work way proximally to see how far edema extends and don’t forget about sacral and scrotal areas
What may be present on cardiac physical exam of HF?
- Pulsus alternans
- Precordial palpation: laterally displaced apical impulse usually indicating LV enlargement, parasternal life of RV with pulmonary HTN
- Heart sounds: S3 gallop associated with systolic HF, S4 gallop more common in diastolic HF
What systems should be covered in HF physical exam?
- General
- Cardiovascular
- Respiratory
- Abdomen
- Skin
- Neuro
- Thyroid
What is the goal of diagnostic studies in HF?
Confirm symptoms are due to HF
Determine cause of HF
What initial testing should be doen in HF?
- Electrocardiogram
- Chest xray
- CBC
- CMP
- Coagulation studies
- fasting blood glucose
- Lipid panel
why might a electrocardiogram be helpful for HF?
- can detect findings that specify a cause
- may show arrhythmia that is cause or result of HF
Why is chest x-ray indicated in HF?
- Evaluate for pulmonary edema
- Cardiopulmonary structural abnormalities
- Other potential causes for dyspnea
What may be findings on chest x-ray in HF?
- Pulmonary vascular congestion
- Cardiomegaly
- Kerley B lines
- Pleural effusions
What might be present on CBC of a patient with HF?
- Anemia
- Pericarditis
- Leukocytosis
What is important on CMP of a patient with HF?
- Electrolytes
- BUN/Cr
- Magnesium, LFTs
What are additional lab tests that can be considered if they will be beneficial in supporting or determining etiology of HF?
- Thyroid function
- Iron studies
- ANA
- Viral serology
- Genetic testing
What is the best test for HF evaluation?
- BNP and NT-proBNP
What is BNP and NT-proBNP?
- Released from ventricles while in HF
- Useful in supporting diagnosis and establishing severity
- Used to exclude HF as a cause of symptoms, because it has a very high negative predictive value
What is the normal value for BNP/pro-BNP?
- BNP <100 pg/mL
- NT-proBNP<300
What are limitations of BNP and NT-proBNP?
- Patient may present with more than one cause for dyspnea
- Pts with severe chronic HF may have persistently elevated levels of BNP
Other causes of elevated BNP:
* ACS, LVH, valvular disease, Afib, S/P cardioversion
* Increased age, severe anemia, renal failure
* PNA, pulmonary hypertension
* Sepsis, severe burns
What biomarkers can be helpful in HF eval?
Troponin I or T and BNP/pro-BNP
Why might troponin I or T be helpful in HF evaluation?
- Significant elevation indicates ischemic source for HF
- Can be elevated with severe HF, without CAD/myocardial ischemia
What imaging should be performed in all patients with new onset heart failure?
- Echocardiography
Wht important information can echo give you?
- Info on ventricular size and function
- LV diastolic function
- Regional wall motion abnormalities
- Pericardial thickening or effusion
- Valvular disease
- RV function and pulm pressures
What testing is useful to exclude CAD?
Stress testing
* Even if normal, if no other cause identifiable, coronary angiography should be considered
* May also perform left ventriculogram during cardiac catheterization to evaluate LV function
What additional imaging may be considered if neccessary?
- Cardiac MRI
- Cardiac CTA
- Endomyocardial biopsy
What is the goal of heart failure treatment?
- Relieve symptoms
- Improve functional status
- Prevent death and hospitalizations
- Clinical benefit of most therapies limited to HFrEF
- HFpEF tx aimed at improving symptoms and treating comorbidities
