Heart Failure -Silverstein Flashcards
What is orthopnea from?
Central redistribution of intravascular volume
causes SOB when laying down
What causes paroxysmal nocturnal dyspnea?
reabsorption of the LE edema
What are some classic symptoms (ROS) of left-sided heart failure?
dyspnea
orthopnea
paroxysmal nocturnal dyspnea
fatigue
What are the common physical exam findings in heart failure?
pulmonary rales
S3 gallop (systolic dysfunction–> distension of the ventricle)
S4 gallop (diastolic dysfunction–> stiff ventricle)
Loud P2 (pulmonary HTN)
can also have JVD< hepatomegaly, peripheral edema, cachexia, cool extremities, cardiac wheeze and cheyne-strokes breathing)
What will the chest x-ray in a heart failure pt show?
cephalization
apical redistribution of fluid to the top of the lung
What does a BNP of 80 indicate? What about 400? 3000?
BNP600=moderate
BNP > 900=severe heart failure
How can you determine whether there is a reduced or preserved ejection fraction?
ECHO!!
What is the number one cause of reduced ejection fraction in the US?
Coronary artery disease
What is the gold standard for Coronary Artery Disease? Should this test be ordered for everyone?
gold standard=angiogram
first do EKG and ECHO and then angiogram if high probability of CAD
What will you get in a pressure overloaded heart?
Concentric hypertrophy
What will you get in a volume overloaded heart?
eccentric hypertrophy
==> dilated
What is the first line therapy for orthopnea related to heart failure?
Furosemide (loop diuretic)
What medication should be given for chronic therapy of HFrEF?
ACE inhibitor (decrease preload and after load)
balanced vasodilator:
- dec vasoconstriction by Ag II
- dec aldosterone-> inc Na+ elimination
- augment bradykinin vasodilation
watch renal function
What can be given for heart failure pts who can’t take ACE inhibitors or who are unresponsive to them?
Nitrates (vasodilator) and hydralazines (decrease after load)
Which heart failure pts should you NOT give a beta-blocker alone to?
volume overloaded
should give loop diuretic AND beta blocker
Patients with heart failure with reduced EF are particularly at risk for which of the following?
A. Torsades de Pointes
B. Delayed after depolarizations
C. Monomorphic VT
Monomorphic VT
because pt has scarring/fibrosis
What are some factors that can precipitate symptoms in pts with chronic compensated heart failure?
- increased metabolic demands (fever, infection, anemia, tachycardia, hyperthyroidism, pregnancy)
- Increased volume/preload (high Na+ diet, too much fluid, renal failure)
- increased after load: (uncontrolled HTN, PE)
- impaired contractility (MI, EtOH, negative inotropic meds)
- slowed HR
What IV medications can be used in decompensated heart failure? (5)
Nesiritide: recombinant BNP -> vasodilator
Dopamine: depends on dose (< 2 local renal vasodilation; 2-10 β1 inotropic; > 10 α vasoconstrict)
Dobutamine:
Beta1, Beta2 and alpha agonist; inotrope/neutral with vasodilation
Milrinone:
Phosphodiesterase inhibitor; inotrope/vasodilator–> increases cAMP and Ca2+==> increased contraction
Nitroprusside:
arterial and venous dilator via activation of guanylate cyclase in vascular smooth muscle
What are the physical exam findings in left heart failure?
Loud P2 (pulmonary HTN)
S4 (decreased compliance)
cephalization on CXR
left atrial enlargement (biphasic P wave in V1)
increased left atrial P (E/e’ >15 on echo)
What will cause heart failure with preserved EF?
diastolic dysfunction–> impaired filling
examples:
- LVH
- restrictive cardiomyopathy
- myocardial fibrosis
- transient myocardial ischemia
- pericardial constriction or tamponade
What are some causes of right sided heart failure?
cardiac causes:
- *left-sided heart failure (most common)
- pulmonary valve senosis
- right ventricular infarction
pulmonary parenchymal diseases:
- COPD
- sarcoidosis
- acute respiratory distress syndrome
pulmonary vascular diseases:
- PE
- primary pulmonary HTN
What medication should be avoided in a right ventricular infarct? Why?
Nitroglycerin
it would further decrease the preload
