HF Pt1 Flashcards
What percentage and total number of Americans have HF?
2-2.5% (6.7 million people)
What is the prognosis of HF?
Survival rate of about 50% in 5 years of HF
What is the definition of HF?
Failure of the heart to pump blood at a rate commensurate with requirements of metabolizing tissues
What is the impairment in cardiac function with HFrEF?
Systolic dysfunction: decreased contractility
What is the definition of HFrEF?
HF sx with EF <40%
What is HFrEF without Sx?
Asymptomatic reduced EF
What are the causes of HFrEF?
Dilated ventricle:
- Ischemic dilated CM
- Non-ischemic dilated CM
- HTN, obesity, stress, etc
What is the impairment in cardiac function of HFpEF?
Diastolic dysfunction: impairment in ventricular relaxation/filling
What is the definition of HFpEF?
HF Sx w EF >50%
What is the most common cause of HFpEF?
HTN
What is the definition of HFmrEF (mildly reduced)?
HF with EF 41-49%
What is the definition of HFimpEF (improved)?
HF w EF >40% and previously had HFrEF
What are the determinants of LV performance?
- Preload
- Myocardial contractility
- Afterload
What are the compensatory mechanisms of HF?
- Increased preload due to Na/water retention
- Vasoconstriction
- Tachycardia and increased contractility (SNS activation)
- Ventricular hypertrophy and remodeling
What is the beneficial effect of increased preload due to Na/water retention?
Optimize stroke volume via Frank-Starling mechanism
What are the detrimental effects of compensation of increased preload due to Na/water retention?
- Pulmonary/systemic congestion and edema
- Increased MVO2
What are the beneficial effects of vasoconstriction?
- Maintain BP in face of reduced CO
- Shunt blood from nonessential tissues to heart
What are the detrimental effects of vasoconstriction?
- Increased MVO2
- Increased afterload: decreases SV and further activates the compensatory responses
What is the beneficial effect of tachycardia and contractility?
Maintain CO
What are the detrimental effects of tachycardia and contractility?
- Increased MVO2
- Shortened diastolic filling time
- B-receptor downregulation and decreased responsiveness
- Ventricular arrhythmias
- Increased risk of myocardial cell death
What are the beneficial effects of ventricular hypertrophy and remodeling?
- Maintain CO
- Reduce myocardial wall stress: decreases MVO2
What are the detrimental effects of ventricular hypertrophy and remodeling?
- Diastolic and systolic dysfunction
- Risk of myocardial cell death and ischemia
- Risk of arrhythmias
- Fibrosis
What are some precipitating factors of HF in resource-limited hospitals?
- Lack of compliance
- With diet, drugs
- Uncontrolled HTN
What are the precipitating factors of HF in “richer” hospitals?
- Non-compliance with drug or diet
- Cardiac ischemia
- Inadequate therapy
What are the clinical presentations of HF?
- SOB
- Swelling of feet and legs
- Chronic lack of energy
- Difficulty sleeping at night due to SOB
- Swollen or tender abdomen
- Cough w frothy sputum
- Increased urination at night
- Confusion and/or impaired memory
What is right ventricular failure?
Primarily systemic venous congestion
What are the sxs of right ventricular failure?
- Abdominal pain
- Anorexia
- Nausea
- Bloating, constipation
What are the signs of right ventricular failure?
- Peripheral edema
- JVD, HJR
- Hepatomegaly
- Ascites
What is left ventricular failure?
Primarily pulmonary congestion
What are the sxs of left ventricular failure?
- DOE, orthopnea, PND, tachypnea
- Bendopnea, cough, hemoptysis
What are the signs of left ventricular failure?
- Rales, S3 gallop, pulmonary edema
- Pleural effusion, Cheyne-Stokes respiration
What are the sxs of nonspecific findings?
- Exercise intolerance, fatigue, weakness
- Nocturia, CNS sxs
What are the signs of nonspecific findings?
Tachycardia, pallor cyanosis, cardiomegaly
What are the major s/sxs of pulmonary edema?
- Exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, rales
- Pulmonary edema, bendopnea, peripheral edema
- Jugular venous distension, hepatojugular reflux, hepatomegaly, ascites
What are other major non-specific findings of pulmonary edema?
- Fatigue, weakness, and weakness intolerance
- Nocturia, cardiomegaly
What are clinical assessment of HF?
H/P, med hx, s/sx, cardiac risk factors
What are initial laboratory assessment of HF?
- CBC, serum electrolytes, BUN, Cr, TFTs
- Electrocardiogram
- Chest x-ray
What are abnormal natriuretic peptide levels?
- BNP (>35 pg/mL)
- NT-proBNP (>125 pg/mL)
What tests evaluate LV function and measure EF?
- Echocardiogram
- Nuclear testing (single photon emission computed tomography, MUGA)
- Cardiac cath
- MRI and CT
What is the gold standard of nuclear testing?
MUGA
What is NYHA FC 1?
Pts w cardiac disease but wo resulting limitations of physical activity (asx)
What is NYHA FC 2?
Pts w cardiac disease resulting in slight limitations of physical activity
What is NYHA FC 3?
Pts w cardiac disease resulting in limitations of physical activity
What is NYHA FC 4?
Pts w cardiac disease resulting in inability to carry on any physical activity wo discomfort
What is AHA stage A?
- High risk of developing HF
- No identified structural or functional abnormalities of pericardium, myocardium, or cardiac valves, and have never show s/sxs of HF
What is AHA stage B?
Structural heart disease that is strongly associated w HF but no s/sxs of HF
What is AHA stage C?
Current or prior sxs of HF associated w underlying structural heart disease
What is AHA stage D?
Advanced structural heart disease and marked sxs of HF at rest despite max med therapy and who require specialized interventions
What is the definition of asx rEF (aka asx LV systolic dysfunction)?
No HF sxs w EF <40%
What are the goals of therapy?
- Slow disease progression
- Reduce sxs and improve QOL and prevent/reduce hospitalizations and need for emergency care
- Reduce mortality
What FC/stage goes w high risk for HF?
Stage A
What FC/stage goes w asx rEF?
Stage B; NYHA FC 1
What FC/stage goes w HFrEF?
Stage C, D; NYHA FC 2-4
What are general measures for HF?
- Tx underlying causes (HTN, CAD)
- Remove precipitating causes
- Exercise (caution during acute sxs)
How should exercise be approached?
Dynamic exercise to increase HR to 60-80% of maximum for 20-60 min 3-5/week
What is the measures for sodium?
- Intake be restricted to 2-3 g/day
- Pts w severe HF may require diets w <2 g/day
What is the measures for alcohol?
- Pts w alc induced HF: totally abstain
- In others, no more than 2 drinks/day for men and 1 drink/day for women
What is the measures for fluid intake?
Restrict to <2 L/day in pts w hyponatremia (<130 mEq/L) or if tx w diuretics is difficult in maintaining fluid volume
What are other general measures?
- Weight monitoring, smoking cessation, immunizations
- Mx and replace electrolytes
- Appropriate thyroid disease management
- Herbal products and nutritional supp education
What are the 4 drug therapy strategies?
- Reduce intravascular volume
- Increase myocardial contractility
- Decrease ventricular afterload
- Neurohormonal blockade
What drug classes reduce intravascular volume?
Diuretics, SGLT2i
What drug class increase myocardial contractility?
Positive inotropes
What drug classes decrease ventricular afterload?
ACEi, vasodilators, SGLT2i
What drug classes cause neurohormonal blockade?
ARNIs, BBs, ACEi, ARBs, MRAs, SGLT2i
What pts should receive diuretics?
All HF pts w s/sxs of fluid retention (symptomatic) should be managed w diuretics
What do diuretics do for HF?
- Reduce hospitalizations but do not have an impact on mortality or natural progression of HF
- Reduce sxs associated w fluid overload, improve exercise tolerance, improve QOL
What dose of diuretics should be used?
Lowest dose that maintains euvolemia
Which pts should not receive diuretics?
Pts who do not have sxs of volume overload should not receive diuretics
What are the short term benefits of diuretics?
Reduce fluid retention via:
- Decreased edema, pulmonary congestion, and JVD by reducing preload and cardiac filling pressure
What are the longer term benefits of diuretics?
Reduced daily sxs and improve ability to exercise
What is the general MOA of diuretics?
Increase sodium and water excretion by reducing sodium reabsorption at a variety of sites in nephron
What is important for diuretics in terms of their pharmacologic response?
Must get to their site of action to elicit a pharmacologic response
What is the MOA of loop diuretics?
Potent diuretics block Na and Cl reabsorption in ascending limb of LOH
What % of Na is reabsorbed in the LOH?
20-25% of filtered Na
What are additional benefits of loop diuretics?
- Enhancing renal release of PGI2 (increases renal blood flow and enhancing venous capacitance)
- Blocked by NSAIDs
What is a problem w furosemide?
- Furosemide has erratic bioavailability
- So torsemide may have advantage in some pts
What is the MOA of thiazides and thiazide like diuretics?
Block Na and Cl reabsorption in DCT
What is the strength of thiazides and thiazide like diuretics?
Relatively weak agents
What are the use of THZs?
Used in pts w mild HF and small amounts of fluid retention
What are the use of thiazide like diuretics (ex. HCTZ and MTZ)?
Frequently used in combo w loops in pts who become resistant to single drug therapy
When are higher doses required for THZs and THZ like diuretics?
Higher doses generally necessary when GFR is decreased (<30 mL/min)
Why does K sparing diuretics work in HF?
Blocks aldosterone, so not necessarily used bc of their diuretics effects
What drugs are traditionally considered K sparing diuretics but will be considered MRAs in HF?
Spironolactone and eplerenone
How are loops initiated?
Initiate at low doses, then double and titrate
How are loops dose adjusted?
Based on weight and sx
If the pt is fluid overloaded, what is the weight reduction goal?
Reduce weight 1-2 lbs/day
What should pts do if they have weight gain?
Report the weight gain (3-5 lbs/week)
What may be indicative of volume depletion?
Hypotension and increased SCr or BUN/Cr ratio
What BUN/Cr ratio is normal?
15:1
What BUN/Cr ratio may indicate pt is volume depleted?
20:1
What is another lab to assess volume depletion?
Hemoglobin and hematocrit:
- Their levels increase as volume decrease
What are the monitoring parameters of loops?
1-2 wks after initiation:
- Fluid intake, urinary output, body weight, s/sx of congestion, JVD
- BP, serum electrolytes
- Renal function
