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Cardio Week 4 > ICL 5.2: Clinical CHF Syndromes > Flashcards

ICL 5.2: Clinical CHF Syndromes Flashcards

1
Q

how have CHF rates changed?

A

overall reduction

probably due to stunting and early detection of CAD

but reduced CHF is starting to go up in women a bit

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2
Q

does preserved or reduced CHF have lower risk for CV death?

A

risk for CV death was lower for HFpEF

but they have the same risk for non-CV death

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3
Q

what are the stages of CHF?

A

A: high risk for CHF like HTN, CAD, DM, family history of cardiomyopathy

B: asymptomatic LV dysfunction – previous MI, LV systolic dysfunction, asymptomatic valvular disease, low EF, LV hypertrophy

C: symptomatic HF – structural heart disease,e DOB, fatigue, reduced exercise tolerance

D: end stage HF – symptoms at rest despite maximal medical therapy

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4
Q

what are the goals and treatment for stage A CHF?

A
  1. treat BP
  2. smoking cessation
  3. regular exercise
  4. reduce alcohol/drug use
  5. treat HTN, DM, dyslipidemia or atherosclerosis if needed

treat with ACEI or ARBs for vascular disease/DM

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5
Q

what are the goals and treatment for stage B CHF?

A
  1. treat BP
  2. smoking cessation
  3. regular exercise
  4. reduce alcohol/drug use

treat with ACEI or ARB and B blockers

B blockers because they have a structural problem and B blockade can help reestablish B receptor ratio and get the heart to positively remodel

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6
Q

how does treating HTN help prevent CHF?

A

by aggressively controlling BP, you decrease the risk of new HF by 50% and by 56% in DM2 population

if you control it in patient with prior MI, you decrease the risk of new HF by 80%

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7
Q

which medications do you use to treat stage A CHF?

A
  1. ACEI

especially in patients with CAD, peripheral vascular disease, stroke or DM

  1. ACEI and B blockers are recommended for all patients with a prior MI
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8
Q

how do you diagnose stage B HF?

A

they’re asymptomatic so they’ll have a negative HPI, ROS and PE

they’ll have an abnormal surveillance testing found coincidentally during an EKG or CXR that then necessitates an echo

then once they do the echo they’ll see the abnormal structure

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9
Q

how do you treat stage B HF?

A
  1. ACEI
  2. ARBs
  3. B blockers

especially in people who have a history of silent MI and EF <40%

this decrease hospitalizations and mortality even if they don’t have symptoms but they’re post MI or LVEF <40%

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10
Q

what are the 2 classes of HF?

A
  1. systolic

2. diastolic

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11
Q

what is heart failure with reduced ejection fraction?

A

HF with EF <40%

aka systolic HF

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12
Q

what is heart failure with preserved ejection fraction?

A

EF >50%

aka diastolic HF

60-90% of HFpEF patients have HTN so treating HTN leads to less episodes of HF

we really don’t know much about HFpEF

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13
Q

what is borderline heart failure with preserved ejection fraction?

A

EF 41-49%

characteristics and outcomes appear similar to those of patients with HFpEF so treat similarly

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14
Q

what is improved heart failure with preserved ejection fraction?

A

if they had previous reduced HF but now they have preserved EF and an EF >40%

we really don’t know what to do with these patients we need more studies

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15
Q

what conditions cause HFrEF? how do you diagnose it?

A
  1. CAD/MI
  2. PAD
  3. HTN
  4. obesity and insulin resistance/DM

EF<40%

get an echo to see wall motion or a nuclear test to test blood flow

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16
Q

what conditions cause HFpEF? how do you diagnose it?

A
  1. HTN
  2. CAD
  3. arrhythmias
  4. morbid obesity
  5. hyperlipidemia

use echo to diagnose

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17
Q

what is class I HF?

A

no limitations

ordinary physical exercise doesn’t cause fatigue, dyspnea or palpitations

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18
Q

what is class II HF?

A

slight limitations

comfortable at rest but ordinary activity results in fatigue, dyspnea or palpitations

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19
Q

what is class III HF?

A

marked limitations

comfortable at rest but less than ordinary activity results in symptoms

20
Q

what is class IV HF?

A

unable to carry out any physical activity without discomfort

symptoms of HF are present even at rest with increased discomfort with any activity

21
Q

what are the signs of decreased perfusion?

A

systolic dysfunction = lower CO = poor perfusion

  1. cool extremities
  2. altered mental status
  3. fatigue
  4. low urine output
  5. inadequate response to IV diuretic
  6. kidney dysfunction
  7. palpations/tachycardia
22
Q

what are the signs of congestion?

A
  1. SOB
  2. orthopnea = can’t lay flat
  3. PND
  4. increased jugular venous distention
  5. increased hepatojugular reflex
  6. peripheral edema
  7. S3
  8. splanchnic congestion
23
Q

how do you classify acute heart failure?

A

are they having perfusion or congestion symptoms or both?

24
Q

what are the clinical signs of stage C or D HF?

A
  1. tachycardia
  2. HTN (in HFpEF)
  3. orthostasis
  4. hypotensive (in HFrEF)
  5. increased respiratory rate
  6. decreased breath sounds/crackles/rales/wheezing
  7. abdominal swelling, ascites, hepatomegaly, peripheral edema
  8. JVD*
  9. murmur usually MR or TR
25
Q

what is JVD? how is it related to HF?

A

JVD = jugular venous distention

put the patient at HOB 45 degrees and measure from the chest wall to the clavicle (5 cm) then add how many cm above that you can see the JV

in a normal patient you should’ve be able to see it over the clavicle so their JVP will be 5

JVD is the most specific sign for CHF – it’s a short term and long term independent predictor of mortality

26
Q

what do you do during a basic evaluation for HF?

A
  1. PE
  2. CXR
  3. EKG
  4. Labs = CBC, electrolytes, BUN, creatine, LFTs, BNP, T4, lipids, A1C, urinalysis
27
Q

what do you do during further evaluation for etiology, prognosis and plan of HF?

A
  1. echo with doppler
  2. nuclear imagining for ischemia
  3. myocardial viability when all scar on nuclear
  4. catheterization increasing right heart pressures
  5. exercise test to look at maximal oxygen uptake
  6. MUGA to asses EF of ventricles
28
Q

what lab values are associated with an increased risk for in hospital mortality in acute HF?

A
  1. BUN>43
  2. creatinine >2.75 mg/dL
  3. hypotension SBP <115 mmHg

these are poor prognostic signs in acute HF patients

29
Q

what conditions can cause increased BNP?

A
  1. myocarditis, pericardial disease, atrial fib
  2. age
  3. anemia
  4. renal failure
  5. pulmonary problems
30
Q

what are some conditions that can cause stage C and D acute HF?

A
  1. ACS
  2. uncontrolled HTN, accelerated HTN, hypertensive emergency
  3. right HF
  4. arrhythmias
  5. PE
  6. aortic dissection
31
Q

what are some common causes of stage C and D acute HF?

A
  1. nonadherence with medication regimen, sodium and/or fluid restriction
  2. recent addition of negative inotropic drugs (eg, verapamil, nifedipine, diltiazem, beta blockers)
  3. initiation of drugs that increase salt retention (eg, steroids, thiazolidinediones, NSAIDs)
  4. excessive alcohol or illicit drug use
  5. endocrine abnormalities (eg, diabetes mellitus, hyperthyroidism, hypothyroidism)
  6. concurrent infections (eg, pneumonia, viral illnesses)
  7. additional acute cardiovascular disorders (valve diseases, endocarditis, myopericarditis)
32
Q

how do you treat stage C and D acute HF with preserved EF?

A
  1. control HTN
  2. DVT prophylaxis
  3. IV loop diuretics
  4. ACEI/ARB of BB AFTER IV HF meds are given
  5. low dose dopamine
  6. hemodialysis to reduce blood volume
  7. IV nitroglycerine
33
Q

how do we treat HFpEF?

A

we only know that we need to control HTN by using diuretics

make sure they don’t have CVD

manage Afib if they have it

34
Q

what pharmacological treatment do you use for stage C HFrEF?

A

ACEI/ARB with a BB

for classes I-IV

if the patient has volume overload, add a diuretic (loop like bumetanide, furosemide or torsemide)

if the patient has symptoms on the ACEI/BB and get SOB, cool extremities etc. and they’re african american, add nitrate = venous and arterial vasodilator and hydralazine = pure arterial vasodilator

for class III and IV and have functional kidneys, add mineralocorticoid aldosterone inhibitor

35
Q

which drugs are ACE inhibitors?

A

“pril”

  1. lisinopril
  2. quinapril
  3. captopril
36
Q

which drugs are ARBs?

A

“sartan”

  1. candesartan
  2. losartan
  3. valsartan
37
Q

after decompensation of HF but before DC from hospital, at medications should patients be on?

A

BB therapy and stop IV medications

BB = bisoprolol, carvedilol, metoprolol

38
Q

which drugs are aldosterone antagonists?

A
  1. spironolactone
  2. eplerenone

mineralocorticoids

if you have significant kidney dysfunction don’t use these

39
Q

what are the effects of neprilysin inhibitors?

A
  1. increased BNP and ANP
  2. increased bradykinin
  3. decreased neurohormonal activation, vascular tone, cardiac fibrosis, hypertrophy and sodium retention
40
Q

what is entresto?

A

combination of neprilysin inhibitor sacubitril and ARB valsartan

stop previous ACE inhibitors for 36 hours before starting

don’t use in patients with angioedema

start with low dose and go up slowly so the vasodilation effect doesnt drop the BP too much

41
Q

what is ivadradine?

A

use when beta blocker therapy isn’t enough

it inhibits funny channels so it slows HR in the SA node different than the MOA of BB and it’s good for HF

this lets you use less energy which is great in HF

don’t use in 3rd degree heart block because it effects funny channels

42
Q

who qualifies for a ventricular defibrillator?

A

HFrEF stage patients who still have ischemic cardiomyopathy 40 days pots MI with an EF < 35%

they’re also used in non-ischemic cardiomyopathy and dilated cardiomyopathy if meds don’t work

they have to have a life expectancy of at least 1 year so no cancer

43
Q

what is cariogenic shock?

A

loss of CO with hypotension and loss of adequate organ/tissue perfusion

SVR will be high to try and compensate for loss of CO (MAP = CO x SVR)

increased preload and after load but decreased CO

you’re at risk for cardiac myocyte death/injury

can happen with MI, drugs, toxins, viruses, arrhythmias

44
Q

what is hypovolemic shock?

A

decreased preload, increased after load from increased SVC so ultimately decreased CO

45
Q

how do you treat cariogenic shock?

A

positive inotropes = dobutamine

make the heart pump harder

46
Q

how do you treat hypovolemic shock?

A

fluid repletion = IV bolus or blood transfusion

Cardio Week 4 (16 decks)

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