L7 - Heart Failure Flashcards
What is the Pathophysiologic State That Exists When the Heart Cannot Delivery the Cardiac Output That Matches the Requirements of the Metabolic Demands of the Tissues OR can only do so by resorting to elevated diastolic filling pressures
Heart Failure
What are the symptoms of heart failure (2)
• Decreased Forward Flow: Exertional Fatigue of Exercising Muscles &/or Sxs of Arterial Hypotension
Describe the effects of elevated filling pressures for R and L HF respectively
- On Left, Pulmonary Congestion and Dyspnea;
* On Right (back up of fluid): Dependent Edema & Sometimes Ascites
Define NYHA Classifications I-IV.
- Class I: Ordinary Activity – No Sxs
- Class II: Ordinary Activity → Sxs
- Class III: Less Than Ordinary Activity → Sxs
- Class IV: Sxs May Be at Rest, & Any Physical Activity →↑ Sxs
Which can shift back and forth (low to high and high to low?)
A. NYHA functional classification
B. Classification of heart failure by stages
A
Vitals of heart failure (3)
- Narrow pulse pressure IF SV diminished
- Resting sinus tachycardia
- increased RR (compensates for dec SV)
PE for LHF (3)
- Pulmonary crackles
- pulmonary congestion
- S3 gallop
PE for RHF (dependent edema and ascites)
- Be able to demo elevated JVP and/or
- positive hepatojugular reflux sign (pressing the examining hand into patient’s right upper quadrant should not cause elevation of height of JVP; if it does, this is a positive hepatojugular reflux)
CXR of HF
- vascular congestion
- cardiomegaly (not diagnostic of HF by itself -e.g. LHF may not have this)
- pulmonary vascular changes of HF
Echo of HF
Diastolic and systolic function
+/- ventricular hypertrophy
+/- associated valvular abnormality
B-type natriuretic peptide (BNP) and pro-BNP in HF
- indications of low levels
- Indications of high levels
- Is BNP helpful in guiding efficacy of therapy?
- Low Levels = SOB NOT caused by Heart Failure
- High Levels Consistent With BUT Not Specific for Heart Failure as Cause of SOB
- no
3 basic cardiac causes (etiology) of HF
- arrhythmia
- myocardial disease or destruction
- mechanical
3rd degree AV block prevent heart from maintaining adequate pressure and flow bc can’t maintain heart rate. None of the pulses get to the ventricle. This is an example of which cardiac cause of HF?
A. arrhythmia
B. myocardial
C. mechanical
A.
What are examples of myocardial causes of HF (2)?
- systolic dysfunction
2. diastolic dysfunction
What are the hallmarks of systolic dysfunction (3)?
- enlarged end diastolic volume with cardiomegaly on CXR
- poor contractility with significantly ↓ ventricular ejection fraction
- S3 gallop
What are the hallmarks of diastolic dysfunction (3)?
- relatively normal end-diastolic volume with minimal or no cardiomegaly on CXR
- relatively normal contractility but ↓ compliance with relatively normal ventricular ejection fraction (≥40% with normal being >50%)
- S4 gallop.
What is common to both systolic and diastolic dysfunction?
Elevated diastolic filling pressure
Pressure overload (e.g. valve stenosis, hypertension), volume overload (e.g. valve insufficiency; shunts) and pericardial (e.g. cardiac tamponade, constrictive pericarditis) are what kind of causes of HF?
Mechanical
List the 3 precipitating causes of HF
- Pathoogical high output states
- intercurrent direct insults to the heart
- intercurrent stresses to the heart of non-high outputtypes
Which is not a high output state precipitating HF? A. fever, infection B. endocarditis C. anemia D. pregnancy E. Thyrotoxicosis
B. endocarditis is a new direct cardiac cause (valvular)
What are the 3 new direct cardiac causes precipitating HF?
- Valvular (e.g. endocarditis, rupture)
- Myocardial damage (e.g. infarction, myocarditis)
- Arrhythmia (e.g. bradycardia, tachycardia)
Which is not an extra demand beyond high output states (e.g. day to day stresses of life)?A. Physical and dietary exercise
B. systemic arterial hypertension
C. pulmonary embolism,
D. Infarction
D. infarction is a new direct cardiac cause
How do you treat NON-hypotensive pulmonary edema? 3 main things
A. oxygen
B. morphine IV
C. Vasodilators
Digoxin is NOT a first line drug except with ___________ and __________
Does it prolong survival?
- AF
- Poor LV systolic function
No. But improves symptoms
Heart failure stages
- Stage A: At High Risk for Heart Failure BUT Without Structural Heart Disease or Symptoms of Heart Failure.
- Stage B: Structural Heart Disease BUT Without Signs or Symptoms of Heart Failure.
- Stage C: Structural Heart Disease With Prior or Current Symptoms of Heart Failure.
- Stage D: Refractory Heart Failure Requiring Specialized Interventions
List the 4 therapies for Stage A HF
- Treat Hypertension & Thyroid Disease
- Control Blood Glucose (diabetes).
- Regular Exercise & Weight Reduction.
- Discourage Excess Alcohol and All Nicotine Use.
What is the therapy for Stage C HF?
All Stage A measures PLUS
- salt restriction
- Diuretics as needed
- ACE-I’s or ARB if ACE-I intolerant (if they have dec LVEF or Phx of MI)
- beta-blockers: if dec LVEF or Phx of MI
Which of these drugs does not have to be avoided in therapy for stage C HF? A. Beta-Blockers B. Anti-arrhythmic drugs C. Ca Channel blockers D. NSAIDS
A
What kind of drugs are:
Amiodarone
Dofetilide
Anti-arrhythmic
What kind of drugs are:
Verapamil
Diltiazem
Ca Channel Blockers
Which is not a SE of ACE-Is
- Orthostatic hypotension
- Hyperkalemia
- Increasing BUN/Creatinine
- Angiodema
- Cough
- Weight gain
6.
Captopril is what kind of drug?
ACE inhibitor
carvedilol and metoprolol are…
beta blockers
Spironolactone and eplerenone are what kind of drugs? And what do they do?
aldosterone antagonists
Increase K levels
improve survival in patients with severe HF and decreased LVEF
If a patient has severe renal insufficency (>2.5 mg/dl in men and >2.0 mg/dl in women) or baseline hyperkalemia what should you not use?
Aldosterone antagonists
When do you use implantable cardioverterdefibrillator?
In those with LVEF
When do you use biventricular electronic pacing (cardiac resynchronization therapy) and how does it help?
patients with:
1. LVEF of or equal to 130 msec on EKG esp if L BBB present
Decreases HF symptoms
May improve survival
Stage D therapy?
All treatment for A, B and C plus end-of-life care discussion
What are the cornerstones of therapy for many of the stages?
ACE-Is (or ARB’s) and beta-blockers
What are the 2 drugs that improve sxs but not survival?
Diuretics (except for aldosterone antagonists)
Digoxin
Cardiac output =
HRxSV (amount of blood pumped per minute)
