Module 2.5 - Heart Failure and Cardiogenic Pulmonary Edema Flashcards
1
Q
What is heart failure?
A
- Heart Failure (HF) is a clinical syndrome rather than a disease in which either structural or functional abnormalities of the heart impair its ability to fill or eject blood.
- It can be caused by a variety of pathophysiological processes that begin with an initial insult to the myocardium.
- It is characterized by “poor pump function” where the heart is unable to meet the metabolic demands of the tissues. HF is defined as left sided HF, right sided HF or a combination of both. There is dilation or hypertrophy of either the left, right or both sides of the heart causing cardiac dysfunction with resultant poor oxygenation of the tissues.
- Current practice guidelines divide HF in terms of the function of the left ventricle (LV).
2
Q
What are the characteristics of systolic HF (HRrEF)?
A
- Ejection fraction (EF) < 40%
- Impaired contractility causes reduced stroke volume and cardiac output
- Associated with eccentric hypertrophy
3
Q
What are the characteristics of diastolic HF (HFpEF)?
A
- EF is > 50%
- There is no dilation of the left ventricle
- There is evidence of volume overload
- Normal contractility is seen but poor relaxation that leads to decreased filling of the LV is noted
- Associated with eccentric hypertrophy
- Borderline HF – EF between 41 and 49% are a subset of HFpEF and will be treated under the same guidelines
4
Q
What are the 4 stages of heart failure according to the American Heart Association?
A
- Stage A - At risk for heart failure but without structural heart disease or symptoms
- Stage B - Structural heart disease but without heart failure
- Stage C - Structural heart disease with prior or current heart failure symptoms
- Stage D - Refractory heart failure requiring specialized interventions
5
Q
What are some predisposing factors for heart failure?
A
- CAD – Patients who suffer an acute MI have a 8-10 x increased risk of developing acute HF post MI. CAD is also the most common cause of chronic HF
- Hypertension – the risk of developing HF in this group of patients is 3 x higher than normotensive patients. Uncontrolled HTN carries a higher risk of acute HF than MI.
- Diabetes
- Physical Inactivity
- Excessive alcohol intake
- Smoking
6
Q
What are some precipitating factors for heart failure?
A
- Infections - viral, bacterial systemic or pericarditis
- Endocrine abnormalities - hyperthyroidism, thyrotoxicosis, pheochromocytoma
- Nutritional disorders – Beriberi (thiamine deficiency), Kwashiorkor (protein deficiency)
- Preeclampsia
- Cardiomyopathy – dilated, restrictive, takotsubo (broken heart syndrome) more about the specifics of cardiomyopathy in the next module.
- Musculoskeletal disorders – muscular dystrophy, myasthenia gravis
- Autoimmune – SLE, sarcoidosis, amyloidosis
- Genetic factors – hypertrophic cardiomyopathy
- Valvular heart disease
- Rheumatic or congenital heart disease
7
Q
What are the 4 compensatory mechanisms seen in the patient with heart failure?
A
- Hypertrophy - the cardiac wall thickens with increased muscle mass over time due to the strain and increased workload of the heart. The results is higher myocardial oxygen demands.
- Dilatation - seen in HFrEF. The chambers of the heart enlarge or dilate to accommodate in response to the need for increased blood volume. The muscle fibers attempt to stretch to increase the force of the contraction of the muscle. The result is over stretching, decreased actin-myosin interaction with a subsequent decrease in the force of each contraction of the heart.
- Sympathetic nervous system - The inadequate cardiac output activates the sympathetic nervous system resulting in the deleterious effects of tachycardia, increases systemic vascular resistance and an increase in myocardial oxygen demand
- Renal (renin-angiotensin-aldosterone cascade - Blood flow is decreased to the kidneys due to decreased cardiac output. The kidneys respond to what they think is a decreased blood volume with an increase in renin. The result is the release of angiotensin I and angiotensin II and subsequent aldosterone excretion. Sodium is retained, the kidneys reabsorb water and there is overall water retention and edema.
8
Q
What are the 11 subjective/physical findings of the patient with heart failure?
A
- Fatigue – May be the first sign and attributed to other factors
- Dyspnea – patients have poor gas exchange due to decreased cardiac output and fluid retention. Complaints range from dyspnea with walking to dyspnea at rest.
- Orthopnea – Number of pillows used at night to breath comfortably may increase to the point of sleeping upright in a recliner
- Paroxysmal nocturnal dyspnea (PND) or night cough – patients describe waking up suddenly with gasping with PND. Night cough improves with sitting upright.
- Tachycardia – related to the sympathetic nervous system response to decreased cardiac output
- Edema – can occur in legs (dependent peripheral), liver (hepatomegaly), spleen (splenomegaly), abdominal cavity (ascites), lungs (pulmonary edema)
- Nocturia – Supine position hastens fluid shifts from the interstitial spaces back into the intravascular spaces, renal blood flow is increased, urine output increases in response
- Skin changes – dusky appearing skin due to poor oxygenation
- Behavioral changes – confusion, decreased memory
- Chest pain – can be related to CAD and/or fluid retention
- Weight Gain – weight monitoring is essential. A gain of 1 kg of body weight on the scale equates to a 1L of fluid retention
9
Q
What ABG changes are you likely to see in a patient with HF?
A
- ABGs are generally not evaluated in the outpatient setting unless the patient is acutely dyspneic with low oxygen saturations.
- You would likely see respiratory alkalosis due to hyperventilation if the patient is hyperventilating
10
Q
What are the lab/diagnostic findings associated with heart failure?
A
- B-type natriuretic peptide (BNP) - Is elevated and indicates LV dysfunction. It is a neurohormone secreted mainly in the cardiac ventricles in response to volume expansion and pressure overload. Elevated levels can be correlated with myocardial ischemia/damage. This value can serve to predict severity of current/future heart failure and cardiac complications.
- BNP Levels:
- Ages 55-64 years = 26 pg/ml
- Ages 65-74 years = 31 pg/ml
- 75 years and older= 63 pg/ml
- Expected levels with concurrent MI = 100-400 pg/ml
- Erythrocyte sedimentation rate (ESR) – decreased
- Electrolytes – hyponatremia may occur with both fluid overload (dilution) and over diuresis. Watch magnesium and potassium closely with medications when first introduced and when up titrated
- BUN/Creatinine/GFR – Renal function may be impaired with decreased cardiac output
- CXR – look for cardiomegaly, fluid overload
- EKG – needed to assess for myocardial ischemia, dysrhythmias (especially atrial fibrillation or atrial flutter), PVCs and conduction defects.
- Echocardiogram – assess valvular function, wall motion abnormalities and function of the left ventricle.
- Stress testing – exercise vs. nuclear depending on patient’s functional capacity to assess for ischemia if CAD is suspected
11
Q
What are the goals of treatment for the medical management of patients with diastolic heart failure?
A
- The treatment of HFpEF is geared towards treating and controlling the underlying and/or associated conditions including HTN, atrial fibrillation, CAD, HLD, DM, and obesity.
- Risk factors of smoking, alcohol consumption and sedentary lifestyle should all be addressed and managed accordingly.
12
Q
What are the goals of treatment for the medical management of patients with systolic heart failure?
A
- The management of patients with HFrEF focuses on cardiovascular risk factors and prevention/reducing ventricular remodeling.
- Treatment is based upon recommendations outlined by the ACC/AHA Guidelines for the management of Heart Failure
13
Q
What are the AHA Guidelines for the management of Heart Failure?
A
- Exercise - cardiac rehab, avoid obesity by monitoring caloric intake. If unintentional weight loss is noted, assess BUN and prealbumin to evaluate for muscle wasting
- Smoking cessation
- Discouraging , restriction or total alcohol consumption
- Blood pressure control
- Use of angiotensin-converting (ACE) therapy - standard therapy. Goals of all pharmacological therapy (ACE, ARB, BB) are to improve symptoms, decrease risk of hospitalization and slow or reverse the deterioration in cardiac function therefore improving mortality. Its use is recommended for all patients with an EF less than 40% that do not have renal insufficiency.
- Angiotensin receptor blockers (ARB) - for patients who cannot tolerate ACE due to cough or angioedema
- Beta blocker therapy - for reduced LVEF regardless of DM status
- Digoxin - Consider to improve mortality
- Diuretics - for evidence of volume overload; fluid restriction
- Aldosterone antagonists - are recommended for patients with Class II-IV symptoms
- African Americans - the combination of hydralazine plus oral nitrates is recommended as part of standard therapy (in addition to other medications)
- Dietary considerations – Limit sodium intake to 2000 mg daily, add MVI
- Assess quality of life (for all HF patients), psycho-social factors and caregiver support. Discuss advance directives.
- Consideration of internal defibrillator for severe HF (AICD)
14
Q
What type of comorbidities do patients with Stage A Heart Failure have and what are the goals of therapy/medications for these patients?
A
Comorbidities seen:
- Hypertension
- Atherosclerotic disease
- Diabetes
- Obesity
- Metabolic syndrome
Goals of therapy:
- Treat HTN
- Encourage smoking cessation
- Treat lipid disorders
- Encourage regular exercise
- Discourage alcohol intake & illicit drug use
- Control metabolic syndrome
Medications:
- Begin ACEI or ARB in appropriate patients for vascular disease or diabetes
15
Q
What type of comorbidities/disorders do patients with Stage B Heart Failure have and what are the goals of therapy/medications for these patients?
A
Comorbidities/disorders seen:
- Previous MI
- LV remodeling including LVH and low EF
- Asymptomatic valvular disease
Goals of therapy (SAME AS STAGE A):
- Treat HTN
- Encourage smoking cessation
- Treat lipid disorders
- Encourage regular exercise
- Discourage alcohol intake & illicit drug use
- Control metabolic syndrome
Medications:
- Begin ACEI or ARB in appropriate patients for vascular disease or diabetes
- Begin beta-blockers in appropriate patients
- Implantable defibrillators in acceptable patients
16
Q
What type of comorbidities/disorders do patients with Stage C Heart Failure have and what are the goals of therapy/medications for these patients?
A
Comorbidities/disorders seen:
- Known structural heart disease
- Shortness of breath & fatigue
- Reduced exercise tolerance
Goals of therapy (SAME AS STAGE A+B):
- Dietary salt restriction < 2000mg daily
- Treat HTN
- Encourage smoking cessation
- Treat lipid disorders
- Encourage regular exercise
- Discourage alcohol intake & illicit drug use
- Control metabolic syndrome
Medications:
- Begin ACEI or ARB in appropriate patients for vascular disease or diabetes
- Begin beta-blockers in appropriate patients
- Implantable defibrillators in acceptable patients
- Begin diuretics for fluid retention
- Begin Digoxin/hydralazine/nitrates
17
Q
What type of comorbidities/disorders do patients with Stage D Heart Failure have and what are the goals of therapy/medications for these patients?
A
Comorbidities/disorders seen:
- Pts will have marked symptoms at rest despite maximal medical therapy
Goals of therapy (SAME AS STAGE A-C):
- Dietary salt restriction < 2000mg daily
- Treat HTN
- Encourage smoking cessation
- Treat lipid disorders
- Encourage regular exercise
- Discourage alcohol intake & illicit drug use
- Control metabolic syndrome
Medications (continue all medications if appropriate):
- Begin ACEI or ARB in appropriate patients for vascular disease or diabetes
- Begin beta-blockers in appropriate patients
- Implantable defibrillators in acceptable patients
- Begin diuretics for fluid retention
- Begin Digoxin/hydralazine/nitrates
- Compassionate end-of-life care
- Heart transplant
- Permanent mechanical support
- Chronic inotropes
19
Q
What causes right heart failure and what symptoms are associated with it?
A
The most common cause of right heart failure is left heart failure. It is condition can occur with severely decompensated HF. Other causes of right HF include chronic lung conditions such as emphysema, pulmonary hypertension, heart valve disease and congenital heart defects.
Physical findings include:
- Increased central venous pressure with jugular venous distention
- Peripheral edema
- Hepatomegaly and positive hepatojugular reflux
- Ascites
- S3 and/or S4 heart sounds
20
Q
What is and what causes cardiogenic pulmonary edema?
A
- It occurs when the lungs are filled with fluid due to increased hydrostatic pulmonary capillary pressure.
- It is most often a result of acute decompensated heart failure (ADHF), either systolic or diastolic.
- An echocardiogram will assess cardiac function and should be repeated if this is a change in the patient’s clinical status since a previous echocardiogram was obtained.
Other causes:
- Fluid overload (blood transfusion)
- severe hypertension
- renal artery stenosis and severe renal disease.
- “Flash” pulmonary edema is a term that is used to describe a particularly severe and dramatic form of CPE and can be seen in hypertensive emergencies, cardiac ischemia and new onset tachy arrhythmias.
22
Q
What is and what causes “bat wing” pulmonary edema?
A
- It is a central, nongravitational distribution of alveolar edema.
- It is seen in less than 10% of cases of pulmonary edema and generally occurs with rapidly developing severe cardiac failure.
- With bat wing edema, the lung cortex is free of alveolar or interstitial fluid. This pathologic condition develops so rapidly that it is initially observed as an alveolar infiltrate, and the preceding interstitial phase that is typically seen in pulmonary edema goes undetected radiologically.
23
Q
What is and what causes Kerley B lines on a CXR?
A
- Kerley B lines are linear opacities seen on the chest radiograph. They are 1-2 cm long horizontal lines, which meet the pleura at right angles. They are typically seen as a ladder up the side of the lungs beginning at the costophrenic angle.
- Kerley B lines represent interlobular lymphatics, which have been distended by fluid or tissue
29
Q
Describe the New York Heart Association Class I stage of Heart Failure
A
- Asymptomatic
- No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, rapid/irregular heartbeat or SOB
30
Q
Describe the New York Heart Association Class II stage of Heart Failure
A
- Symptomatic with moderate exertion
- Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, rapid/irregular heartbeat, or SOB
31
Q
Describe the New York Heart Association Class III stage of Heart Failure
A
- Symptomatic with minimal exertion
- Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, rapid/irregular heartbeat, or SOB
32
Q
Describe the New York Heart Association Class IV stage of Heart Failure
A
- Symptomatic at rest
- Unable to carry out any physical activity without discomfort. Symptoms of fatigue, rapid/irregular heartbeat, or SOB are present at rest. If any physical activity is undertaken, discomfort increases.
