MTB 2 Flashcards
Presentation of CHF
Dyspnea
Which type of Heart failure is there preserved EF
Diastolic
Systolic Dysfunction
MC Causes
Dilated Cardiomyopathy + Low EF
Infarction
Cardiomyopathy
Valve disease
MCC of CHF
HTN resulting in cardiomyopathy or of myocardial muscle
Presentation of Systolic Dysfnc
Dyspnea (SOB), DOE Pulmonary Edema = worst form Orthopnea Peripheral Edema Rales JVD Paroxysmal nocturnal dyspnea (PND) S3 gallop
What is an S3 Gallop
Ken-Tucky Low frequency Early Diastolic Inflow from LA strikes blood that is already in LV - Reverberation of blood b/t LV walls Sign of LV Failure
Is S3 ever normal?
Can be normal in athletes and young adult
When do we hear S4
Late Diastole
Dyspnea + dullness to percussion at bases
Pleural Effusion
Dyspnea + recent anesthetic use + brown blood , not improved with oxygen, clear lungs
Methemoglobinemia
Most important test for CHF
Echo
Only way to differentiate b/c systolic and diastolic
Best initial test for EF
TTE
Most accurate test for EF
MUGA
Nuclear Ventriculography
Most accurate test for heart valve function
TEE
Reduce mortality in Systolic Dysfunction
ACE/ARBs Beta Blockers Spironolactone Hydralazine/nitrates Implantable defibrillator
First line TX for Systolic Dysfunction
Diuretic + Vasodilator
Beta blockers used in Systolic Dysfunction
Metoprolol - B1 only
Bisoprolol - B1 only
Carvedilol - non-specific, a-1 antag
Which drugs do we NOT use in Diastolic dysfunction
Digoxin
Spironolactone
Uncertain benefit
ACE/ARBs
Hydralazine
Vasodilators used in Systolic Dysfunction
ACE, ARBS
Hydralazine
Nitrates
Why are beta blockers used in CHF
Antiischemic
Decrease HR = decreased O2 consumption
Antiarrhythmic
MCC death from CHF
Arrhythmias
Sudden death
Presentation of Beta blocker toxicity
Bradycardia AV block HypoTN Diffuse wheezing Cardiogenic shock = cold, clammy Delirium Seizures Hypoglycemia
TX for Beta blocker toxicity
Glucagon - increases cAMP to increase contractility Calcium Gluconate Epinephrine Insulin Sodium Bicarbonate
Spironolactone MOA
Use?
AE?
Inhibits Aldosterone
Advanced CHF - Class III, IV
gynecomastia, Hyperkalemia
CHF pt develops gynecomastia
Switch spironolactone to Eplerenone
Presentation of Digoxin Toxicity
GI: N/V
Arrhythmia - Atrial Tach w AV block, paroxysmal atrial tachycardia
Blurred vision, yellow halos
TX of Digoxin toxicity
- Stop drug
- Administer K+ if needed
- Lidocaine + Phenytoin
- Digibind = digoxin immune fab only for acute OD
Does Digoxin lower mortality in CHF
No.
Controls Sx’s
When do we use implantable defibrillator
Ischemic Cardiomyopathy + EF < 35%
When do we use biventricular pacemaker
Dilated Cardiomyopathy + EF < 35% + QRS > 120 msec
What is Diastolic Dysfunction
CHF w Preserved EF
Which drugs are clearly beneficial in Diastolic Dysfunction
Beta blockers
Diuretics
Which drugs are clearly NOT beneficial in Diastolic Dysfunction
Digoxin
Spironolactone
Does implantable defibrillator lower mortality in diastolic dysfunction?
Yes
What is Pulmonary Edema
Worst, most severe form of CHF
Rapid onset of fluid in lungs
Presentation of Pulmonary Edema
Rales JVD S3 Gallop Edema Orthopnea Cyanosis Increased respiratory rate Productive cough with pink, frothy sputum Noctural Dyspnea Ascites, enlarged liver and spleen
What does a normal BNP exclude
CHF
Pulmonary Edema
CXR in Pulmonary Edema
Vascular Congestion
Cephalization of flow (filling of blood vessels twds head)
ABG in Pulmonary Edema
Hypoxia
Respiratory Alkalosis bc of hyperventilation
Increased RR = so CO2 leaves more easily than O2 enters bloodstream
Hypoxia v Hypoxemia
Hypoxia - inadequate O2 supply in body
Hypoxemia - low arterial O2 supply
Management if A fib, A flutter, or V tach are cause of Pulmonary Edema
Rapid synchronized cardioversion
What tests done in Pulmonary Edema
EKG
Echo
TX for Pulmonary Edema
Preload reduction: MONA
Positive Inotropes
- Dobutamine
- Amrinone and milrinone - PDE inhibitors that increase contractility and decrease afterload
Positive inotrope, increases contractility
Afterload Reduction
- ACE/ARBs
TX for chronic Pulmonary Edema
Digoxin
ACE/ARBs
MCC regurgitant disease
HTN
Ischemic heart dz
Consequences of infarction
Regurgitation -> Dilatation -> CHF
Murmurs that increase in intensity/loudness w inhalation
Right sided - inhalation increases venous return to right
Tricuspid
Pulmonic
Murmurs that increase in intensity/loudness w exhalation
Left sided - exhalation squeezes blood out of lungs, into left
Mitral
Aortic
Best initial test pulmonary edema
TEE
Most accurate test pulmonary edema
Catheterization
