Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Internal Medicine Clerkship > STEPUP Cardiovascular System: Congestive Heart Failure > Flashcards

STEPUP Cardiovascular System: Congestive Heart Failure Flashcards

1
Q

What is congestive heart failure (CHF)?

A

1) CHF is a clinical syndrome resulting from the heart’s inability to meet the body’s circulatory demands under normal physiologic conditions
2) It is the final common pathway for a wide variety of cardiac diseases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the Frank-Starling relationship? How does this change in CHF?

A

1) In a normal heart, increasing preload results in greater contractility
2) When preload is low (at rest), there is little difference in performance between a normal and a failing heart. However, with exertion a failing heart produces relatively less contractility and symptoms occur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is systolic dysfunction? What is it caused by?

A

1) Owing to impaired contractility (i.e., the abnormality is decreased EF)
2) Causes include:
a) Ischemic heart disease or after a recent MI - infarcted cardiac muscle does not pump blood (decreased EF)
b) HTN resulting in cardiomyopathy
c) Valvular heart disease
d) Myocarditis (postviral)
e) Less common causes: Alcohol abuse, radiation, hemochromatosis, thyroid disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is diastolic dysfunction? What is more common: diastolic dysfunction or systolic dysfunction? What does echocardiogram in diastolic dysfunction show?

A

1) Owing to impaired ventricular filling during diastole (either impaired relaxation or increased stiffness of ventricle or both)
2) Diastolic dysfunction is less common than systolic dysfunction
3) Echocardiogram shows impaired relaxation of left ventricle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are causes of diastolic dysfunction?

A

1) HTN leading to myocardial hypertrophy - most common cause of diastolic dysfunction
2) Valvular diseases such as aortic stenosis (AS), mitral stenosis, and aortic regurgitation
3) Restrictive cardiomyopathy (e.g., amyloidosis, sarcoidosis, hemochromatosis)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Are systolic and diastolic dysfunctions even present simultaneously?

A

Yes, both systolic and diastolic dysfunctions are often present simultaneously

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

In high-output heart failure, what is an increase in cardiac output needed for?

A

For the requirements of peripheral tissues for oxygen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are causes of high-output heart failure? Do these conditions often cause heart failure alone?

A

1) Causes:
a) Chronic anemia
b) Pregnancy
c) Hyperthyroidism
d) AV fistulas
e) Wet beriberi (caused by thiamine [vitamin B1] deficiency)
f) Paget disease of bone
g) Mitral regurgitation
h) Aortic insufficiency
2) The conditions listed above rarely cause heart failure by themselves. However, if these conditions develop in the presence of underlying heart disease, heart failure can result quickly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are symptoms of left-sided heart failure?

A

1) Dyspnea
2) Orthopnea
3) Paroxysmal nocturnal dyspnea (PND)
4) Nocturnal cough (nonproductive)
5) Confusion and memory impairment
6) Diaphoresis and cool extremities at rest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is dyspnea in the setting of left-sided heart failure due to?

A

Difficulty breathing secondary to pulmonary congestion/edema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is orthopnea? What relieves it?

A

1) Difficulty breathing in the recumbent position

2) Relieved by elevation of the head with pillows

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is paroxysmal nocturnal dyspnea (PND)?

A

Awakening after 1 to 2 hours of sleep due to acute shortness of breath (SOB)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

In what position is nocturnal (nonproductive) cough worse?

A

Worse in recumbent position (same pathophysiology as orthopnea)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

When do confusion and memory impairment occur in the setting of left-sided heart failure?

A

Confusion and memory impairment occur in advanced CHF as a result of inadequate brain perfusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

In which patients do diaphoresis and cool extremities at rest occur in the setting of left-sided heart failure?

A

Desperately ill patients (NYHA class IV)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are signs of left-sided heart failure?

A

1) Displaced PMI (usually to the left)
2) Pathologic S3 (ventricular gallop)
3) S4 gallop
4) Crackles/rales at lung bases
5) Dullness to percussion and decreased tactile fremitus of lower lung fields
6) Increased intensity of pulmonic component of second heart sound indicates pulmonary HTN (heard over left upper sternal border)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is displaced PMI due to in left-sided heart failure?

A

Cardiomegaly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is a pathologic S3? In what patients may an S3 be normal? Although it is difficult to hear, why is an S3 a good sign for left-sided heart failure? Where is an S3 best heard on the chest wall and with what part of the stethoscope? What is the sequence in the cardiac cycle for S3?

A

1) Rapid filling phase “into” a noncompliant left ventricular chamber
2) May be normal finding in children; in adults, usually associated with CHF
3) May be difficult to hear, but is among the most specific signs of CHF
4) Heard best at apex with bell of stethoscope
5) S3 follows S2 (ken-tuck-Y)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is an S4 gallop? Where is it heard best on the chest wall and with what part of the stethoscope? What is the sequence in the cardiac cycle for S4?

A

1) Sound of atrial systole as blood is ejected into a noncompliant, or stiff, left ventricular chamber
2) Heard best at the left sternal border with bell of stethoscope
3) S4 precedes S1 (TEN-nes-see)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are crackles/rales at lung bases caused by in left-sided heart failure? What does it indicate? What do rales heard over lung bases suggest in the setting of left-sided heart failure?

A

1) Caused by fluid spilling into alveoli
2) Indicates pulmonary edema
3) Rales heard over lung bases suggest at least moderate severity of left ventricular heart failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What do dullness to percussion and decreased tactile fremitus of lower lung fields in the setting of left-sided heart failure indicate?

A

Pleural effusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are symptoms/signs of right-sided heart failure?

A

1) Peripheral pitting edema
2) Nocturia
3) Jugular venous distention (JVD)
4) Hepatomegaly/hepatojugular reflux
5) Ascites
6) Right ventricular heave

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Is peripheral pitting edema a specific test for right-sided heart failure? In the elderly, why might this be?

A

1) No, pedal edema lacks specificity as an isolated finding

2) In the elderly, it is more likely to be secondary to venous insufficiency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is nocturia due to in the setting of right-sided heart failure?

A

Due to increased venous return with elevation of legs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Given enough time, will left-sided heart failure lead to right-sided heart failure and vice versa? Would patients present with signs/symptoms of both?

A

1) Yes

2) Yes, patients may present with signs/symptoms of both right- and left-sided HF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What are the New York Heart Association (NYHA) Classifications?

A

1) NYHA Class I: Symptoms only occur with vigorous activities, such as playing a sport. Patients are nearly asymptomatic
2) NYHA Class II: Symptoms occur with prolonged or moderate exerrtion, such as climbing a flight of stairs or carrying heavy packages. Slight limitation of activities
3) NYHA Class III: Symptoms occur with usual activities of daily living, such as walking across the room or getting dressed. Markedly limiting
4) NYHA Class IV: Symptoms occur at rest. Incapacitating

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What tests should you order for a new patient with CHF and what are you ordering them for?

A

1) Chest X-ray (pulmonary edema, cardiomegaly, rule out COPD)
2) ECG
3) Cardiac enzymes to rule out MI
4) CBC (anemia)
5) Echocardiogram (estimate EF, rule out pericardial effusion)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What tests may be ordered for diagnosis of CHF?

A

1) Chest X-ray (CXR)
2) Echocardiogram (transthoracic)
3) ECG
4) Radionuclide ventriculography using technetium-99m
5) Cardiac catheterization
6) Stress testing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What might a CXR show when diagnosing CHF?

A

1) Cardiomegaly
2) Kerley B lines are short horizontal lines near periphery of the lung near the costophrenic angles, and indicate pulmonary congestion secondary to dilation of pulmonary lymphatic vessels
3) Prominent interstitial markings
4) Pleural effusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is the initial test of choice for diagnosing CHF? Why is this test useful? What does this test estimate? What two heart changes does this test show?

A

1) Echocardiogram (transthoracic). It should be performed whenever CHF is suspected based on history, examination, or CXR
2) Useful in determining whether systolic or diastolic dysfunction predominates, and determines whether the cause of CHF is due to a pericardial, myocardial, or valvular process
3) Estimates EF (very important): Patients with systolic dysfunction (EF < 40%) should be distinguished from patients with preserved left ventricular function (EF > 40%)
4) Shows chamber dilation and/or hypertrophy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Why is ECG used for diagnosis of CHF?

A

ECG is usually nonspecific but can be useful for detecting chamber enlargement and presence of ischemic heart disease or prior MI

32
Q

What is another name for radionuclide ventriculography using technetium-99m (“nuclear ventriculography”)?

A

Multigated acquisition (MUGA) scan

33
Q

What are advantages to using cardiac catheterization in CHF diagnosis?

A

1) Cardiac catheterization can provide valuable quantitative information regarding diastolic and systolic dysfunction, and can clarify the cause of CHF if noninvasive test results are equivocal
2) Consider coronary angiography to exclude CAD as an underlying cause of CHF

34
Q

What does stress testing identify in the setting of CHF? What does it quantify? What can it differentiate between? What can it assess?

A

1) Identifies ischemia and/or infarction
2) Quantitates level of conditioning
3) Can differentiate cardiac versus pulmonary etiology of dyspnea
4) Assesses dynamic responses of HR, heart rhythm, and BP

35
Q

What are symptoms suggestive of heart failure?

A

1) Paroxysmal noctural dyspnea
2) Orthopnea
3) Dyspnea on exertion or at rest
4) Lower extremity edema
5) Decreased exercise tolerance
6) Unexplained confusion, altered mental status, or fatigue in an elderly patient
7) Abdominal symptoms associated with ascites and/or hepatic engorgement (e.g., nausea, abdominal pain, bloating, loss of appetite)

36
Q

What are indications for hospitalization in patients with heart failure?

A

1) Hypotensive with organ hypoperfusion
2) Severely dyspneic or periodic respirations
3) Profound fluid retention states
4) Substantive renal or hepatic insufficiency
5) Hemodynamic instability requiring IV inotropes
6) Dysrhythmias requiring IV antidysrhythmic Tx or malignancy
7) Decompensated HF with refractory angina
8) Complication after cardiac transplantation including rejection with hemodynamic instability
9) Elevated CPK and CPK-MB and/or 12-lead ECG obtained in ED reflects diagnosis of myocardial ischemia/injury or new necrosis

37
Q

What are physical findings that support a diagnosis of heart failure?

A

1) Elevated jugular venous pressure or positive abdominal-jugular reflux
2) A third heart sound
3) Laterally displaced cardiac apical impulse
4) Pulmonary rales that do not clear with cough
5) Peripheral edema not due to venous insufficiency
6) Narrow pulse pressure

38
Q

What is the general nonpharmacological management of CHF?

A

1) 2-g sodium diet
2) Low animal fat diet (ischemic etiology)
3) Fluid restriction
4) Weight control (BMI < 27)
5) Avoidance of alcohol/nicotine
6) Regular aerobic physical activity - 3 times/wk, moderate intensity - 30 minutes
7) Stress management
8) Self-management, education, and compliance monitoring
9) Avoid NSAIDs, decongestants, licorice, and ginseng
10) Yearly flu shot

39
Q

What is BNP released in response to? What BNP level correlates strongly with the presence of decompensated CHF? What may BNP be useful in differentiating between? What is the N-terminal pro-BNP and when may it exclude the diagnosis of HF?

A

1) BNP is released from the ventricles in response to ventricular volume expansion and pressure overload
2) BNP levels > 150pg/mL correlate strongly with the presence of decompensated CHF
3) BNP may be useful in differentiating between dyspnea caused by CHF and COPD
4) N-terminal pro-BNP (NT-proBNP) is a newer assay with similar predictive value as BNP. The normal range for this value depends on the age of the patient, but a NT-proBNP < 300 virtually excludes the diagnosis of HF

40
Q

What are the treatments for systolic dysfunction?

A

1) General lifestyle modification
2) Diuretics
3) Spironolactone (aldosterone antagonist)
4) ACE inhibitors
5) Angiotensin II receptor blockers (ARBs)
6) Beta-blockers
7) Digitalis
8) Hydralazine and isosorbide dinitrates

41
Q

What are general lifestyle modifications recommended for systolic dysfunction CHF?

A

1) Sodium restriction (less than 4g/day)
2) Fluid restriction (1.5 to 2.0L daily)
3) Weight loss
4) Smoking cessation
5) Restrict alcohol use
6) Exercise program
7) All patients should monitor weight daily to detect fluid accumulation
8) Annual influenza vaccine and pneumococcal vaccine recommended

42
Q

What are diuretics most effective for in the setting of systolic dysfunction? When are they recommended? What is their relationship to mortality or prognosis in patients? Which diuretics are used and how potent are they?

A

1) Diuretics are most effective means of providing symptomatic relief to patients with moderate to severe CHF
2) Recommended for patients with systolic failure and volume overload
3) Have not been shown to reduce mortality or improve prognosis, just for symptom control. Goal is relief of signs and symptoms of volume overload (dyspnea, peripheral edema)
4) a) Loop diuretics: Furosemide (Lasix) - most potent, usually used
b) Thiazide diuretics: Hydrochlorothiazide - modest potency

43
Q

Does spironolactone affect survival in patients with CHF? What labs should be monitored while someone is taking spironolactone? For what stages of CHF is spironolactone proven effective? What is an alternative to spironolactone and why is it used?

A

1) Yes, it does prolong survival in selected patients with CHF
2) Monitor serum potassium and renal function
3) Spironolactone is proven effective only for more advanced stages of CHF (classes III and IV)
4) Eplerenone is an alternative to spironolactone (does not cause gynecomastia)

44
Q

What is the function of ACE inhibitors? What type of heart failure are they indicated for? When is the combination of a diuretic and an ACE inhibitor commonly used?

A

1) Cause venous and arterial dilation, decreasing preload and afterload
2) Indicated for left ventricular systolic dysfunction (LV EF less than 40%)
3) The combination of a diuretic and an ACE inhibitor should be the initial treatment in most symptomatic patients

45
Q

Do ACE inhibitors affect mortality, survival, or symptoms? When should a patient with systolic dysfunction be given an ACE inhibitor?

A

1) ACE inhibitors reduce mortality (Cooperative North Scandinavian Enalapril Survival Study [CONSENSUS] and Studies of Left Ventricular Dysfunction [SOLVD] trials), prolong survival, and alleviate symptoms in mild, moderate, and severe CHF
2) All patients with systolic dysfunction should be on an ACE inhibitor even if they are asymptomatic

46
Q

What level dose of ACE inhibitor should you give to a patient with systolic dysfunction and why? What should you monitor in a patient taking an ACE inhibitor?

A

1) Always start at a low dose to prevent hypotension

2) Monitor BP, potassium, BUN, and creatinine

47
Q

When should you use an angiotensin II receptor blocker (ARB) instead of an ACE inhibitor for CHF?

A

Used in patients unable to take ACE inhibitors due to side effect of cough, but should not replace ACE inhibitors if patient tolerates an ACE inhibitor

48
Q

In which patients with CHF do beta blockers decrease mortality?

A

Post-MI heart failure

49
Q

How do beta blockers help patients with CHF?

A

1) Reported to improve symptoms of CHF
2) May slow progression of heart failure by slowing down tissue remodeling
3) The decrease in heart rate leads to decreased oxygen consumption
4) Beta blockers also have antiarrhythmic and anti-ischemic effect

50
Q

What patients with CHF should be given a beta blocker?

A

Should be given to stable patients with mild to moderate CHF (class I, II, and III) unless there is a noncardiac contraindication

51
Q

Which beta blockers should be used for CHF?

A

Not all beta blockers are equal. There is evidence only for metoprolol, bisoprolol, and carvedilol

52
Q

What is digitalis? In which patients is digitalis used for? How does it improve the patient’s CHF?

A

1) Positive inotropic agent
2) Useful in patients with EF < 40%, severe CHF, or severe AFib
3) Provides short-term symptomatic relief (used to control dyspnea and will decrease frequency of hospitalizations) but has not been shown to improve mortality

53
Q

In which patients is it important to use digitalis for? What laboratory tests should be done when taking digoxin?

A

1) For patients with EF < 40%, who continue to have symptoms despite optimal therapy (with ACE inhibitor, beta-blocker, aldosterone antagonist, and a diuretic)
2) Serum digoxin level should be checked periodically

54
Q

When are hydralazine and isosorbide dinitrates given to patients with CHF? Which patients is this medication combination particularly shown to help with mortality? What are two downsides of hydralazine and isosorbide dinitrates in treating CHF?

A

1) Can be used in patients who cannot tolerate ACE inhibitors
2) The combination of hydralazine and isosorbide dinitrate has been shown to improve mortality in selected patients (African Americans) with CHF
3) But not as effective as ACE inhibitors and require inconvenient dosing schedules

55
Q

Which medications are contraindicated in patients with CHF?

A

1) Metformin - may cause potentially lethal lactic acidosis
2) Thiazolidinediones - causes fluid retention
3) NSAIDs may increase risk of CHF exacerbation
4) Some antiarrhythmic agents that have negative inotropic effects

56
Q

How does an implantable cardioverter-defibrillator (ICD) lower mortality? When it is indicated in patients with CHF?

A

1) An ICD lowers mortality by helping prevent sudden cardiac death (which is the most common cause of death in CHF)
2) It is indicated for patients at least 40 days post-MI, EF < 35%, and class II or III symptoms despite optimal medical treatment

57
Q

What is cardiac resynchronization therapy (CRT)? What are the indications for CRT? Why do patients with CRT usually also receive a combined device with ICD?

A

1) This is a biventricular pacemaker
2) Indications are similar to ICD (indicated for patients at least 40 days post-MI, EF < 35%, and class II or III symptoms despite optimal medical treatment) except these patients also have prolonged QRS duration > 120 msec
3) Most patients who meet criteria for CRT are also candidates for ICD and receive a combined device

58
Q

What is the last alternative to treatment of CHF if all else fails to control symptoms?

A

Cardiac transplantation

59
Q

How is diastolic dysfunction treated? Do any medications improve mortality in patients with diastolic dysfunction?

A

1) There are few therapeutic options available; patients are treated symptomatically
2) NO medications have proven mortality benefit

60
Q

What medications are beneficial in treatment of CHF?

A

1) Beta blockers have clear benefit and should be used

2) Diuretics are used for symptom control (volume overload)

61
Q

What medications should not be used in treatment of diastolic dysfunction? What medications do not have a clear benefit for diastolic dysfunction?

A

1) Digoxin and spironolactone should NOT be used

2) ACE inhibitors and ARBs - benefit is not clear for diastolic dysfunction

62
Q

What did the RALES trial show?

A

1) The RALES trial showed that spironolactone reduces morbidity and mortality in patients with class III or IV heart failure
2) It is contraindicated in renal failure

63
Q

What three components should you monitor in a patient with CHF? What should you check for within in each category?

A

1) Weight - unexplained weight gain can be an early sign of worsening CHF
2) Clinical manifestations (exercise tolerance is key); peripheral edema
3) Laboratory values (electrolytes, K, BUN, creatinine levels; serum digoxin, if applicable)

64
Q

What is the standard treatment of CHF? Depending on severity and patients factors, what other medications may be added?

A

1) Loop diuretic, ACE inhibitor, and beta blocker

2) Digoxin, hydralazine/nitrate, and spironolactone

65
Q

What is the most common cause of death from CHF? What provokes this cause?

A

1) Sudden death from ventricular arrhythmias

2) Ischemia provokes ventricular arrhythmias

66
Q

What did the COMET trial show?

A

It compared two beta blockers in the treatment of CHF and showed that carvedilol led to significant improvement in survival compared with metoprolol

67
Q

What medications have been shown to lower mortality in systolic heart failure?

A

1) ACE inhibitors and ARBs
2) Beta-blockers
3) Aldosterone antagonists (spironolactone)
4) Hydralazine, plus nitrate

68
Q

What medications do NOT decrease mortality in systolic heart failure?

A

1) Loop diuretics

2) Digoxin

69
Q

What are signs of digoxin toxicity?

A

1) GI: Nausea/vomiting, anorexia
2) Cardiac: Ectopic (ventricular) beats, AV bloc, AFib
3) CNS: Visual disturbances, disorientation

70
Q

Can calcium channel blockers be used to treat CHF? What calcium channel blockers safe to use in CHF if they are needed for another indication (e.g., hypertension or angina)?

A

1) Calcium channel blockers (CCB) play no role in treatment of CHF and some may actually raise mortality
2) However, amlodipine and felodipine are safe to use in CHF if CCBs are needed for another indication (e.g., hypertension or angina)

71
Q

What is the overall 5-year mortality for all patients with CHF?

A

About 50%

72
Q

Is there one simple treatment regimen suitable for all patients with CHF?

A

No

73
Q

How do you treat mild CHF (NYHA Classes I to II)?

A

1) Mild restriction of sodium intake (no-added-salt diet of 4g sodium) and physical activity
2) Start a loop diuretic if volume overload or pulmonary congestion is present
3) Use an ACE inhibitor as a first-line agent

74
Q

How do you treat mild to moderate CHF (NYHA Classes II to III)?

A

1) Start a diuretic (loop diuretic) and an ACE inhibitor
2) Add a beta-blocker if moderate disease (class II or III) is present and the response to standard treatment is suboptimal

75
Q

How do you treat moderate to severe CHF (NYHA Classes III to IV)?

A

1) Add digoxin (to loop diuretic and ACE inhibitor)
2) Note that digoxin may be added at any time for the relief of symptoms in patients with systolic dysfunction (It does not improve mortality)
3) In patients with class IV symptoms who are still symptomatic despite the above, adding spironolactone can be helpful

Internal Medicine Clerkship (25 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions