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Acute Care II - Summer 2017 > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

what is the definition of heart failure

A

progressive structural or functional disorder of the myocardium, endocardium or pericardium which results in heart muscle mass enlargement due to compensatory mechanisms of increased heart rate to increase cardiac output, narrowing of coronary vessels to sustain blood pressure, with decreased blood flow to the kidneys, heart and brain. compensatory mechanism may take years until fatigue, shortness of breath and edema develop left sided heart failure occurs before right sided heart failure. heart failure can involve the hearts left, right or both sides.

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2
Q

what are some heart failure statistics

A

75% of those with HF have HTN the lifetime risk of HF is doubled for patients with HTN 160/90 vs those with BP < 140.90

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3
Q

what is expected cost of HF in 2015

A

22.5 billion 63% attributable to direct medical costs

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4
Q

what is future projection of HF cost?

A

2030 total cost will increase by 84% to 41.5 billion, from 2015.

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5
Q

what is the simplified pathophysiology of HF

A
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6
Q

what are the 2 key features of pathophysiology of HF

A
  1. impaired cardiac output (perfusion) 2. increased cardiac filling pressures (volume)
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7
Q

what are the factors impairing cardiac output

A
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8
Q

stage A HF

A

at high risk for HF but without structural heart disease or symptoms of HF

Patients with: HTN, atherosclerostic disease, DM, obesity, metabolic syndrome or patients using cardiotoins, with family history of cardiomyopathy

therapy

Goals:

  • heart health lifestyle
  • prevent vascular, coronary disease
  • prevent LV structural abnormalities

Drugs:

  • ACEI or ARB in appropriate patients for vascuarl disease or DM
  • statins as appropraite
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9
Q

stage b HF

A

structural heart disease but without signs or symptoms of HF

patients with: previous MI, LV remodeling including LVH & low EF, asymptomatic valvular disease

THERAPY

Goals:

  • prevent HF symptoms
  • prevent further cardiac remodeling

​drugs:

  • ACEI or ARB as appropriate
  • beta blockers as appropriate

in selected patients

  • ICD
  • revascularization or vasular surgery as appropriate
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10
Q

stage C HF

A

structural heart disease with prior or current symptoms of HF

patients with: known structural heart disease and HF signs and symptoms

HFpEF Therapy

Goals

  • control symptoms
  • improve HRQOL
  • prevent hospitalization
  • prevent mortality

Strategies - idenfification of comorbidities

Treatment

  • diuresis to relieve symptoms of congeiton
  • follow guideline driving indications for comorbidities (HTN, AF, CAD, DM)

HFrEF Therapy

Goals:

  • control symptoms
  • patient education
  • prevent hospitalization
  • prevent mortality

Drugs for routine use

  • diurtics for fluid retention
  • ACEI or ARB
  • beta blocker
  • aldosteone antagonists

drugs for use in selected patients

  • hydralazine/ISDN
  • ACEI and ARB
  • digitalis

in selected patients

  • CRT
  • ICD
  • revsacularization or vascular surgery as appropriate
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11
Q

stage D HF

A

refractory HF

Patients w/ marked HF symptoms at rest

recurrent hospitalizations despite GDMT

Therapy

  • control symptoms
  • improve HRQOL
  • reduce hospital readmissions
  • establish pareitn end of life goals

Options

  • advanced care measures
  • heart transplant
  • chronic inotropes
  • temporary or permanent MCS
  • experimental surgery or drugs
  • palliative care and hospice
  • ICD deactivation
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12
Q

what are the 2 types of left sided heart failure

A
  1. heart failure with reduced ejection fraction (HFrEF) AKA systolic failure - heart gets tired of beating -left ventricle loses its ability to contract normally. heart can’t pump with enough force to push enough blood into circulation 2. heart failure with preserved EF (HFpEF) AKA diastolic failure/dysfunction -has S3/gallop -left ventricle loses its ability to relax normally b/c muscle has become stiff -heart can’t properly fill with blood during the rest period between each beat
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13
Q

information on right sided HF

A

-right ventricular dysfunction is most commonly caused by either hypoxic pulmonary disease of LV dysfunction -when right ventricle is unable to fill or eject adequate amounts of blood, it leads to an elevated right atrial pressure -this contributes to increased pressure in the vena cava and impaired venous drainage from the liver, GI tract, lower extremities, resulting in hepatomegaly, abdominal pain and peripheral edema

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14
Q

what are clinical recommendations for HF

A

-initial evaluation of patients with suspected heart failure should include a history & physical examination, lab assessment, CXR, and electrocardiography. echocardiography can help confirm the diagnosis

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15
Q

what are good predictors to rule in the diagnosis of heart failure

A

displaced cardiac apex, third heart sound, CXR findings of pulmonary venous congestion or interstitial edema.

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16
Q

how can you rule out systolic heart failure

A

systolic heart failure can be effectively ruled out with a normal B type natriuretic peptide or N-terminal pro-BNP natriuretic peptide level

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17
Q

what is another way to rue out heart failure

A

systolic heart failure can be effectively ruled out when the Framinham criteria are not et.

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18
Q

what will give you the exact EF?

A

a mugga scan

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19
Q

what do you need to rule in heart failure using the Framingham definition of HF

A

2 major or 1 major + 2 minor criteria

20
Q

what are the major criteria of the Framingham definition

A

-paroxysmal nocturnal dyspnea -orthopnea -elevated Jugular venous pressure -pulmonary rales -third heart sound -cardiomegaly on chest radiograph -pulmonary edema on chest radiograph

21
Q

what are the minor criteria of the Framingham definition

A

-peripheral edema -night cough -dyspnea on exertion -hepatomegaly -pleural effusion -heart rate > 120 -weight loss > 4.5 kg in 5 days.

22
Q

what are the 3 categories of heart failure

A
  1. HFpEF 2. HFrEF 3. HFmrEF
23
Q

what is HFpEF

A

patients with symptoms +/- signs of heart failure, but a normal left ventricular ejection fraction (LVEF > 50%)

24
Q

what is HFrEF

A

patients with symptoms +/- signs of heart failure and a reduced left ventricular ejection fraction (LVEF < 40%)

25
Q

what is HFmrEF

A

patients with symptoms +/- signs of heart failure and a ‘mid-range’ left ventricular ejection fraction (LVEF 40-49%)

26
Q

what are vasodilators used to reduce BP in HTN acute HF

A

nitrates nitroprusside infusion nesiritide morphine sulfate hydralazine

27
Q

what are diuretics/loop diuretics used to reduce BP in HTN acute HF

A

-furosemide, torsemide, or bumetanide -initial dose should equal or exceed chronic dose -subsequent dose may be required and/or addition of a second diuretic (such as a thiazide diuretic)

28
Q

when should you consider advanced therapies, what are signs of pos prognosis?

A

-hyponatremia (<125) -high diuretic requirements (>1.5 mg/kg furosemide) -intolerant to guideline based medications (ACE/BB) -worsening renal insufficiency -recurrent hospitalizations -low systolic blood pressure (<90) -use of inotropic medications -high biomarker or risk score

29
Q

when should you use inotropes?

A

-inotropic support is not for routine use in heart failure patients, especially those warm & wet -increase mortality in the long run -use only if cold and wet or palliative care -use only with systolic heart fialure

30
Q

what is acute treatment for HFpEF

A

-stiff heart is dependent on preload for filling -aggressive preload reduction can lead to hypotension -cautious use of preload reducers -reducing BP (after load) in a HTN patient can reduce LVEDP -consider short acting drips that can be turned off quickly (nitroprusside)

31
Q

what is acute treatment for advanced HFpEF

A

-since there is normal EF no role for inotropic therapy -may benefit from ultrafiltration if unable to achieve volume loss

32
Q

acute management take home points for HF

A

-determine if warm/wet/dry/cold -generally continue chronic HF medication but no rush to start new chronic HF medication -IV diuretics with a goal of achieving euvolemia -ultrafiltration only in very refractory cases -vasodilators before inotropes if BP allows -inotropes only in the ‘cold’ patient (look for signs of end order perfusion - urine output, rising creatinine, lactic acidosis, mental status) -no clear role for nesiritide or renal dosed dopamine.

33
Q

hospital management for HF

A

-once stabilized identify type, etiology (if new onset) or precipitating factors (if prior history) -correct any reversible causes -optimize volume status -echoardiogram to evaluate LV function -transition to chronic therapy medications

34
Q

what are some precipitating factors?

A

-ischemia -noncompliance with medications -excessive fluid/salt intake -thyroid dysfunction (TSH, free T4 & free T3) arrhythmias (a-fib, ventricular tachycardia) -anemia -malignant HTN -drug interactions (including negative inotropic drugs and those that increase salt retention NSAIDs)

35
Q

what are medications the patient should have at discharge

A

-ACEI/ARB -beta blocker (once euvolumic) - titrate slowly -aldosterone antagonist (if K+ and renal function are ok and can monitor potassium) -hydralazine/ISDN (if black) -sacubitril/valsartan (Entresto) instead of ACE/ARB -diuretic if CAD ASA +/- statin

36
Q

HFpEF treatment

A

treat underlying condition -HTN: control SBP & DBP -no benefit of particular drugs over others in contrast to HFrEF (systolic HF); CCB will sometimes cause foot/ankle edema -ischemia: consider revascularization: ASA, statin, ACEI, beta blocker -if tachyardic (a-fib) control heart rate -use diuretics for symptomatic improvement

37
Q

drugs to avoid with HF

A

-most antiarrhythmics (except amiodarone, does not improve mortality & deofetilie) non-dihydropyridine calcium channel blockers (verapamil, diltiazem) negative inotropes NSAIDs long term inotropes unless used for palliation nutritional supplements and hormonal therapies are not indicated unless repleting deficiencies ACD+ARB+aldosterone antagonist combination is contraindicated

38
Q

load dependency of measurement of LV function

A

stroke volume: preload / after load dependent cardiac output: preload / after load / heart rate ejection fraction: preload / after load dependent

39
Q

what is stroke volume

A

quantity of blood ejected with each heart beat mL

40
Q

what is cardiac output

A

quantity of blood delivered to the systemic circulation per unit time (L/min) (stroke volume * HR)

41
Q

what type of non-invasive cardiac imaging is recommended?

A
  1. patients w/ suspected acute or new onset HF should undergo a CXR 2. 2D echocardiogram with doppler should be performed for initial evaluation of HF 3. repeat measurement of EF is useful in patients w/ HF who have had a significant change in clinical status or received treatment that might affect cardiac function or for consideration of device therapy.
42
Q

recommendations for invasive evaluation

A

monitoring with a pulmonary artery catheter should be performed in patients with respiratory distress or impaired system perfusion when clinical assessment is inadequate.

43
Q

recommendations for inotropic support, MCS, and cardiac transplantation?

A
  1. HF patients hospitalized with fluid overload should be treated with IV diuretics 2. HF patients receiving loop diuretic therapy should receive an initial parental dose greater than or equal to their chronic oral daily dose, the dose should be serially adjusted 3. HFrEF patients requiring HF hospitalization on GDMT should continue GDMT except in cases of hemodynamic instability or where contraindicated 4. initiation of beta-blocker therapy at a low dose is recommended after optimization of volume status and discontinuation of IV agents. 5. thrombosis/thromboembolism prophylaxis is recommended for patients hospitalized with HF 6. serum electrolyte, BUN, creatinine should be measured during titration of HF medications, including diuretics
44
Q

recommendations for treatment of HFpEF

A

systolic & diastolic BP should be controlled according to published clinical practice guidelines diuretics should be used for relief of symptoms due to volume overload.

45
Q

recommendations for pharmacologic therapy for management of stage C HFrEF

A
  1. diuretics are recommended in patients with HFrEF with fluid retention 2. ACEI are recommended for all patients with HFrEF 3. ARBs are recommended in patients with HFrEF who are ACEI intolerant 4. use of 1 of the 3 beta blocker (bisoprolol, carvedilol, or metoprolol) proven to reduce mortality is recommended for all stable patients 5. aldosterone receptor antagonists are recommended in patients with NYHA class II-IV who have LVEF 35% 6. aldosterone receptor antagonists (aldactone) are recommended in patients following an acute MI who have LVEF < 40% with symptoms of HF or DM 7. the combination of hydrazine and ISDN is recommended for blacks with NYHA class III-IV HFrEF on GDMT 8. patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardio-embolic stroke should receive chronic anticoagulation therapy 9. the selection of an anticoagulation agent should be individualized
46
Q

recommendations for treatment of stage B HF

A
  1. in patients with a history of MI and reduced EF, ACEI or ARBs should be used to prevent HF 2. in patients with MI and reduced EF, evidence based beta blockers should be used to prevent HF 3. in patients with MI, statins should be used to prevent HF 4. blood pressure should be controlled to prevent symptomatic HF 5. ACEI should be used in all patients with a reduced EF to prevent HF 6. beta blockers should be used in all patients with a reduced EF to prevent HF
47
Q

recommendations for biomarkers in HF

A
  1. natriuretic peptides: diagnosis or exclusion of HF & prognosis of HF. both ambulatory & acute 2. biomarkers of myocardial injury, additive risk stratification. acute & ambulatory

Acute Care II - Summer 2017 (10 decks)

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