HYHO HPS

Question 1

What is the most predominant cause of heart failure with reduced ejection fraction?

Answer 1

Coronary artery disease is the predominant cause of heart failure with reduced ejection fraction, which most commonly results in left ventricular dilation

Question 2

What does heart failure with reduced ejection fraction result in most commonly?

Answer 2

Coronary artery disease is the predominant cause of heart failure with reduced ejection fraction, **which most commonly results in left ventricular dilation**

Question 3

What is the most predominant cause of heart failure with preserved ejection fraction?

Answer 3

hypertension is the predominant cause of heart failure with preserved ejection fraction, which is usually associated with left ventricular hypertrophy

Question 4

What does heart failure with preserved ejection fraction result in most commonly?

Answer 4

hypertension is the predominant cause of heart failure with preserved ejection fraction, **which is usually associated with left ventricular hypertrophy**

Question 5

What are the 4 NYHA classes? What are each of the clinical levels of impairment?

Answer 5

Question 6

What are the steps of measuring JVP?

Answer 6

Raise the head of the bed or examining table to about 30°. Turn the patient’s head slightly away from the side you are inspecting.

Identify the external jugular vein on each side, then find the internal jugular venous pulsations.

If necessary, raise or lower the head of the bed until you can see the oscillation point or meniscus of the internal jugular venous pulsations in the lower half of the neck.

Focus on the right internal jugular vein. Look for pulsations in the suprasternal notch, between the attachments of the SCM muscle on the sternum and clavicle, or just posterior to the SCM. Distinguish the pulsations of the internal jugular vein from those of the carotid artery.

Identify the highest point of pulsation in the right jugular vein. Extend a long rectangular object or card horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right angle. Measure the vertical distance in centimeters above the sternal angle where the horizontal object crosses the ruler and add to this distance 5 cm, the distance from the sternal angle to the center of the right atrium. The sum is the JVP.

Question 7

What is the categorization of HFrEF vs. HFpEF? What is borderline reduced ejection fraction?

Answer 7

Can be categorized as either heart failure with reduced ejection fraction (left ventricular ejection fraction of 40% or less) or heart failure with preserved ejection fraction (left ventricular ejection fraction of 50% or more). Patients with values of 41% to 49% are classified as having borderline reduced ejection fraction

Question 8

Where are the four listening posts of the heart and what are their corresponding valves?

Answer 8

Question 9

What does the S1 heart sound represent?

Answer 9

Closure of the mitral valve produces the first heart sound, S1.

Question 10

What does the S2 heart sound represent?

Answer 10

Aortic valve closure produces the second heart sound, S2, and another diastole begins.

Question 11

What do the S3 and S4 heart sounds correspond to?

Answer 11

In most adults over age 40 years, the diastolic sounds of S3 and S4 are pathologic, and are correlated with heart failure and acute myocardial ischemia. In recent studies, an S3 corresponds to an abrupt deceleration of inflow across the mitral valve, and an S4 to increased left ventricular end diastolic stiffness which decreases compliance.

Question 12

What diseases is an elevated JVP associated with?

Answer 12

An elevated JVP is highly correlated with both acute and chronic heart failure.

It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis

In patients with obstructive lung disease, the JVP can appear elevated on expiration, but the veins collapse on inspiration. This finding does not indicate heart failure

Question 13

What are the perameters of an ABNORMAL JVP?

Answer 13

JVP measured at >3 cm above the sternal angle, or more than 8 cm in total distance above the right atrium, is considered elevated above normal.

Question 14

What are the major characteristic PE findings that suggest a severity of cardiac dysfunction?

Answer 14

Four major findings suggest severity of the cardiac dysfunction: resting sinus tachycardia, narrow pulse pressure, diaphoresis, and peripheral vasoconstriction. The last abnormality is manifested as cool, pale, and sometimes cyanotic extremities (due to the combination of decreased perfusion and increased oxygen extraction).

Question 15

What are the three major manifestations of volume overload in patients with HF?

Answer 15

Volume assessment — There are three major manifestations of volume overload in patients with HF: pulmonary congestion, peripheral edema, and elevated jugular venous pressure.

Question 16

How is pulmonary congestion with corresponding rales on auscultation different in acute HF vs. chronic HF?

Answer 16

Pulmonary congestion that may manifest as rales is more prominent in acute or subacute disease. As noted above, chronic HF is associated with increases in venous capacitance and lymphatic drainage of the lungs; as a result, rales are often absent even though the pulmonary capillary pressure is elevated.

Question 17

What PE finding, if present, is virtually pathognomonic of severe left ventricular (LV) systolic failure?

Answer 17

Pulsus alternans, if present, is virtually pathognomonic of severe left ventricular (LV) systolic failure.

Question 18

What special considerations/test are ordered to assess if a patient has HF or not ?

Answer 18

Measurement of naturetic peptide levels, 2-dimensional echocardiography with Doppler, and chest radiography support the diagnosis of heart failure

Question 19

Most dyspneic patients with HF have a BNP of what?

Answer 19

BNP — Most dyspneic patients with HF have values above 400 pg/mL, while values below 100 pg/mL have a very high negative predictive value for HF as a cause of dyspnea.

Question 20

Recommended initial blood tests for patients with symptoms and signs of HF include:

Answer 20

According to HYHO:

CBC, Complete Metabolic Panel, Cardiac Enzymes, UA, beta-natriuretic peptide

According to UpToDate:

Cardiac troponin T or I in patients with acute decompensated HF and/or suspected acute coronary syndrome

A complete blood count, which may suggest concurrent or alternate conditions. Anemia or infection can exacerbate pre-existing HF.

Serum electrolytes, blood urea nitrogen, and creatinine may indicate associated conditions. Hyponatremia generally indicates severe HF, though other causes should be considered . Renal impairment may be caused by and/or contribute to HF exacerbation. Baseline evaluation of electrolytes and creatine is also necessary when initiating therapy with diuretics and/or angiotensin converting enzyme inhibitors.

Liver function tests, which may be affected by hepatic congestion.

Fasting blood glucose to detect underlying diabetes mellitus.

BNP— BNP is a natriuretic hormone released primarily from the heart, particularly the ventricles.

Question 21

How many Framingham criteria are needed to make a Dx of HF?

Answer 21

Question 22

What are the classic findings on a chest XR of a HF patient?

Answer 22

Question 23

What are the major and minor Framingham criteria for HF?

Answer 23

Question 24

What does increased parasympathetic tone do to the heart? What nerve is this mediated by? What are the corresponding vertebral levels? What are the associated tender points?

Answer 24

Increased tone = bradycardia w/ vagus nerve ~ ΟΑ, ΑΑ, Χ2

Associated tender points:

Tissue texture changes over cervical pillars

Rotated vertebrae

Compression of occipitomastoid sutures as well as occipito-atlantoid joint

Question 25

What does increased sympathetic tone do to the heart? What are the corresponding vertebral levels? What are the corresponding tender points?

Answer 25

• increased sympathetic tone = tachycardia
• T1-5

Tissue texture changes over transverse processes/rotated vertebrae

Question 26

What are some somatic dysfunctions that can be found in a patient with heart failure?

Answer 26

Dependent extremity edema

Rib dysfunction

Flattened diaphragm

Scalene hypertonicity and tender points

Pectoralis minor hypertonicity and tender points

Question 27

What would be an appropriate 2 minute OMM treatment for a HF patient?

Answer 27

2-Minute Treatment:

Lower extremity—pedal pump

Question 28

What would be an appropriate 5 minute OMM treatment for a HF patient?

Answer 28

5-Minute Treatment

Rib raising

Question 29

What are some “extended OMM treatments” for HF?

Answer 29

Head—vagus: OA release or V spread

Head—decreased CRI: CV4 hold

Abdomen—diaphragm

Doming technique

Thoracolumbar junction: ME, MFR, HVLA

Thoracic—MFR

Rib dysfunction—ME

Cervical—C2, C3–C5: MFR, ME, and/or FPR

Lower extremities and upper extremities—effleurage

Cervical—scalenes: CS or ME

Upper extremity—pectoralis minor: CS or MFR

Abdomen/other/viscerosomatic—Chapman’s reflex for heart

Question 30

What are the most common treatment modalities with HF w/ reduced EF?

Answer 30

For patients with HFrEF and hypertension, a beta blocker; an angiotensin converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or angiotensin receptor-neprilysin inhibitor (ARNI); and mineralocorticoid receptor antagonist (MRA) are the preferred antihypertensive agents because these agents improve survival in patients with HFrEF, as discussed below.

Beta blockers can also provide anginal relief in patients with ischemic heart disease and rate control in those with atrial fibrillation.

For patients who are still hypertensive after optimization of treatment with a beta blocker, an ACE inhibitor (or ARB or ARNI), and an MRA (if indicated) or who cannot tolerate these drugs, appropriate agents include loop diuretics, nitrates, some vasoselective calcium channel blockers (eg, amlodipine and felodipine [7]), and hydralazine.

Question 31

What are the most common treatment modalities with HF w/ preserved EF?

Answer 31

The results of clinical trials have demonstrated that while neurohumoral antagonists such as beta blockers, angiotensin converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) as well as cardiac resynchronization are effective in HFrEF, these therapies do not decrease morbidity and mortality in HFpEF.

Based upon the available evidence, we suggest treatment with a mineralocorticoid receptor antagonist in patients with HFpEF who can be appropriately monitored. Diuretics are used to treat volume overload, but as noted above, care must be taken to avoid volume depletion. Other medications such as ARBs, ACE inhibitors, calcium channel blockers, and beta blockers are used as need to treat hypertension but lack proven efficacy to alter clinical outcomes in HFpEF. We recommend against use of phosphodiesterase-5-inhibitors, organic nitrates such as isosorbide, or digoxin (aside from use for ventricular rate control in atrial fibrillation) to treat HFpEF. (See ‘Treatment overview’ above.)

Question 32

What is acute decompensated HF?

Answer 32

Acute decompensated heart failure (ADHF) is a syndrome defined by worsening fatigue, dyspnea, or edema that results from deteriorating heart function and usually leads to hospital admission or unscheduled medical intervention.

Question 33

What are the signs and symptoms of acute decompensated HF?

Answer 33

Question 34

What are the important diagnostic studies of ACHF?

Question 35

How is acute decompensated HF treated for patients with adequate end organ perfusion?

Answer 35

Question 36

How is ADHF treated in patients with known diastolic function?

Answer 36

Question 37

How is ADHF treated in patients with known systolic function?

Answer 37

discontinue beta blocker therapy and give an iv ionotrope

Question 38

What are the stages of heart failure progression (A-D)?

Answer 38

Question 39

The HYHO says to “review epidemiology from Harrison’s”

So here it is:

Answer 39

HF is a burgeoning problem worldwide, with >20 million people affected.

The overall prevalence of HF in the adult population in developed countries is 2%.

HF prevalence follows an exponential pattern, rising with age, and affects 6–10% of people aged >65.

Although the relative incidence of HF is lower in women than in men, women constitute at least one-half the cases of HF because of their longer life expectancy.

In North America and Europe, the lifetime risk of developing HF is approximately one in five for a 40-year-old.

HF was once thought to arise primarily in the setting of a depressed left ventricular (LV) ejection fraction (EF); however, epidemiologic studies have shown that approximately one-half of patients who develop HF have a normal or preserved EF (EF ≥50%).

Patients with a LV EF between 40 and 50% have been considered as having a borderline or mid-range EF.

Question 40

What are the possible alternative differentials to HF in the setting of:

-acute onset that progressed rapidly over a few minutes.

Answer 40

• PE
• Pneumothorax
• Left ventricular failure
• Asthma
• Inhaled foreign body

Question 41

What are the possible alternative differential diagnoses to HF that include

-gradual onset that progressed rapidly over a few days

Answer 41

• PNA
• Asthma
• Exacerbation of COPD

Question 42

What are the possible alternative differential diagnoses to HF that include

-GRADUAL onset that progressed rapidly over weeks to months

Answer 42

• Anemia
• Pleural effusion
• Respiratory neuromuscular disorders

Question 43

What are the possible alternative differential diagnoses to HF that include

-GRADUAL onset that progressed rapidly over months to years

Answer 43

• COPD
• pulmonary fibrosis
• pulmonary TB

Question 44

Draw out the flow chart that pertains to treating patients with HFpEF and HFrEF?

Answer 44

Question 45

How are patients who cardiac status is unknown but present with signs of ADHF?

Answer 45

• give an IV iontrope with or without an iv vasopressor and assess the need for mechanical support
• obtain an immediate echo as needed

Question 46

How are pt’s with ADHF treated after getting the initial oxygen/intubation as needed/vital sign monitoring?

Answer 46