Lecture 12: Heart Failure - Part 1

Question 1

What are the 3 most common causes of HF?

Answer 1

• CAD - ischemic heart disease
• Idiopathic, dilated cardiomyopathy
• Valvular heart disease

Question 2

What are 4 causes of restriction/obstruction to ventricular filling which can lead to HF?

Answer 2

• RV infarct
• Constrictive pericarditis
• Mitral stenosis
• Atrial myxoma

Question 3

Using the AHA/ACC heart failure staging guidelines, what does stage A represent?

Answer 3

Pts at high risk for HF but WITHOUT structural heart disease or sx’s of HF

Question 4

Using the AHA/ACC heart failure staging guidelines, what does stage B represent?

Answer 4

Asymptomatic pts WITH structural heart disease (i.e., LVH and/or impaired LV function (low EF), valvular dz, but hemodynamically stable

Question 5

Using the AHA/ACC heart failure staging guidelines, what does stage C represent?

Answer 5

Pts WITH current or prior sx’s of HF WITH structural heart disease; SOB, fatigure, reduced exercise tolerance

Question 6

Using the AHA/ACC heart failure staging guidelines, what does stage D represent?

Answer 6

Pts w/ refractory HF requiring specialized treatment/interventions

Question 7

Using the NYHA functional classification for HF, what does class I-class IV represent?

Answer 7

• Class I = asymptomatic; no physical activity limitations
• Class II = no sx’s at rest; exertional sx’s w/ ordinary activity
• Class III = no sx’s at rest; sx’s with minimal activity
• Class IV = sx’s AT rest

Question 8

Which imaging modality is essential in the evaluation of heart disease and for distinguishing systolic HF from diastolic HF?

Answer 8

Echocardiogram

Question 9

List 5 causes of acute HF

Answer 9

• Acute MI
• Ruptured papillary muscle
• MR
• AI
• Toxins

Question 10

What are some distinguishing sx’s of systolic HF vs. diastolic HF?

Answer 10

• Systolic HF = DOE, orthopnea, paroxysmal nocturnal dyspnea
• Diastolic HF = SOB, DOE, and pulmonary edema

Question 11

Which type of HF (diastolic/systolic) is associated with HTN, obesity, DM, CAD, and aging?

Answer 11

Diastolic HF

Question 12

What are 3 common underlying causes of imparired ventricular relaxation leading to diastolic HF?

Answer 12

• Acute ischemia
• Myocardial fibrosis
• Amyloidosis

Question 13

List 6 causes of high-output HF?

Answer 13

• Hyperthyroidisim
• Anemia
• Pregnancy
• A-V fistula
• Beriberi
• Paget’s

Question 14

What are the CO and EF like in high output HF?

Answer 14

• High CO
• Low EF

Question 15

Which hormones released as a compensatory mechanism for HF causes an increased preload and which causes inceased afterload?

Answer 15

• Aldosterone —> Na and H₂O retention = ↑ preload, congestive sx’s and volume expansion
• Angiotensin II –> vasoconstrictor –> ↑PVR (↑ afterload)

Question 16

What is the effect of increased ADH released during compensatory phase of HF?

Answer 16

• Stimulates thirst –> ↑ TBW and hyponatremia (dilutional)
• ↑ preload (Na and H₂O retention)

Question 17

What are 2 major non-compliance issues which precipitate HF?

Answer 17

• Non-compliance with diet = too much Na⁺, too many kcals, too many stimulants
• Non-complance with meds = AE’s and cost

Question 18

What are 4 medication classes which can worsen/precipitate HF?

Answer 18

• Antiarrhythmics
• Beta-blockers
• CCBs
• NSAIDs

Question 19

How can anemia precipitate HF?

Answer 19

↑ O₂ needs of tissues –> ↑ CO

Question 20

By which mechanism do tachyarrhythmias lead to ischemia?

Answer 20

↓ diastolic filling time

Question 21

What is the most common sx of HF?

Answer 21

Dyspnea –> ↓ arterial perfusion to organs and venous congestion

Question 22

Presence of which sx ↑ the likelihood of HF by 2-fold?

Answer 22

Paroxysmal nocturnal dyspnea

Question 23

Which PE of the lung is common with HF?

Answer 23

Crackles in lung due to pulmonary edema; may wheeze or cough (frothy- pink fluid)

Question 24

What are 4 signs/sx’s of RV failure?

Answer 24

• Peripheral/sacral edema
• Hepatomegalia
• Ascites
• ↑ JVD, hepatojugular reflex

Question 25

When measuring JVP, how many cm’s is considered above normal?

Answer 25

• >3 cm above the sternal angle
• 8-9 cm in total distance above the RA

Question 26

What are findings on a CXR associated with HF?

Answer 26

• Cardiomgalia
• Pulmonary edema w/ central peripheral infiltrates
• ↑ size of vessels in upper portions of lungs
• Pleural effusions

Question 27

What is the usefulness of ordering a CBC, CMP, and UA when assessing possible HF?

Answer 27

• CBC looking for anemia 2’ to chronic disease
• CMP looking for electrolyte imbalance; pre-renal azotemia (BUN:Cr)
• UA looking for protein in urine

Question 28

Which lab must always be ordered in pt with HF who is >65 yo with Afib?

Answer 28

Thyroid

Question 29

What is the significance of a BNP <100 pg/mL in terms of HF?

Answer 29

97% chance of NO HF

Question 30

BNP is a neurohormone made in the ventricle that is sensitive to what (i.e., what are the stimuli)?

Answer 30

• Sensitive to ventricle stretching and volume overload.
• Preload/afterload are the stimuli

Question 31

What are pulmonary and liver problems which may mimic HF?

Answer 31

• Pulmonary = PE, asthma, and pneumonia
• Liver = cirrhosis –> ascites + edema