B P6 C48 Approach to the Patient with Heart Failure Flashcards
Heart failure (HF) is a complex clinical syndrome resulting from _____.
Structural and functional impairment of ventricular filling or ejection of blood
Risk factors for HF include:
Ischemic heart disease
Incident or prevalent MI
Myocarditis
Valvular heart disease
Tachycardia
Diabetes mellitus
Structural heart disease related to CHD
Sleep apnea
Excessive drug or alcohol use
Obesity
HFpEF is generally defined as a left ventricular EF ____, whereas HFrEF is generally defined as an EF _____.
HFpEF >/= 50%
HFrEF <40%
The prevalence of HFpEF increases dramatically with age and is much more common in _____ at any age
Women
Patients in this category (HFrecEF) have somewhat characteristic demographics, in that they are more likely to be _____.
Younger
Female
Have nonischemic HF
Shorter duration of HF
Have less remodeling of their left ventricle at the time of diagnosis
A working definition of HFrecEF that is consistent with the majority of studies in the literature includes: ______ These improvements in LVEF are typically accompanied by a reduction in LV volumes.
(1) Documentation of a decreased LVEF less than 40% at baseline
(2) 10% absolute improvement in LVEF
(3) a second measurement of LVEF greater than 40%
Although demonstrating improvement in LVEF, many of these patients may have persistent biochemical signs of HF pathophysiology with abnormal concentrations of natriuretic peptides, and a recent study suggested that discontinuation of GDMT for HF was accompanied by an unacceptably high rate (___%) of recrudescent HFrEF.
44%
When the diagnosis of HF is suspected, the goals of the clinical assessment are to _____.
(1) Determine whether HF is present
(2) Define the underlying cause and the type of HF (HFrEF vs. HFpEF)
(3) Assess the severity of HF
(4) Identify comorbidities that can influence the clinical course and response to treatment
ACC/AHA stages of HF
A
At high risk for HF but without structural heart disease or symptoms of heart failure.
B
Structural heart disease but without signs or symptoms of heart failure.
C
Structural heart disease with prior or current symptoms of heart failure.
D
Refractory heart failure requiring specialized interventions.
NYHA Functional Classification
I
No limitation of physical activity.
Ordinary physical activity does not cause symptoms of heart failure.
II
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical activity results in symptoms of heart failure.
III
Marked limitation of physical activity.
Comfortable at rest, but less than ordinary activity causes symptoms of heart failure.
IV
Unable to carry on any physical activity without symptoms of heart failure, or symptoms of heart failure at rest.
_____ is a cardinal symptom of HF, and is typically related to increases in cardiac filling pressures but also may represent restricted cardiac output.
Worsening dyspnea
_____ is often mentioned by patients hospitalized with HF and has a high-diagnostic sensitivity and significant prognostic ramifications in this population. However, it is also cited by patients with many other medical conditions, so that the specificity and positive predictive value of this symptom alone are low.
Dyspnea at rest
Patients may sleep with their heads elevated to relieve dyspnea while recumbent (_____); additionally, dyspnea while lying on the left side (_____) may occur.
Orthopnea
Trepopnea
_____, shortness of breath developing while recumbent, is one of the most highly reliable indicators of HF.
PND
______ respiration (also referred to as periodic or cyclic respiration) is common in advanced HF and is usually associated with low cardiac output and sleep-disordered breathing. The presence of this respiration is generally indicative of an adverse prognosis.
Cheyne-Stokes respiration
While nonspecific, _____due to congestion of the liver is common in those with significant right HF, and may be incorrectly attributed to other conditions
RIght upper quadrant pain
Another cardinal symptom of HF is _____, generally held to be reflective of reduction in cardiac output as well as abnormal skeletal muscle metabolic responses to exercise.
Fatigue
Other causes of fatigue in HF may include _____.
Major depression
Anemia
Renal dysfunction
Endocrinologic abnormalities
Side effects to medications
Unintended weight loss, often leading to _____, may be prominent and is a major prognostic indicator.
Cachexia
Physical examination findings in HF which are indicative of more severe diseaase:
Narrow pulse pressure or thready pulse
Pulses alternans
Cool and/or mottled extremities
Anasarca
The presence of _____ is particularly helpful because these conditions account for approximately 90% of the population attributable risk for HF in the United States
Hypertension, CAD, and/or DM
This class of agents is well recognized to lead to HF through their ability to worsen renal function, trigger hypertension, and lead to fluid retention, particularly in older adults.
NSAIDS
The skin exam may show pallor or cyanosis due to under perfusion, stigmata of alcohol abuse (such as _____), _____ due to sarcoidosis, _____ due to hemachromatosis, or _____ from amyloidosis; additional findings supporting amyloidosis include _____.
Alcohol abuse: spider angiomata or palmar erythema
Sarcoidosis: erythema nodosum
Hemachromatosis: Bronzing
Amyloidosis: easy bruising + deltoid muscle infiltration (leading to the “shoulder pad sign”), tongue hypertrophy, and bilateral thenar wasting from carpal tunnel syndrome
The presence of a third heart sound is a crucially important finding and suggests increased ______; while difficult to identify, a third heart sound is highly specific for HF, and carries a substantial prognostic meaning
Increased ventricular filling volume