CHF 2

Question 1

What are the major s/s of HF?

Answer 1

dyspnea, orthopnea, nocturnal dyspnea, cachexia, tachycardia, + hepato-jugular reflex, S3/S4, ascites

Question 2

What are the minor s/s of HF?

Answer 2

depression, MR, afib, peripheral edema

Question 3

Can a pt w HF be asx?

Answer 3

Yes, it depends on the severity of the dz

Question 4

What are the s/s of L sided HF?

Answer 4

exertional dyspnea, non-productive cough, fatigue, orthopnea, paroxysmal nocturnal dypsnea, basilar rales, gallops, exercise intolerance

Question 5

What are the s/s of R sided HF?

Answer 5

distended neck veins, tender or non-tender hepatic congestion, nausea, dependent pitting edema, often caused by L sided HF

Question 6

What are the NYHAF classes of HF?

Answer 6

Class 1 = sx only at activity levels that would limit normal ppl
Class 2 = sx w ordinary exertion
Class 3 = sx w less than ordinary exertion
Class 4 = sx at rest

Question 7

What are the ACC/AHA stages of development of HF?

Answer 7

Stage A = high risk w/o structural heart dz or sx
Stage B = heart dz w asx LV dysfunction
Stage C = prior or current sx
Stage D = refractory end stage

Question 8

What is the pathophys of HF?

Answer 8

LV has decreased CO, pulmonary back up, RV congestion which leads to pedal edema and increased JVD

Question 9

In order to dx HF what does everyone get in terms of imaging?

Answer 9

EKG
CXR
Echo

Question 10

What would you be able to see on an EKG to dx HF?

Answer 10

signs of ischemia, LVH, heart block, tachycardia (a fib w RVR)

Question 11

What would you be able to see on a CXR to dx HF?

Answer 11

cardiomegaly, pulm edema (fluffy infiltrates), Kerley B lines, pleural fluid, redistribution, boot shaped heart

Question 12

What are Kerley B lines?

Answer 12

They are seen on a CXR of some pts w HF when fluid leaks into the peripheral interlobular septa, it is seen as septal lines or Kerley B lines. They are peripheral, short 1-2 cm horizontal lines near the costophrenic angles that run perpendicular to pleura

Question 13

What would you be able to see on an echo to dx HF?

Answer 13

ventricle size & shape, LV EF%, valves (structure and function), wall motion, synchronicity of ventricular contraction, LV remodeling, LVH or RVH, pressure gradient, valve inflow/outflow properties, output state

Question 14

What cardiac specific labs would you order for a pt w HF?

Answer 14

Creatine Kinase & CKMB
Troponins
BNP
Lipids (TC, HDL, LDL, triglycerides)

Question 15

What are you looking for when assessing CK levels?

Answer 15

They will be elevated in 4-8 hrs after the event and peak after 24 hrs, then decline in 2-3 days
Trend the peak
Ratio of CK to CKMB of >2.5 is indicative of an MI
Skeletal injury would make results invalid

Question 16

What are you looking for when assessing Troponin levels?

Answer 16

They will be released/elevated after 3 hrs post event and persist for 7-10 days. Troponin I (binds actin & inhibits actin-myosin interactions)

Question 17

What are you looking for when assessing BNP levels?

Answer 17

400 has high predictive value for CHF (find underlying cause if there is one), compare levels to baseline.
Remember there will be lower levels in obese pts and higher levels in pts with renal failure & sepsis

Question 18

Which routine labs are important to order when assessing a pt with HF?

Answer 18

CBC, BMP, LFTs, TSH, UA

Question 19

What are the treatment goals in HF?

Answer 19

Remove fluid (loops, spironolactone)
Work directly on Ca++ movement in and out of SR (digitalis & CCB)
Decrease cardiac work, after load (ACEi)
Increase contractility (inotropic support - dobutamine, milrnone)

Question 20

Who gets hospitalized for AHF?

Answer 20

hypotension, acute kidney injury, altered MS (any new organ dz)
dyspnea at rest
dangerous arrhythmias
ACS
wt gain >/= 5 Kg (pulm/systemic congestion)
electrolyte disturbances
PNA, PE, DKA, TIA/CVA
ICD fires
previous undo HF w s/s of systemic/pulmonary congestion

Question 21

What are the goals for AHF treatment for hospitalized pts?

Answer 21

improved sx
optimize volume status
id etiology
id precipitating factors
optimize chronic oral therapy
minimize SEs
id pts whom may benefit from revascularization
EDUCATE pts
initiate a dz mgmt program

Question 22

What should the hemodynamic monitoring of a hospitalized pt with AHF entail?

Answer 22

vitals
possible swan, arterial/central line
echo
ekg

Question 23

What can be done to assess and stabilize systolic & diastolic dysfunction?

Answer 23

ABCs ( is bipap or cpap needed)
IV access
upright position (tripod)
O2 (only when needed)
diuresis (lasix) 
vasodilator therapy (NTG)
morphine (MONA)
monitor UOP

Question 24

What is the mainstay treatment for AHF?

Answer 24

diuretics

caution if pt is hypotensive & LVOT obstruction should be diuresed w caution bc they are preload dependent

Question 25

What are some other treatments for AHF besides diuretics?

Answer 25

Sodium & fluid restricton vasodilators (NTG) ACEi/ARB (for systolic dysfunc - start once pt is stable) Inotropic agents (for severe systolic dysfunction -- dobutamine, milrinone) BB Morphine (decrease anxiety & WOB) mechanical cardiac assistance (balloon pump, VAD) Ultrafiltration Vasopressin receptor antagonists

Question 26

What is important to do when discharging a pt that was treated for AHF?

Answer 26

Address exacerbating factors, achieve near optimal volume status & pharm therapies (goal doses), will need f/u!!

Question 27

What are the goals for treatment of Chronic HF?

Answer 27

Improve sx, slow or reverse deterioration & reduce mortality in addition to treating underlying systemic effects of HF

Question 28

What are some echo findings for Systolic dysfunction?

Answer 28

``` decreased EF (<45%) enlarged LV w thin wall eccentric LV remodeling Mitral regurg pulm HTN decreased mitral filling increased filling pressure ```

Question 29

What are some echo findings for diastolic dysfunction?

Answer 29

``` Normal EF > 45% normal LV size thick LV wall dilated atria concentric LV remodeling pulm HTN abnl mitral filling increased filling pressure ```

Question 30

``` What are the treatments for systolic dysfunction - CHF? Which NYHA class should they be started at? ```

Answer 30

ACEi/ARB (mainstay for chronic HF) Class 1-4 BB Class 1-4 Loop diuretics Class 3-4 Hydralazine & nitrates (ISDN/mononitrates, better in AA) Class 3-4 Aldosterone Antagonist (spironolactone Class 3-4, eplerenone Class 2) Digoxin Class 3-4 esp if pt has a fib Inotropic agents - severe fish oil, statins, exercise NO CCB AICD - post cardiac arrest

Question 31

What are the treatments for diastolic dysfunction - CHF?

Answer 31

Tx underlying cause: HTN anti-htn (regression of LVH) ARBs/CCB/ACEi control afib (preload dependent) anti-ischemic tx (BB, nitrates, PCI & CABG) aldosterone antagonists statins exercise slightly better prognosis than systolic dysfunction

Question 32

What drug should not be used in diastolic dysfunction?

Answer 32

digoxin bc contractility is intact

Question 33

What should you keep in mind when treating diastolic dysfunction?

Answer 33

There is a decrease LV volume & therefore must be cautious as not to decrease preload much - don't overload too much

Question 34

What is the prevention recommendation of HF?

Answer 34

early detection and removal of reversible predisposing conditions, prevention is aimed to Class A & B HF