CHF

Question 1

epidemiology of CHF

Answer 1

effects 10% of men and 8% of women over 60yo
incidence on the rise, especially diagnosis 3mil visits/yr
5yr mortality after diagnosis is 50%

Question 2

etiology of CHF

Answer 2

1. CAD & HTN are most common
2. cardiomyopathies - alcoholic, viral myocarditis, idiopathic, infiltrative, post partum
3. valvular dz
4. cardiotoxins - chemo, anabolic steroids
5. arrhythmias, diabetes, and congenital heart disorders
6. dz promotion - renal dz, NSAIDS, CCBs

Question 3

s/s systolic left sided failure

Answer 3

fatigue
crackles/rales - small clicking, bubbling or rattling sounds in lungs
DOE
orthopnea
PND
Cheyne-Stokes respiration
diminished pulse pressure, cyanosis, JVD, S3 gallop, tachycardia, murmurs

Question 4

what is cheyne-stokes respirations

Answer 4

apnea = hyperventilation = apnea

caused by diminshed sensitivity of resp center to arterial PCO2

Question 5

what is diastolic (right sided) failure

Answer 5

disruption in diastolic filling or contractility of RV secondary to MI, obstructive outflow process (anatomical vs inc p ulm capillary wedge pressures resulting from L sided failure)

Question 6

what is left sided failure CHF

Answer 6

LV remodeling secondary to MI, HTN, or obstructive outflow process

Question 7

s/s of diastolic (right sided) failure

Answer 7

1. peripheral pitting edema - may be on back or buttocks if sedentary
2. GI tract congestion - decreased appetite, hepatomegaly,ascites
3. JVD, prolonged L parasternal impulse with RV hypertrophy

Question 8

DDX for CHF - cardiovascular

Answer 8

acute coronary syndrome
valvular/septal rupture
aortic dissection
arrhythmia
critical aortic stenosis
endocarditis/myocarditis
HTN crisis
pericardial tamponade

Question 9

DDX for CHF - pulm

Answer 9

COPD 
PE
multilobar pneumo
ARDS
asthma

Question 10

ddx for chf - other

Answer 10

acute renal failure
iatrogenic volume overload
post transfusion overload
sepsis
med non compliance
new meds

Question 11

w/u for CHF

Answer 11

(results are related to progression of dz)

1. labs: CBC, CMP, UA, A1C, lipid panel, TSH, BNP, troponin
2. EKG: LV hypertrophy, MI/prior MI (Q waves), arrhythmia/tachycardia
3. ECHO: assess for LV/RV hypertrophy, wall motion abnormalitites, ejection fraction (>50% normal), valvular abnormalities***essential for DX, Tx, management
4. CXR (see other flash card for findings)

Question 12

what is BNP

Answer 12

vasodilatory protein released by stretched myocardium in response to increased ventricular filling pressures. attempts to offset the effects of neurohormonal activation by promoting diuresis, vasodilation and suppressing the renin-angiotensin system.
***>500 is diagnostic

Question 13

definition of CHF

Answer 13

cardiac pumping capacity that is inadequate to meet the body’s metabolic demands

Question 14

CHF tx

Answer 14

1. treat reversible causes - HTN, DM, CAD, arrhythmias, structural
2. diuretics

Question 15

pharacology tx for CHF - diuretics

Answer 15

1. diuretics: most effective agents for chronic symptomatic relief –thiazides for mild CHF
   - HCTZ
   - chlorthalidone
   - loop diuretics - used for mod-severe HF
2. K+ sparing - hypo K, dehydration, hypouricemia due to diuretics (used in combo with thiazide or loop

Question 16

pharm tx for CHF - ACE-I & ARBS

Answer 16

3. ACE-I: 20% reduction in mortality, increased exercise tolerance
4. ARBS: demonstrated improved mortality rates and symptom control when added to ACE?

Question 17

pharm tx for CHF - beta blockers

Answer 17

5. beta blockers: strongly recommended if symptoms are stable; carvedilol preferred

Question 18

pharm tx for CHF - digitalis

Answer 18

digitalis: increased myocardial contractility, increases mortality due to arrhythmias and MI

Question 19

list pharm options for tx CHF

Answer 19

1. diuretics
(K+sparing drugs)
2. ACE-I
3. ARBS
4. beta blockers
5. digitalis
6. vasodilators

Question 20

pharm tx for CHF - vasodilators

Answer 20

7. vasodilators - improves SOB but no improvement in limiting advancing HF
   - generally reserved for inability to tolerate other meds or failure to control symptoms
   * *Nitrates - mostly venodilation, some arterial dilation at higher doses ex. nitroglycerin: most useful in acute exacerbations IC or transdermal
   * *Hydralazine - mostly arteriolar dilation. ARB preferred

Question 21

what would you tx CHF pt if rate is not controlled or if Afib is present

Answer 21

anticoagulation and amiodarone

Question 22

non pharm tx of CHF

Answer 22

1. defibrillator: HF+cardiomyopathy +EF

Question 23

new/future tx of CHF

Answer 23

1. Ivabradine - selective sinus node inhibitor, rate control
2. Ranolazine - antischemic agent, inhibit the late sodium current in myocytes
3. tolvaptan/conivaptan: vasopressin receptor antagonists, anti-hyponatremia
4. sildenafil - decreases pulm vascular resistance
5. serelaxin - is a recombinant form hormone relaxin which is naturally occurring hormone that is elevated in pregnancy, increase cardiac output, arterial compliance and renal blood flow

Question 24

what is acute decompensated failure

• symptoms
• causes

Answer 24

pulmonary edema

• acute or subacute worsening dyspnea
• causes: acute MI, arrhythmia, infection, med/dietary noncompliance, sepsis, DIC, transfusion rxns

Question 25

acute decompensated failure - PE/labs

Answer 25

- PE: hypoxia anxious or somulent, distress, diaphoresis, cyanosis, frothy cough, edema, rales (bases to apices) - labs: increased BNP, troponin, or creatine (digoxin/INR if appropriate)

Question 26

acute decompensated failure - imaging

Answer 26

EKG: acute MI, arrhythmia, low coltage (pericardial effusion) CXR: increased interstitial markings, butterfly pattern, cardiomegaly bedside ultrasound: assess for b-lines, wall motion, abnormalities

Question 27

CXR findings in CHF

Answer 27

1. bat wing sign = alveolar edema 2. kerley b lines: interstitial pulmonary edema - they are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs (diaphragmatic corners) 3. pleural effusion 4. cardiomegaly 5. prominent upper lobe vessles

Question 28

tx for acute decompensated failure

Answer 28

1. sitting upright, oxygen, IV access, consider foley 2. morphine IV - vasodilator, reduces anxiety 3. diuretic IV - intravascular fluid reduction (lasix) 4. nitrates - vasodilator, reduces BP and LV filling pressures 5. support ventilation - CPAP better than BiPAP 6. endotracheal intubation - indicated for severe distress or decreased mentation

Question 29

what is CPAP vs BiPAP

Answer 29

CPAP - continuous positive airway pressure - improves pulm compliance, reduces work of breathing/preload/afterload BiPAP - biphasic positive airway pressure - inspiratory and expiratory assitance

Question 30

discharge planning for CHF

Answer 30

factors that may contribute to prolonged admission or re-admission 1. prior hospitalization during adulthood 2. arterial pH1.3 4. hemoglobin levels -

Question 31

heart failure pathophys

Answer 31

1. myocardial injury (loss of functioning cardiac muscle or disruption of forces (MI, HTN, valves)) 2. reduced CO 3. decreased carotid barorecptor stimulation, decr renal perfusion 5. activation of SNS, RAAS - increase HR and inotropy/myocardial toxicity - vasoconstriction incr. afterload/hemodynamic alterations (increase afterload and preload) 6. negative remodeling = worsened LV function 7. symptomatic pts

Question 32

cardiorenal syndrome CHF pathophys -

Answer 32

poorly function heart: 1. systolic dysfunction (poor CO) = renal hypoperfusion occurs 2. activation of the RAAS 3. increased blood volume and vasoconstriction which activates sympathetic nervous system = venous congestion, vasoconstriction, hypertrophy, apaptosis, and fibrosis of cardiomyocytes and renal tubular cells 4. diastolic dysfunction = fluid overload = increased central venous pressure resulting in renal vascular congestion with poor renal perfusion Poorly functioning kidneys: 1. electrolyte abnormalities resulting in : -impaired renal K excretion -reduced calcium absorption in GI -kidneys not producing EPO needed for RBC production resulting in anemia and increasing cardiac workload

Question 33

staging of CHF - ACC/AHA

Answer 33

A: high risk for developing CHF, no structural disorder of heart B: structural disorder of heart, never developed s/s of CHF 3.C: past or current symptoms of CHF, symptoms associated with underlying heart dz D: end stage dz, requires specialized treatment strategies

Question 34

staging of CHF - NYHA

Answer 34

I: no limitation of physical activity II: slight limitation of physical activity, comfortable at rest III: marked limitation of physical activity, comfortable at rest -IIIa:no dyspnea at rest -IIIb: recent dyspnea at rest IV: inability to carry on any physical activity w/o discomfort, symptoms present at rest