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Flashcards in CHF Review and Palliative Care Deck (58):
1

1. What causes HF?


2. Causes? 7

1. The loss of a critical quantity of functioning myocardial cells after injury to the heart

2. due to
-CAD,
-HTN,
-idiopathic,
-infections (viral, Chagas disease),
-toxins (ETOH or cytotoxic drugs, cocaine, meth),
-valvular disease,
-prolonged arrhythmias

2

State what kind of HF is associated with the following:
1. Age?
2. HTN?
3. Afib?
4. Obesity?
5. Gender?
6. CAD?
7. DM?
8. Renal Dysfunction?

1. (DHF>SHF)
2. (DHF>SHF)
3. DHF
4. (DHF≥SHF)
5. (DHF: women>men)
6. (SHF > DHF)!
7. (DHF=SHF)
8. DHF

3

1. What are the non-myocardial causes of HF with reduced EF?

2. HF with preserved EF? 2

1. Valvular disease

2.
-valvular dz
-Postcardial contraint

4

Unusual Causes of Cardiomyopathy
6

1. Hypertrophic Obstructive Cardiomyopathy (HCM)
-LV myocyte hypertrophy - genetic

2. AL Amyloid Cardiomyopathy
-LVH without other causes; very poor prognosis

3. Myocarditis
-Inflammatory disease from infectious or noninfectious process

4. Tachycardia-Induced Cardiomyopathy (TIC)
-Systolic or diastolic dysfunction due to rapid and/or irregular arrhythmia

5. Takotsubo Cardiomyopathy (TTC) (broken heart syndrome)
Transient apical ballooning syndrome post severe stress

6. Peripartum Cardiomyopathy (PPCM)
-Low EF heart failure in last month of pregnancy to 5 months post delivery

5

Cormorbid: Coexisting Conditions (up to 40% of HF patients have 5 or more chronic conditions)?
8

1. Anemia
2. Gout
3. Hypertension
4. Renal dysfunction
5. Lung disease; sleep-disordered breathing
6. Rapid or irregular dysrhythmias
7. Diabetes
8. Thyroid disorders

6

Describe the two types of remodeliing for CHF?

1. Heart becomes
more spherical
/dilated; LVEF less than 40%

2. Muscle becomes
thick
/hypertrophy; LVEF >50%

7

Clinical features of volume overload HF?
2

1. ↓ activity tolerance and
2. QOL similar to low EF patients

8

HFpEF almost always associated with what?

diastolic dysfunction

9

Diastolic dysfunction:
1. Ventricle stiffness?
2. Compliance?
3. Relaxation?
4. What levels will be down?


5. Diastolic dysfunction: dx?

1. ↑ LV wall stiffness and
2. ↓ compliance/
3. impaired relaxation;
4. ↓ CO

5. diagnosed and graded I-IV by ECHO evaluation

10

Pulmonary HTN almost always present; ____________ ≥25%?

RV dysfunction

11

3 stages of diastole

1. *Isovolemic (active) relaxation and rapid early filling (requires ATP)

2. *Diastasis (passive) filling; dictated by how compliant the ventricle is; there is slowed LV relaxation and rise in LV diastolic pressure (↓ transmitral flow); stage worsens with age

3. *Active filling during atrial contraction (kick); dependent on LV diastolic pressure

12

1. CHF: All phases of diastole are affected by what? 4

2. systolic flow > diastolic flow until what?

1.
-preload,
-afterload,
-HR and
-contractility

2. diastolic dysfunction due to stiff ventricle and ↓ atrial emptying

13

Grading of diastolic dysfunction
I-IV?

1. Grade I – impaired relaxation (suckers – normal DF and mild DD)

2. Grade II – pseudonormal, usually concomitant LAE, LVH and/or ↓LVEF

3. Grade III/IV – restrictive/constrictive

14

Whats the difference between Grade III and IV of diastolic dysfunction?

reversibility with medical therapy (Grade II, III/IV: pushers – impaired LV relaxation, ↑ LV stiffness, ↑ LA pressures)

15

1. Dilation (systolic failure) compensates for what?

2. Left ventricular systolic dysfunction (LVSD); impairment of what?

3. EF?

4. Stroke volume?
5. Cardiac output?

6. Describe backward failure and forward failure?

1. Dilation – compensate for
-poor cardiac output,
-ventricle dilates,
-becomes thinned and weakened

2. LV myocardial contraction

3. less than 40%

4. ↓ Stroke volume

5. ↓ cardiac output (normal range is 4-8L/min)

6.
-“Backward” failure due to ↓ contractility, fluid build-up, engorgement of systemic veins
-“Forward “ failure secondary to inadequate cardiac output resulting in ↓ perfusion to vital
organs

16

Characteristics of right HF?
3

1. Flattened septum
2. Compressed D-shape LV
3. Increased pericardial constraint

17

Describe the following in the left ventricle/systemic circulation HF and rigt ventricle/pulmonary circulation HF:
1. Size and Shape?

2. Pressure?

3. Contraction?

4. Coronary
Perfusion?

1.
LV- Conical, walls 8-11 mm thick
RV- Crescent shaped, walls 2-3 mm thick

2.
LV- High pressure
RV- Low pressure

3.
LV- Pulsatile contraction
RV- Bellows-like contraction

4.
LV- Occurs during diastole
RV- Continuous throughout
cardiac cycle

18

Arrhythmias
1. _________ heart susceptible to arrhythmias

2. Contribute to symptoms and ↑ risk of what?

3. AF: can lead to acute decompensated state, common cause of what?

4. What are the primary causes of syncope and sudden death? 2

5. Factors that contribute to arrhythmias? 5

1. Weakened

2. Sudden death

3. symptoms, e.g. fatigue, dyspnea, especially in preserved EF patients

4. Ventricular arrhythmias and bradycardia

5.
-cardiac chamber enlargement,
-conduction system and anatomical heart abnormalities,
-adaptations of SNS,
-adverse responses to medications,
-electrolyte abnormalities

19

Heart Failure Disease Progression: ACC/AHA Heart Failure Stages
4

A. High Risk
B. Asymptomatic LVD
C. Symptomatic HF
D. Refractory End-Stage HF

20

What are the treatments for the following categories:
A. High Risk? 6
B. Asymptomatic LVD? 2
C. Symptomatic HF? 5
D. Refractory End-Stage HF? 3

1. Treat
-hypertension and
-lipids,
-smoking cessation,
-exercise,
-limit alcohol,
-ACE inhibitors in appropriate populations

2.
-PLUS ACE inhibitors,
-beta blockers in appropriate populations

3.
-PLUS ACE inhibitors,
-beta blockers,
-diuretics,
-aldosterone receptor antagonists,
-dietary salt restriction

4.
-PLUS inotropes,
-transplant,
-VAD

21

New York Heart Association Functional Classification
Describe Class I-IV?

Class I: Minimal (Ordinary physical activity doesn’t cause undue symptoms; no limitations)

Class II: Mild (Ordinary activity causes symptoms; no strenuous exercise)

Class III: Moderate (Less than ordinary activity causes symptoms; activity limited to ADLs)

Class IV: Severe (Symptoms with any physical activity)

22

Signs/symptoms
of congestion (wet) HF?
7

1. Orthopnea/PND
2. JV distension
3. Ascites
4. Edema
5. Rales (rare in HF)
6. S3
7. Hepato-jugular reflex

23

Possible evidence of low perfusion (cold) HF?
6

1. Narrow pulse pressure
2. Sleepy/obtunded
3. Low serum sodium
4. Cool extremities
5. Hypotension with ACE inhibitor
6. Renal dysfunction (one cause)

24

What does congestion at rest indicate for type of HF?

Low perfusion at rest?

Warm and wet

Cold and dry

25

Lower stroke volume = what?

Congestion

26

Diagnostic Testing For HF

1. CXR
2. LAB (to include biomarkers, i.e., BNP)
3. ECG
4. ECHO, MUGA, MRI(infiltrative disease)
5. Risk stratification for CAD
noninvasive imaging:

27

Risk stratification for CAD
noninvasive imaging?2

Invasive?

1. nuclear stress test,
2. stress echo

1. Invasive imaging: cardiac cath (left & right)

28

Lab Testing Done Initially and as Indicated
11

1. Renal function and electrolytes; magnesium

2. BNP (in clinical uncertainty, to establish prognosis/disease severity)

3. Blood glucose; A1c

4. CBC without diff

5. TSH

6. Serum albumin

7. LFTs

8. Lipid panel

9. UA (proteinuria, red blood cells)

10. Uric acid

11. CXR in suspected or new onset HF

29

What BNP levels would lead you to think the following:
1. HF very improbable 2%?
2. HF probable 90%?
3. HF very Probable 95%?

1. BNP less than 100 pg/mL
2. BNP 100-500 pg/mL
3. BNP >500 pg/mL

30

1. Meds to Stabilize the dz? 2

2. Stabilize pt? 1

3. Treat residual symptoms? 1 (maybe!)

1. ACEI and B-Blocker

2. Diuretic

3. Dig

31

1. Diurectics are used for what?

2. Which have higher bio-availability can be effective in patients with poor absorption of oral medications or erratic diuretic effect, especially in right sided HF and refractory retention despite high doses of other loop diuretics. (ACCF/AHA 2013)? 2

3. What may be necessary to relieve congestion?

1. Diuretics: used in symptomatic patients to reduce fluid; no survival benefit.

2. Torsemide and bumetanide

3. IV diuretics

32

1. Add what when high-dose loop diuretic therapy not effective: *avoid chronic daily use, but use periodically (e.g., every other day or weekly) to optimize fluid management? 2

2. Monitor what closely in these meds? 2

3. Diuretic refractoriness may represent what? 3

4. Observe for side effects including what? 4

1. chlorthiadone or metolazone

2. *monitor volume status and electrolytes closely and routinely.

3.
-patient non-adherence,
-a direct effect of diuretic use on the kidney or
-progression of underlying cardiac dysfunction.

4.
-electrolyte abnormalities,
-symptomatic hypotension,
-renal dysfunction, or
-worsening renal function.

33

ACE Inhibitors: Proven to Reduce Morbidity & Mortality
1. MOA?
2. Proven to reduce what?
3. All pts with what should recieve ACEIs?

1. Inhibits conversion of angiotensin 1 to II (dilates blood vessels and ↓SVR and BP)

2. Reduces morbidity and mortality

3. All patients with LVEF less than 40% should receive an ACEI; ARBs used when intolerant of ACEI (Diovan, Atacand, losartan) for reasons other than hyperkalemia, renal insufficiency


Captopril, Enalapril, Lisinopril, Ramipril

34

ACEI/ARBs
1. Contraindications? 5

2. Surveillance? 4

1. Hx of intolerance;
2. contraindicated in pregnancy
3. Serum K+ > 5 mEq/L
4. Symptomatic hypotension: asymptomatic SBP less than 80 or symptomatic orthostatic BP when patient is euvolemic
5. Caution in patients with Cr >3.0 mg/dL


Surveillance
1. Monitor BP, renal function and K+ within 1 week of initiation of therapy and with med titration

2. Modify Rx if increase in Cr of 0.5 mg/dL; if BUN/Cr increase less than 50%, maintain dose; if increases by >100%, switch to HYDZ/ISOS

3. Assess volume status if patient develops renal insufficiency or hypotension

4. Physicians/patient may need to tolerate mild to moderate renal insufficiency to maintain

35

β Blockade in HF: First Line Therapy
Why?
5

1. ↑ LVEF
2. Global symptom improvement
3. ↓ hospitalizations and mortality
4. ↓sympathetic stimulation;
5. antiarrhythmic activity benefit

36

All pts with what should recieve a BB?
4

All patients with
1. stable HF with
2. LVEF less than 40% should receive a β blocker;
3. beneficial in those with or without DM2 or CAD;
4. OK to use in COPD, PAD

37

Managing Side Effects During β-Blocker Up-titration
How should we manage the following:
1. Vasodilator side effects (Coreg)? 3

2. Fluid retention? 2

3. Bradycardia/AV block? 2

1.
-Side effects usually temporary
-Separate dosing of β-blocker and ACEI
-If persistent, reduce vasodilators

2.
-Increase diuretic to restore baseline weight
-Delay up-titration until weight is at baseline

3.
-Check dig level
-If persistent, consider cardiac pacing

38

Digoxin can be beneficial in patients with HFrEF, for what; no survival benefit?

↓ hospitalization for HF

39

Hydralazine/Nitrates
1. Isosorbide dinitrate: MOA?
2. Hydralazine: MOA?

1. Isosorbide dinitrate:
Nitric oxide (NO) donor; large and small artery dilator, venous dilator

2. Hydralazine
Antioxidant (inhibits destruction of NO), arteriolar dilator, NO enhancer

40

1. ___________ has adverse effects on cardiac structure and function

2. Low dose what reduces mortality in moderate to severe heart failure patients (RALES mortality trial, 1999)?

1. Aldosterone

2. spironolactone/eplerenone (aldosterone antagonist)

41

Addition of aldosterone antagonist recommended in NYHA-FC II-IV and EF less than ___% who can be carefully monitored for what? 2

1. less than 35

2.
-renal function and
-normal K+ level

42

Patient Selection for Aldosterone Antagonists
3

1. Patient already on ACEI/ARB and βB therapy

2. K+ less than 5.0; Cr less than 2.5 in men and 2.0 in women

3. Aldosterone antagonist in absence of concomitant loop diuretic not recommended

43

New HF Drugs
1. Entresto (Sacubitril/valsartan) indications?

2. MOA? 2

3. Monitoring? 5

1. Chronic HFrEF, NYHA-FC II-IV; used with other HF meds in place of ACEI or ARB

2.
- sacubitril – inhibits breakdown of vasoactive peptides including BNP, bradykinin; results in natriuresis, diuresis
-Valsartan – ARB, antagonizes angiotensin II at ATI receptor, ↓ ATII dependent aldosterone release, ↑ vasodilation

3. Monitoring:
-BP,
-volume status,
-BUN/SCr,
-K+,
-may impact BNP

44

Corlanor (Ivabradine)
MOA?

Indications? 2

1. Reduces the slow diastolic depolarization phase

2. Indications:
-Reduce risk of hospitalization for worsening HFrEF
-SR with HR resting >70 bpm on maximum βB or contraindicated for βB use

45

Other Medical Treatments
for CHF?
7

1. Vasodilators (nesiritide, nitroglycerine, nipride)

2. Inotrope infusion: Dobutamine: stimulates β –adrenergic receptors; cannot be used with β blockers
Dopamine: norepi release; promotes diuresis on receptors in renal vasculature

3. Milrinone (Primacor) “inodilator”
Used in RV and LV failure as ↓ SVR and PVR; ↑ CO
Does not ↑ MVO2; can be used with β blockers
Do not use with obstructive aortic or pulmonic valvular disease

4. Anticoagulation

5. Dysrhythmics

6. Lipid management; omega 3

7. Screen for sleep disordered breathing

46

HFpEF Dysfunction: Treatment Strategies: Manage co-morbidities? 6

1. Control of BP (less than 130/80)
2. Rate control in AF
3. Alleviation of myocardial ischemia
4. Management of DM2
5. Screen for/treat sleep disordered breathing (SDB)
6. Na+ restriction

47

Helping the Right Side of the Heart Do Its Work: Treatment strategies – on the right side?
5

1. Oxygen therapy - ↑ RV function (SV); ↓RV afterload; ↑survival

2. Inhalers; CPAP if indicated

3. Digoxin – treatment for rhythm problems that occur in the right atria

4. Diuretics (some lower extremity swelling OK)

5. Treatment strategies for pulmonary HTN

48

Early Intervention Phase: Surgeries and Medical Devices
5

1. CABG; TAVR

2. Cardiac transplantation

3. CRT (bi-ventricular pacing)

4. ICD

5. Left ventricular assist devices (LVAD) - destination therapy (DT) or bridge to transplant (BTT) therapy) or bridge to decision (BD)

49

Indications for ICD?
3

1. LVEF less than 35% on GDMT
2. QRS >120 ms
3. NYFC III-IV

50

What is an LVAD?

When is it done?

1. type of mechanical circulatory support device sufficient to replace/assist pumping function of the LV;

2. rx for end stage HF

51

What do the following mean:
1. Sodium free or salt free?
2. Very low sodium?
3. Reduced sodium or less sodium?
4. Light in sodium?

1. Less than 5 mg/Na per serving

2. Less than 35 mg/Na per serving

3. less than 25% sodium per serving vs usual version

4. less than 50% less sodium than usual version

52

1. Limit fluids in hyponatremic patients (generally how much Na?)

2. Common recommendation: ____ cups/day?

1. 130 mg/dL or less

2. 6-8

53

What are some breathing patterns that may be representative of CHF?
2

1. SDB: Cheyne Stokes Breathing-Central Sleep Apnea (CSB-CSA)

2. Obstructive Sleep Apnea (OSA)

54

1. HF patients with BMI ______ kg/m2 – lower mortality, morbidity than normal range


2. What weight predicts a worse prognosis?

1. 30-35


2. Cachexia – predicts worse prognosis; wt loss >5% in 12 months or BMI less than 20 with muscle wasting, fatigue, anorexia, anemia, low albumin, ↑ inflammation markers

55

When should hospitalization be considered in CHF?
7

1. Worsened congestion even without dyspnea

2. Signs and symptoms of pulmonary or systemic congestion even in absence of weight gain

3. Major electrolyte disturbance

4. Associated comorbid conditions (pneumonia, PE, diabetic ketoacidosis)

5. Symptoms suggestive of transient ischemic accident or stroke

6. Repeated ICD firings

7. Previously undiagnosed HF with signs/symptoms of systemic or pulmonary congestion

56

Conventional Treatments of Acute CHF: How do the following help:
1. Diuretics?
2. Vasodilators?
3. Inotropes?

1. Reduce fluid volume
2. Decrease preload and afterload
3. Augment contractility

57

Top 3 Predictors of Mortality for
Patients Admitted With Acute CHF

1. BUN
2. SBP
3. SCr

58

A Guide to Reduce HF Readmissions: Factors that put patient at highest risk for readmission
7

1. Advanced age

2. Comorbidities: renal disease, DM2, COPD, HF severity, psychiatric dx (esp. depression), frailty

3. Low education/literacy level

4. Prior admissions for HF

5. Patient behaviors: lacking self-care skills, adherence issues, substance abuse

6. Not ready for discharge

7. Absence of family, friend, religious, social, and financial support, access to transportation