Congestive Heart Failure

Question 1

What is CHF?

Answer 1

Inability of the heart to pump enough blood to provide the O2 needed by the body, LV is not efficently pumping to meet metabolic needs

Question 2

What is stroke volume driven by?

Answer 2

preload, afterload, and contractility

Question 3

Ejection

Answer 3

amount of blood pumped out of heart during each beat

Question 4

Fraction

Answer 4

the volume of blood expelled vs remaining volume after pumping

Question 5

Normal EF

Answer 5

55-75%

Question 6

Systolic heart failure is caused by

Answer 6

decrease in ventricular EF, impaired contractility, increased afterload, aortic stenosis, cardiomyopathy, mechanical abnormalities

Question 7

Diastolic heart failure is caused by

Answer 7

decrease in ventricular relaxation during diastole, chronic hypertension, pulmonary hypertension

Question 8

Mixed heart failure pts will have

Answer 8

low EF, high pulmonary pressures, dilated cardiomyopathy

Question 9

Drugs that cause HF

Answer 9

antiarrhythmics, CCBs, chemotherapy, Na and H2O retention by steroids, NSAIDs, some diabetic drugs

Question 10

Cardiovascular symptoms

Answer 10

tachycardia, cardiomegaly, dysrhythmias, fatigue, exercise intolerance

Question 11

Repiratory symptoms

Answer 11

SOB, orthopnea, pulmonary edema, cyanosis

Question 12

GI symptoms

Answer 12

epigastric fullness, anorexia, ascites, cardiac cachexia, hepatomegaly

Question 13

Renal symptoms

Answer 13

peripheral edema, hypernatremia, hypomagnesemia, decreased urine output, hypokalemia

Question 14

Class I

Answer 14

no limitation of activity, activity does not induce fatigue, dyspnea, angina

Question 15

Class II

Answer 15

slight limitation of activity, no symptoms at rest, ordinary activity results in fatigue, angina, dyspnea

Question 16

Class III

Answer 16

Marked limition of activity, comfortable at rest, activity causes angina, dyspnea, fatigue

Question 17

Class IV

Answer 17

inability to carry on any physical activity w/o discomfort, cardiac insufficiency or angina present at rest, discomfort increased with activity

Question 18

Stage A

Answer 18

Patients at high risk of developing dysfunction because of existing conditions

Question 19

Stage B

Answer 19

Patients develop structural heart disease but do not show symptoms

Question 20

Stage C

Answer 20

patients have current or prior symptoms associated with underlying heart disease

Question 21

Stage D

Answer 21

advanced structural heart disease and marked symptoms of HF at rest despite intervention, end stage disease

Question 22

Goals of therapy

Answer 22

prevent disease progression, reduce morbidity/mortality, reduce hospitalizations

Question 23

Non-pharmacological approaches

Answer 23

remove precipitating causes, exercise if able, Na restriction, fluid restriction, weight control

Question 24

Focus of medical treatment

Answer 24

inhibit compensatory processes, ACE inhibitors, BB, aldosterone antagonists, prevent cardiac remodeling, vasodilators, diuretics, inotropic agents, Symptom control!

Question 25

Most common treatment

Answer 25

Furosemide, bumetanide, LOOP diuretic, end stage will include thiazide too

Question 26

Diuretic key points (4)

Answer 26

daily dose adjustment based on weight, keeps pts out of hospitals, increase dose with decrease kidney, K sparing used for activity of aldosterone

Question 27

ACE-I key points (5)

Answer 27

used to prevent cardiac remodeling, use with caution with K sparing, sudden fluid changes can drop BP, NO pregnant pt, renal artery stenosis or angioedema, can cause hyperkalemia or hypotension

Question 28

ARB key points (2)

Answer 28

usually used as alternative to ACE-I when not tolerated, used for SE

Question 29

Hydralazine/isosorbide dinitrate combo

Answer 29

acts on artery and vein, reduces pre and afterload, hard to tolerate, limits use, African american pt use as adjunct therapy

Question 30

BB key points (3)

Answer 30

improve outcome because effect NE, EPI, and angiotensin II, Metroprolol DOC, use low dose

Question 31

Spironolactone (4)

Answer 31

only use 25 mg, only benefit for NYHA III or IV, also benefit post-MI, watch K+

Question 32

Digoxin (6)

Answer 32

no benefit on outcome, mild positive inotropic, Never discontinue once start, decrease node conduction, only HF and Afib, TDM required

Question 33

Digoxin toxicity presents as

Answer 33

anorexia, N/V/D, abdominal pain, visual disturbances, fatigue, confusion, arrhythmias, AV block, tachycardia

Question 34

Acute decompensated heart failure

Answer 34

CV function becomes so impaired it requires hospital admission for aggressive treatment and monitoring

Question 35

Cardiogenic shock

Answer 35

profound hypotension and low CO

Question 36

What causes AHF

Answer 36

uncontrolled HTN, poor compliance, Afib, environmental factors, inadequate therapy, pulmonary infection, arrhythmias, CCB, ibuprofen, naproxen

Question 37

Diagnosing AHF

Answer 37

BNP, ECHO, BP, pulmonary artery catheters, central venous pressure (2-6), MAP (80-100)

Question 38

Warm and wet

Answer 38

pt has normal cardiac index, good bp, high PCWP, fluid in lungs or other lung symptoms

Question 39

Cool and dry

Answer 39

poor perfusion, low crdiac index, PCWP normal, no lung symptoms

Question 40

Cool and wet

Answer 40

worst case scenario, poor perfusion, lung symptoms, requires ICU admission

Question 41

Loop diuretic treatment for AHF

Answer 41

use with caution, too rapid diuresis can decrease CO, usually give furosemide or bumetanide IV, chronic therapy can lead to resistance

Question 42

Vasodilators treatment for AHF

Answer 42

Nitroprusside reduces preload and SVR, but decrease BP and reflex tachy; Nitroglycerin most beneficial for pt with MI; Nesiritide used as 2nd or 3rd after nitro and diuretics, $$$$; enalaprilat only for stable pt; Hydralazine limited because of variances with pts

Question 43

Dopamine for AHF

Answer 43

primarily a B and a agonist to increase CO, dose dependent, too low= inc renal blood flow and urine output, intermediate= inc HR, CO, high= vasoconstriction and inc BP; DOC for low BP/HF, no use for MI, vesicant

Question 44

Dobutamine for AHF

Answer 44

B1 agonist w/ some B2 no a, inc CO, no effect on BP, short T1/2, give continuous infusion, first line for AHF

Question 45

Milrinone for AHF

Answer 45

PDE-3 inhibitor, inhibits cGMP breakdown, inc contractility, artery and vein vasodilation, dec SVR, no change BP, reserved for pt who don't respond to other meds, T1/2=2-4 hours; continuous infusion, gets complicated

Question 46

Goal for warm and wet/ treatment

Answer 46

reduce PCWP, diuretics and/or vasodilators, always IV because don't have time to wait

Question 47

Goal for cool and dry/ treatment

Answer 47

inc CO, fluid and inotropic agents, start with fluids, once hydrated start inotrope, normotensive- dobutamine or milrinone; hypotensive- dopamine; if not at goal CO- vasodilator (IV)

Question 48

Goal for cool and wet/ Treatment

Answer 48

reduce preload to reduce pulm congestion, incr CO to improve perfusion