Congestive Heart Failure I - Exam 2

Question 1

What is heart failure? What is important to note? What are the s/s related to?

Answer 1

ACCF/AHA/HFSA define HF as a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood

is it a SYNDROME not a disease, need to figure out the underlying cause

s/s related to reduced CO and volume overload

Question 2

______ is MCC of HF

Answer 2

Ischemic heart disease

Question 3

**What are the risk factors for heart failure?

Answer 3

Hypertension

CVD

Diabetes

Obesity

Exposure to cardiotoxic agents

Genetic variants for cardiomyopathy

Family history of cardiomyopathy

Question 4

HF classifications are based on _____ and _____. Give the 3 options for classifications

Answer 4

timing and function

acute vs chronic
high output vs low output
reduced vs preserved EF

Question 5

What is the difference between acute and chronic heart failure?

Answer 5

acute: last few days to weeks

chronic: symptoms present for months

Question 6

Shortness of breath, paroxysmal nocturnal dyspnea (PND), orthopnea, and RUQ pain

acute or chronic s/s?

Answer 6

acute

Question 7

Fatigue, anorexia, abdominal distention and edema

acute or chronic s/s?

Answer 7

chronic

Question 8

What is the difference between high and low output heart failure?

Answer 8

High: heart is unable to meet the demands of the peripheral needs although it is working normally

think the body is the problem

Low: insufficient forward output

think heart is the problem

Question 9

What is the difference between reduced and preserved EF? What is it called if the pt falls in the middle?

Answer 9

reduced: EF ≤40% HFrEF

preserved: EF ≥ 50% HFpEF

borderline EF is betwwen 41-49% EF

Question 10

How do you determine treatment for a pt with borderline EF?

Answer 10

borderline is 41-49% and treatment is based on symptoms

Question 11

What are the 4 different classifications with regards to EF? Draw the chart from lecture

Answer 11

Question 12

What are the s/s of LEFT sided HF? What are the s/s of RIGHT sided HF?

Answer 12

First symptoms are from the LUNGS
-> Orthopnea, DOE

First symptoms are from the BODY ->
JVD, hepatic congestion, ascites, anorexia, LE edema

Question 13

What is the MC cause of RIGHT sided HF?

Answer 13

Most common cause is left sided HF

Question 14

**________ uses functional limitation classes to determine severity by assessing ______. Can it change?

Answer 14

New York Heart Association (NYHA)

effort needed to elicit symptoms in a HF patient

classification can change at any time

Question 15

**What are the 4 different NYHA classification of severity?

Answer 15

Question 16

_____ describes the evolution of HF. Helps to define the appropriate ______ and determine ______. Can it change?

Answer 16

American College of Cardiology Foundation (ACCF) // American Heart Association (AHA)

therapeutic approach and determine prognosis

CANNOT CHANGE

Question 17

** What are the 4 different classifications for HF as defined by the ACC/AHA?

Answer 17

A and B have no symptoms

C and D have symptoms

Question 18

What is afterload? What is preload?

Answer 18

afterload: the amount of pressure the heart needs to exert to pump blood out of the ventricles during a heartbeat

preload: the force that stretches the heart’s muscle before it contracts and a factor in bearings that improves running accuracy:

Question 19

What are the neurohumoral adaptations for heart failure?

Answer 19

Maintain systemic pressure by vasoconstriction

Restores cardiac output by increasing myocardial contractility and heart rate

Question 20

What are the 3 major determinants of the LV stroke volume?

Answer 20

Preload – venous return and end-diastolic volume

Contractility – the force generated at any given end-diastolic volume

Afterload – aortic impedance, vascular resistance, wall stress

Question 21

The pressure-volume relationship with systolic dysfunction leads to a reduction in ______. Which leads to a reduction in _____ and _____. What does this promote?

Answer 21

reduction in myocardial contractility

reduction in SV and CO

Promotes salt and water retention, leading to expansion of blood volume, therefore raising end-diastolic pressure and volume

Question 22

What type of HF?

Answer 22

systolic HF

Question 23

What type of HF?

Answer 23

diastolic HF

Question 24

What type of HF?

Answer 24

none! it is normal

Question 25

_____ is one of the first responses to low cardiac output. What is the result? What happens to contractility and HR?

Answer 25

Activation of the SNS Results in increased release and decreased reuptake of norepinephrine Increases ventricular contractility and heart rate

Question 26

activation of the SNS also leads to ______ and _______ which increases ______. In the kidney is leads to _________ and worsening _______

Answer 26

vasoconstriction and enhanced venous tone increases peload Also stimulates proximal tubular sodium reabsorption, contributing to sodium retention in HF → worsening fluid overload

Question 27

What is the RAAS system stimulated by? What happens next?

Answer 27

Stimulated by decreased glomerular filtration and increased beta-1 adrenergic activity increases sodium reabsorption and induces vasoconstriction

Question 28

RAAS can act directly on _____ to promote pathologic remodeling via hypertrophy, apoptosis, necrosis leading to an increase in ________

Answer 28

myocytes increase in AT2 receptors

Question 29

Low cardiac output leads to activation of ______ and ______ which release _____ and stimulate _______

Answer 29

activation of carotid sinus and aortic arch baroreceptors → release of ADH and stimulation of thirst

Question 30

ADH release leads to an increase in _________ and promotes _____ leading to _____

Answer 30

]increase in systemic vascular resistance Promotes water retention → fluid overload!

Question 31

ANP is released from the _____ in response to ______. When does it rise in HF?

Answer 31

atria in response to volume expansion ANP rises early in HF

Question 32

BNP is released from the _______ in response to ________. When it is present? What does it reduce?

Answer 32

ventricles high ventricular filling pressure BNP is present in chronic and advanced HF Reduces systemic vascular resistance and central venous pressure, while increasing natriuresis, which reduces afterload

Question 33

What are the 2 natriuretic peptides? Which one has a longer half-life and is the preferred test?

Answer 33

ANP and BNP BNP is preferred and is used to guide therapy

Question 34

Consequences of Compensation include elevation in diastolic pressures that are then transmitted to the _____ and ______ and _____ venous circulation

Answer 34

atria pulmonary systemic venous circulations

Question 35

as a consequence of compensation, the increased afterload can _____ cardiac function and _________.

Answer 35

depress cardiac function enhance detorioration

Question 36

_______ and _______can worsen coronary ischemia. ______ and ______ promote myocyte loss, resulting in cardiac remodeling

Answer 36

Catecholamine-stimulated contractility increased heart rate Catecholamines angiotensin II

Question 37

What are the cardinal symptoms of heart failure?

Answer 37

Dyspnea Fatigue Fluid retention: lower extremity edema

Question 38

What is one way to tell if the edema present is due to HF?

Answer 38

Elevated jugular venous pressure will be present if edema is due to HF

Question 39

What is the proper way to assess LE edema?

Answer 39

ALWAYS start at the feet, then work your way proximally to see how far the edema extends need to check sacral and scrotal areas and need to check over a bone

Question 40

**What is the edema rating scale? Specifically need to know time frame

Answer 40

Question 41

Pulsus alternans is pathognomonic for _____

Answer 41

severe LV failure

Question 42

What does a laterally displaced apical impulse indicate? May feel _____ with pulmonary HTN

Answer 42

indicates LV enlargement parasternal lift of RV

Question 43

______ is associated with systolic HF ______ more common to find in diastolic HF

Answer 43

S3 gallop S4 gallop

Question 44

What is the goal of diagnostic studies in HF?

Answer 44

is not only to confirm that symptoms are due to HF but then to **determine the CAUSE** of the HF

Question 45

What are tests you want to order when working a pt up for HF? What are you looking for in each?

Answer 45

EKG -> arrhythmia that might be cause CXR -> pulm edema or cardiomegaly

Question 46

What are Kerley B lines? Where are they most commonly seen?

Answer 46

(thickened interlobular septa) are thin, 1-2 cm lines, virtually always at the lungs BASE and at the lung PERIPHERY lying perpendicular to the pleural surface to which they contact

Question 47

What lab studies do you want to order in CHF?

Answer 47

BNP Tropinin I and T Magnesium (plus all the normal ones)

Question 48

_____ is the best lab for HF evaluation. Why is it really good? What is it used for?

Answer 48

BNP and NT-proBNP really good at excluding HF because it has a very high negative predictive value so if BNP is normal, swelling is from something else!! Useful in supporting diagnosis and establishing severity

Question 49

What are the normal ranges for BNP? NT-proBNP? What is the difference between the two?

Answer 49

Normal value for BNP is < 100 pg/mL (NT-proBNP <300) Only difference is their half life - NT-proBNP is longer

Question 50

a BNP of _____ and NT proBNP of _____ = Low probability of HF

Answer 50

Question 51

a BNP of _____ and NT proBNP of _____ = intermediate probability of HF

Answer 51

Question 52

a BNP of _____ and NT proBNP of _____ = high probability of HF

Answer 52

Question 53

What are the limitations of BNP and NT-proBNP?

Answer 53

Pt may present with more than one cause for dyspnea, ex. PNA and HF Pts with severe chronic HF may have persistently elevated levels of BNP

Question 54

There are ____ causes of elevated BNP. Name a few

Answer 54

MANY!! ACS, LVH, valvular disease, Afib, S/P Cardioversion Increased age, Severe anemia, Renal failure PNA, Pulm HTN Sepsis, Severe burns

Question 55

What does a significant elevation of troponin I or T indicate?

Answer 55

Significant elevations and upward trend typically indicates an ischemic source for the HF but can be elevated without an ischemic cause

Question 56

What are 2 non-ischemic related causes of elevated troponin?

Answer 56

ongoing myocardial injury or necrosis associated with increased mortality rate

Question 57

All HF pts need a ________. Why?

Answer 57

Echocardiography!!! ECHO!! looks at ventricular size and function and can detect regional wall motion abnormalities

Question 58

_____ is especially helpful in detecting _______. If that is normal, ____ needs to be considered

Answer 58

Stress testing CAD coronary angiography

Question 59

**______ is the gold standard for diagnosing heart failure. What is being measured? **What number does it have to be to confirm diagnosis?

Answer 59

Right heart catheterization identification of an elevated pulmonary capillary wedge pressure (PCWP) at rest or exercise on an invasive hemodynamic exercise test in a patient with symptoms of HF **If a patient has symptoms consistent with HF and PCWP ≥15 mmHg at rest or ≥25 mmHg during exercise, a diagnosis of HF is confirmed, regardless of LVEF

Question 60

What is the Pulmonary capillary wedge pressure (PCPW)?

Answer 60

is a measurement of the pressure in the pulmonary arterial system that estimates the pressure in the left atrium of the heart

Question 61

What are the 5 classes of recommendations with regards to HF treatment options?

Answer 61