EXAM #2: CHF I & II

Question 1

What is the definition of heart failure?

Answer 1

Inability of the heart to pump sufficient blood to meet the metabolic needs of the body

Question 2

What is the definition of myocardial failure?

Answer 2

Defective myocardial contraction

Question 3

What is the definition of circulatory failure?

Answer 3

Abnormality of a component of the circulatory system leads to inadequate CO

Question 4

What is the neurohormonal model of heart failure?

Answer 4

A series of compensatory adaptations that normally preserve CO are activated:

1) SNS is activated while the PNS is suppressed
2) RAAS is activated

Question 5

What are the results of the changes seen in the neurohormonal model of HF?

Answer 5

1) Peripheral arterial constriction
2) Na+/ water retention
3) Activation of inflammatory mediators that induce cardiac remodeling

Question 6

What are the specific results of adrenergic stimulation in the neurohormonal model of HF?

Answer 6

1) Increased SNS tone
- Increased vascular tone
- Increase circulating NE
- Decreased myocardial NE
2) Beta-1 increased HR and contractility
3) Alpha-1 increased inotropism and peripheral vasoconstriction

Question 7

When is the RAAS activated in HF?

Answer 7

Later than the SNS

Question 8

What causes activation of the RAAS in the neurohormonal model of HF?

Answer 8

1) Decreased RBF
2) Decreased Na+ in the distal renal tubule
3) SNS increases renin release

Question 9

What are the consequences of sustained high levels of Angiotensin II?

Answer 9

1) Organ fibrosis i.e. heart and kidney

2) Enhanced NE release

Question 10

What is the difference between the hypertrophy of pressure and volume overload?

Answer 10

Pressure= parallel/ concentric

Volume= series/ eccentric

Question 11

What are the adverse consequences of LV remodeling in HF?

Answer 11

1) Hypertrophy
2) APD increases
3) Contractile/ regulatory proteins altered
4) Increased myocardial wall tension
5) MV regurgitation

Question 12

What is backward heart failure?

Answer 12

This is the sequelae that result from failure of the LV to fully eject its contents

Question 13

What is forward heart failure?

Answer 13

This describes the effects of HF i.e. reduced CO

• Decreased perfusion of vital organs
• Mental clouding
• Weakness
• Na+ and water retention

Question 14

What is the basic manifestation of left heart failure?

Answer 14

Central venous/ pulmonary congestion

Question 15

What is the basic manifestation of right heart failure?

Answer 15

Systemic congestion

Question 16

What is systolic heart failure?

Answer 16

Abnormal systolic function leading to high residual volume in the ventricle

*Leads to poor perfusion

Question 17

What is diastolic heart failure?

Answer 17

Abnormal diastolic filling

*Leads to pulmonary and systemic congestion

Question 18

What are the most common causes of HF?

Answer 18

1) Ischemia/ infarction
2) HTN
3) Arrhythmias
4) Infection/inflammatory disease
5) PE

Question 19

What are the major sx. associated with HF?

Answer 19

1) Progressive dyspnea
2) Diminished exercise capacity
3) Fatigue
4) Nocturia
5) CNS impairment

Question 20

Why do patients with HF get nocturia?

Answer 20

• Lying down= better renal perfusion

- Increased kidney function w/ increased perfusion

Question 21

What is Class I HF?

Answer 21

Asymptomatic i.e. no activity limitation

Question 22

What is Class II HF?

Answer 22

Slight activity limitation

*ORDINARY activity causes sx.

Question 23

What is Class III HF?

Answer 23

Marked activity limitation

*LESS than ordinary activity causes sx.

Question 24

What is Class IV HF?

Answer 24

Symptomatic at rest

“Conversational dyspnea”

Question 25

What causes pallor and cool extremities in HF?

Answer 25

SNS tone that causes cutaneous vasoconstriction

Question 26

What PE sign is indicative of LV failure?

Answer 26

Pulmonary rales

Question 27

What PE signs are indicative of RV failure?

Answer 27

1) Jugular venous distention (no valves) | 2) Kussmaul's sign

Question 28

What is Kussmaul's sign?

Answer 28

Increased jugular venous distention with inspiration

Question 29

What is hepatojugular reflux?

Answer 29

- RV failure= hepatomegaly - Hold hand over dome of the liver - After a minute, jugular venous pulses rise

Question 30

What findings are associated with HF on cardiac PE?

Answer 30

1) Apical impulse displaced left and down 2) S3 3) Pulsus alternans 4) Murmurs *Note that "cardiac cachexia" is a late sign of HF*

Question 31

List the lab findings associated with HF.

Answer 31

1) Hyponatremia from H20 excess | 2) Liver enzyme elevations

Question 32

What CXR findings are associated with HF?

Answer 32

1) Cardiomegaly 2) Pulmonary congestion/effusion 3) Kerley "B" lines

Question 33

What are Kerley B lines?

Answer 33

Congestion of the pulmonary lymphatics

Question 34

What are the leading causes of death from HF?

Answer 34

1) Pump failure | 2) Tachyarrhythmias

Question 35

What factors are associated with worse prognosis in HF?

Answer 35

1) Males 2) IHD 3) S3 4) Low pulse pressure 5) High functional class (III and IV) 6) Reduced exercise capacity

Question 36

What is high output HF?

Answer 36

Despite high CO, the metabolic demands of the body are NOT met

Question 37

What are the four goals of therapy in HF?

Answer 37

1) Relieve sx. 2) Prolong survival 3) Improve quality of life 4) Delay or prevent progression of myocardial dysfunction

Question 38

What is the therapy based on in HF?

Answer 38

Functional Class

Question 39

What immunizations do patients with HF need?

Answer 39

1) Pneumonia | 2) Influenza

Question 40

What are the two major factors that lead to a worsening of HF?

Answer 40

1) Dietary indiscretion | 2) Inappropriate reduction in HF meds

Question 41

What is Stage A HF?

Answer 41

High risk for HF, but NO disease yet E.g. HTN, IHD...etc.

Question 42

What is Stage B HF?

Answer 42

Structural heart disease evident, but no symptoms

Question 43

What is Stage C HF?

Answer 43

Structural disease with sx

Question 44

What is Stage D HF?

Answer 44

Refractory HF

Question 45

What are the general measures to treat HF?

Answer 45

1) Reduce risk factors 2) Education on lifestyle/diet modifications 3) Activity-modification

Question 46

What type of diuretic should be used for a patient with a high creatinine?

Answer 46

Loop *Thiazide is fine if creatinine is less than 2

Question 47

What are the anti-neurohormonal durgs?

Answer 47

- ACEIs - ARBs - Beta-blockers

Question 48

What are the "agents of choice" for HF?

Answer 48

ACEIs E.g. Lispinopril/ enalapril

Question 49

What is the hallmark ARB?

Answer 49

Losartan *Note that Candasartan is more efficacious in treating HF

Question 50

What type of beta-blockers are indicated for HF?

Answer 50

1) Beta-1 selective | 2) Beta-1 + alpha-1

Question 51

What are the two beta-blockers used to treat HF?

Answer 51

Metoprolol and Carvedilol* In US, this is the only one approved for HF (Coreg)

Question 52

What is the MOA of spironolactone?

Answer 52

Aldosterone antagonist

Question 53

What are the non-pharmacologic therapies for HF?

Answer 53

1) Intra-aortic balloon pump 2) LV assist device 3) Transplant