Heart failure Flashcards
1
Q
what is heart failure?
A
complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood
2
Q
heart failure is characterized by s/s of …… and ……
A
reduced CO; volume overload
3
Q
MC cause of death for HF
A
- progressive HF
- sudden cardiac death
4
Q
risk factors for HF
A
- CAD/atherosclerosis
- DM
- HTN
- Obesity
5
Q
what is considered acute HF
A
symptoms began within last few days to weeks
6
Q
s/s of acute HF
A
- SOB
- paroxysmal nocturnal dyspnea
- orthopnea
- RUQ pain
7
Q
what is considered chronic HF
A
symptoms present for months
8
Q
s/s of chronic HF
A
- fatigue
- anorexia
- abdominal distention
- pitting edema
9
Q
High vs Low Output HF
A
- high: heart is unable to meet the demands of the peripheral needs
- low: insufficient forward output
10
Q
Causes of high output heart failure
A
- thyrotoxicosis
- severe anemia
- sepsis
11
Q
Causes of Low Output Heart Failure
A
- reduced EF
- hypovolemia
12
Q
HFrEF vs HFpEF
A
- HFrEF: reduced EF (systolic) (EF below 40)
- HFpEF: preserved EF (diastolic) (EF over 50)
13
Q
patients with EF 41-49 can appear similarly to patients with ….
A
HFpEF
14
Q
MC side of HF
A
left
15
Q
s/s related to LHF
A
- DOE
- PND
- orthopnea
- fatigue
16
Q
MCC of RHF
A
LHF
17
Q
causes of RHF
A
- COPD
- PE
- Pulm HTN
- valvular disorders
18
Q
s/s associated with RHF
A
- JVD
- hepatic congestion
- ascites
- anorexia
- lower extremity edema
19
Q
NYHA classification of HF
A
- Class 1: no limitations
- Class 2: slight limitations of physical activity
- Class 3: Marked limitation of physical activity
- Class 4: inability to do physical activity without discomfort and sx at rest
20
Q
ACC/AHA stages of HF classify based on the _____ of HF
A
evolution
21
Q
ACC/AHA stages of HF
A
- A: at risk for HF but no structural heart disease or symptoms of HF
- B: structural heart disease without s/s of HF
- C: structural heart disease with prior or current symptoms of HF
- D: refractory HF requiring specialized interventions
22
Q
neurohormonal adaptations of HF
A
compensatory mechanisms used in attempt to adjust for a reduction in cardiac output
23
Q
compensatory mechanisms
A
- maintain systemic pressure by vasoconstriction
- restored cardiac output by increasing myocardial contractility and HR
24
Q
drugs used to treat the compensatory mechanisms of HF such as:
* increased sympathetic activity
* vasoconstriction
* RAAS system
A
- increased sympathetic activity: beta blockers
- vasoconstriction: vasodilators
- RAAS: ACEI/ARBS/aldosterone antagonists
25
... is one of the first responses to low CO
activation of the SNS
26
activation of the SNS results in ... and ... of NE
* increased release
* decreased uptake
27
effects of activated SNS
* increased ventricular contractility
* increased HR
* vasoconstriction
* enhanced venous tone
28
SNS stimulated proximal tubular .... rebsorption
Na
29
SNS results in an increase of ..... concentration
plasma NE
30
RAAS system is stimulated by ....
* decreased glomerular filtration
* increased beta-1- adrenergic activity
31
actions of RAAS
* increases Na reabsorption
* induces systemic and renal vasoconstriction
32
RAAS and apoptosis
RAAS can be detrimental because as HF progresses, myocytes develop more AT2 receptors, which results in cell apoptosis
33
low CO and ADH
activation of baroreceptors cause release of ADH and thirst stimulation
34
ADH promotes ......
water retention
35
the degree of ..... with ADH release parallels the severity of HF
hyponatremia
36
ANP
Released from atria in response to increased volume
37
ANP rises in ....
early HF
38
BNP
released from the ventricles in response to high ventricular filling pressures
39
BNP is present in .....
chronic or advanced HF
40
why is BNP the preferred test?
longer half life
41
maladaptive consequences of HF
elevation in diastolic pressures are transmitted to the venous circulations which leads to pulmonary vascular congestion and peripheral edema
42
PE of pulmonary vascular congestion
rales/crackles in lung bases
43
increase in ..... can depress cardiac function and enhance deterioration
peripheral resistance (afterload)
44
..... and ...... can worsen coronary ischemia
* catecholamine-stimulated contractility
* increased HR
45
.... and ..... promote myocyte loss, resulting in cardiac remodeling
* catecholamines
* angiotensin II
46
3 major determinants of the LV stroke volume
* preload: venous return and end diastolic volume
* contractility: force generated at any given end-diastolic volume
* afterload: vascular resistance
47
with systolic dysfunction, there is a reduction in .....
myocardial contractility
48
presenting s/s of HF
symptoms due to low CO and fluid accumulation
* dyspnea
* fatigue
* fluid retention
49
vital signs of HF
* resting sinus tachy
* narrow pulse pressure
* diaphoresis
* diminished peripheral pulses
50
volume assessment of HF
* pulmonary congestion
* peripheral edema
* elevated jugular venous pressure
51
cardio PE findings for HF
* pulsus alternans
* precordial palpitation
* heart sounds
52
..... is pathognomonic of severe LV failure
pulsus alternans
53
precordial palpatation
laterally displaces apical impulse usually indicated LV enlargement
54
heart sounds of HF
* S3 in systolic HF
* S4 in diastolic HF
55
initial testing for HF
* EKG
* chest xray
56
EKG for HF
may show an arrhythmia that is the cause or result of HF
57
CXR of HF
* pulmonary congestion
* cardiomegaly
* kerley b lines
* pleural effusions
58
best test for HF evaluation
BNP and NT-proBNP
59
BNP is used to ...... as a cause of symptoms because it has a .......
exclude HF;very high negative predictive value
60
normal BNP
under 100
61
normal NT-proBNP
under 300
62
NP-proBNP and BNP both arise from ...
proBNP
63
Limitations to BNP/ NT-proBNP
* may present with more than one cause of their sx
* patients with severe chronic HF may have persistently elevated elevated BNP
* other causes of BNP elevation
64
significant elevation in troponin I or T indicates...
ischemic source of HF
65
echo of HF provides...
* info on ventricular size and fxn
* detect regional wall motion abnormalities
66
t/f denying CP is enough reason to exclude CAD
false
67
when is stress testing useful in the diagnosis of HF?
when you're trying to rule out CAD
68
even if stress test is normal, if no other cause can be determined...
the patient should undergo coronary angiography
69
treatment of HF is aimed at ...
* relieving symptoms
* improving functional status
* preventing death and hospitalizations
70
BNP greater than ..... is suggestive of HF
100
71
HFrEF
EF < 40%
72
HFpEF
EF > 50%
73
treatment of HF is aimed at ...
* relieving symptoms
* improving functional status
* preventing death and hospitalizations
74
which type of HF has the most evidence for clinical benefits?
HFrEF
75
treatment of HFpEF is focused on ...
* improving symptoms
* managing comorbidities
76
classes of intervention recommendations for HF treatment
* class 1: evidence that it is effective and is recommended
* class 2a: should be considered
* class 2b: may be considered
* class 3: is not recommended
77
management of RHF is the same as .....
HFpEF
78
t/f there is no clear evidence that pharm, diet, or other therapies can reduce the mortality risk of HFpEF patients
true
79
HFpEF patients should follow up every .... months
1-6
80
key components of HFpEF management
* ongoing monitoring
* chronic disease management
* lifestyle modifications
81
rule of 2s for HFpEF patients
* if they gain 2 lbs in 1 day, they need to take an extra diuretic
* no more than 2L of fluids every day
* no more than 2g of Na per day
82
pharmacological treatment of choice for HFpEF
diuretics
83
added therapies for HFpEF
* SGLT2i (2a)
* ARNI (2b)
* MRA (2b)
* ARB (2b)
84
do patients need to be on diuretics if they are not symptomatic?
no
85
diuretic of choice for mild fluid retention in HFpEF
thiazides
86
diuretic of choice for severe fluid retention in HFpEF
loop
87
what must be monitored when patients are on loop diuretics?
* renal fxn
* K+
88
combination of loop and thiazide
it is possible to give the patient both if they continue to have symptoms, but be cautious of massive diuresis and electrolyte abnormalities
89
......should be initiated when patients are on loop diuretics
K replacement
90
monitoring for diuretic therapy
* assess weight daily
* BMP one week after initiation or dose change
91
if the patient gains 2 lbs in 1 day or 5 lbs in 1 week, ...
take an extra diuretic
92
can you take SGLT2i for HF if you dont have DM?
yes, it has a diuresis effect
93
examples of SGLT2i
* jardiance
* farxiga
* invokana
94
therapy dosing for HFrEF
low doses titrated to target doses based on tolerability
95
class 1 options for HFrEF
* diuretics
* ARNI (NYHA class 2 and 3)
* ACE/ARB (NYHA class 2-4)
* BB
* MRA
* SGLT2
96
ARNI
Sacubitril/Valsartan (Entresto)
97
loop diuretics provide symptoms relieve due to ...
fluid overload
98
when are ARBs given in HFrEF?
* if ACEs cannot be tolerated (class 1)
* if patient is already on ARB at time of dx (class 2a)
* add to ACE if aldosterone antagonist is CI (class 2b)
99
use BB cautiously in what populations?
* bradycardia
* acute HF
* first degree Av block
* hx of asthma
* hypotension
100
why can you give BB in chronic HF but not in acute?
in the acute phase, the heart is beating extra hard to compensate. if you give a BB in acute phase, it will slow down the heart, compensation will not happen, and the patient will die
101
aldosterone antagonists reduce .... in HFrEF
cardiac remodeling
102
aldosterone antagonists CI
* elevated K
* GFR under 30
103
MOA of entresto
inhibits neprilysin, which limits the breakdown of BNP and allows it to stay around longer
104
t/f entresto can be used along with an ACE/ARB
false. it is used in place of the ACE/ARB
105
process of switching someone from ACEi to entresto?
patient will need a 36 hour washout period of ACEI prior to starting entresto
106
CI of entresto
hx of angioedema with ACEi
107
recommendation class for hydralazine
* class 1 in black patients
* class 2a in non-black patients
108
MOA of corlanor
inhibits funny channel in the sinus node which slows down the sinus rate
109
when can corlanor be used?
* stable
* HR over 70
* in sinus rhythm
* on max dose of BB or BB are CI
110
digoxin has greater ...... effects than .....
negative chronotropic; ionotropic
111
which CBB are harmful in HFrEF and should be avoided?
diltiazem and verapamil
112
preferred agents in treating arrhythmias in HFrEF
* amiodarone
* dofetilide
113
what drugs should be avoided in HFrEF?
NSAIDs
114
cardiac rehab is recommended to which NYHA classes?
* 2 and 3
* 1 does not have sx so they don't need cardiac rehab
* 4 has symptoms even at rest, so the patient wouldn't be able to do it
115
functions of cardiac rehab
* increases exercise capacity
* improves quality of life
* reduces hospitalizations
* improves survival
116
cardiac resynchronization therapy (CRT)
a treatment for heart failure in which a device paces both ventricles to synchronize contractions
117
what would you see on an EKG for ventricular dessynchrony?
wide QRS
118
functions of CRT therapy
* improve exercise tolerance
* improve NYHA functional class
* reduce morbidity and mortality
119
recommendations for LVEF for CRT
less than 35%
120
recommended NYHA classed for CRT
3 and 4
121
t/f ventricular arrythmias are common in patients with HF and cardiomyopathy
true
122
preventing sudden cardiac arrest
implantable defibrillator
123
primary prevention of SCA
for patients who have not suffered SCA before
124
indications for primary prevention implantable defibrillator in ischemic CM
* EF is less than 35
* NYHA class 2 or 3
* over 40 days post MI
125
indications for primary prevention implantable defibrillator in nonischemic CM
* EF is less than 35
* NYHA class 2 or 3
* more than 90 days post diagnosis
* expected survival over 1 year
126
what do we give to the patient in the 90 days prior to the implantable defibrillator in nonischemic CM?
external defibrillator (life vest)
127
indications for secondary prevention of SCA
implantable defibrillator in patients who have survived an episode of SCA
128
indications for defibrillator in unexplained syncope
* patients with LVEF under 30
* unexplained syncope
129
acute decompensated HF
common and potentially fatal cause of acute respiratory distress
130
causes of acute decompensation
* medication noncompliance
* MI
* tachyarrhythmia
* excessive salt intake
131
acute decompensated HF is characterized by...
* acute dyspnea
* rapid accumulation of fluid
132
acute decompensated HF requires rapid .... and ...
assessment
; stabilization
133
presentation of acute decompensated HF
* acute pulmonary edema
* dyspnea
* pink, frothy sputum
* diaphoresis
* cyanosis
* inspiratory rales on auscultation
134
why do you see pink frothy sputum in acute decompensated HF?
due to vessel damage in their lungs
135
management of acute decompensated HF
* oxygen (if needed)
* IV diuretics
* vasodilators
136
goal O2 sat for acute decompensated HF
94%
137
method of oxygen supplementation in acute decompensated HF
* nonrebreather mask with high flow o2
* noninvasive positive pressure ventilation (CPAP or BPAP)
138
if NPPV fails or cannot be tolerated, the patient should be .....
intubated
139
what type of diuretics are first line in acute decompensated HF?
loop
140
cardiorenal syndrome in acute decompensated HF
AKI due to elevated venous pressure and reduced CO, but may improve with diuresis
141
t/f if loops do not diurese the patients enough, you can add on a second diuretic
true
142
vasodilator therapy is recommended for patients without ..... and .....
hypotension; severe symptomatic fluid overload
143
144
MC used vasodilator in acute decompensated HF
NTG
145
administration of vasodilators in acute decompensated HF
continuous IV infusion
146
nitropress has both ..... and .... effects
venous ; arteriolar
147
nitropress is used when ...... is needed
afterload reduction
148
risks of nitropress
CN toxicity
149
why may vasodilators cause reflex tachycardia?
because the heart is pumping harder and faster to get more blood out
150
...... is highly effective in pulmonary edema
morphine
151
how does morphine lead to CO2 retention?
reducing respiratory rate
152
natrecor
recombinant BNP
153
when can ACE/ARBs be initiated in acute decompensated HF?
after they are stable
154
patients that are already on ACE/ARBs can continue to take them during acute decompensated HF, unless that patient has...
* hypotension
* AKI
* hyperkalemia
155
if patient are on chronic BB therapy when they have acute decompensated HF...
hold therapy
156
when can you initiate BB therapy in acute decompensated HF?
once patient is stable
157
ionotropic agents, such as milrinone and dobutamine, are indicated for patients with...
severe LV systolic dysfunction to maintain systemic perfusion and preserve end-organ performance
158
venous thromboembolism prophylaxis
* anticoagulants
* wraps around legs that inflate and deflate to break up clots if anticoagulants are CI
159
ultrafiltration
process using peripheral venous access to remove excess fluid without affecting BP and electrolytes too much
160
mechanical cardiac assistance is considered for patients in...
cardiogenic shock
161
indications for mechanical cardiac assistance
* cardiac index less than 2
* systolic pressure less than 90
* pulmonary capillary wedge pressure above 18
162
2 types of mechanical cardiac assistance
* intraaortic balloon counterpulsation
* LVAD
163
if the patient has a really high pulmonary wedge pressure, that tells us that they probably also have a really high pressure in the .....
left atria
164
mechanical cardiac assistance is a bridge to ....
transplant
165
presentation of cardiogenic shock
* cool, clammy skin
* hypotensive
* tachicardia
166
wedge pressure in cardiogenic shock
over 15
167
cardiac index of cardiogenic shock
less than 2.2
168
cardiac index
cardiac output per minute per square meter of body surface area
169
cardiac index provides info on ...
LV function
170
normal CI range
2.6-4.2
171
principle feature of shock
hypotension with evidence of end-organ hypoperfusion
172
diagnostics for cardiogenic shock
* EKG for underlying cause
* echo
* CXR
173
treatment of cardiogenic shock
* oxygen supplementation
* vasopressors/ionotropes
174
if the patient has a suspected MI that has caused circulatory shock, how should that be managed?
* treat the MI
* ASA, heparin, urgent cath, revascularize
175
a swan ganz catheter provides an indirect estimate of .....
Left Atrial pressure
176
normal pulmonary capillary wedge pressure
8-10mmHg
177
pulmonary capillary wedge pressure in cardiogenic shock
elevated
178
actions of ionotropic/vasopressor agents
increase contractility of the heart, heart rate, and peripheral vascular tone
179
examples of ionotropic/vasopressor agents
* dopamine
* dobutamine
* norepinephrine
180
doses of dopamine and their effects
* low dose: predominately dilated renal arterioles
* intermediate dose: beta 1 receptor stimulation and enhances myocardial contractility
* higher doses: alpha receptor stimulation in addition to continues beta1 stimulation and tachycardia
181
dobutamine effects in cardiogenic shock
strong B1 and B2 effects resulting in increased CO, BP, and HR
182
difference in dobutamine compared to dopamine
* does not cause renal vasodilation
* much stronger B2 effect
183
NE effects in cardiogenic shock
* strong b1 and alpha adrenergic effects and moderate B2 effects
* increases CO and HR
184
how should ionotropes/vasopressors be administered?
central line. can cause necrosis if administered peripherally
185
circulatory support devices in cardiogenic shock
intra-aortic balloon pump and LVAD
