Heart failure Flashcards by Maya Birchler

What side of heart failure has these symptoms:
Systemic congestion
JVD
Hepatosplenomegaly
Dependent extremity pitting edema
Weight gain
GI symptoms – abdominal bloating, anorexia, early satiety (due to bowel wall + hepatic congestion), RUQ pain
Anasarca = development of massive edema involving entire body w/ recurrent pleural effusions +/o ascites

Signs of fluid overload predominate

right

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Most common cause of RHF is

LHF

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RHF is _____

systemic congestion

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Traffic in 3 roads to the heart is

right heart failure

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What does this PE tell you
Peripheral edema
Ascites
Scrotal edema
Hepatosplenomegaly
Elevated JVP >3 cm above sternal, 8 above RA
Crackles, rhonchi, wheezing
Right ventricular heave or parasternal lift in biventricular or severe HF

right sided heart failure

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Kussmaul’s sign

rise in JVP w/ inspiration – severe biventricular HF + poor outcome

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RHF: Dx lab value

elevated BNP

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What’s first line for all heart failure?

Lifestyle changes – cessation or restriction ETOH, tobacco cessation, limit sodium to 2.5g/day, fluid restriction only if class IV, weight loss

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What are the four pillars of meds for heart failure?

PRIMARY: 4 pillars of meds
Renin-angiotensin system inhibitors:
Preferred: sacubitril/valsartan
Beta blockers:
Preferred: carvedilol, metoprolol, succinate, bisoprolol
Mineralocorticoid receptor antagonists:
Preferred: spironolactone, eplerenone
SGLT2 inhibitors:
Preferred: dapagliflozin, empagliflozin

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What are addition meds for heart failure?

Diuretics (loop) + low sodium diet
Cardiac rehab

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What are secondary meds (don’t memorize) for HF?

SECONDARY: don’t memorize
vasodilators/nitrates (isosorbide dinitrate + hydralazine)
Alt to ACEI/ARB, for persistent symptoms, anti-HTN, shown to decrease mortality
Ivabradine
Persistent symptoms, esp tachycardia w/ max BB
Vericiguat
Persistent symptoms
Digoxin
Persistent symptoms

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How do you treat heart failure with life-threatening arrhythmias?

Life-threatening arrhythmias = implantable ICD, pacemaker for bradycardia or prolonged QRS (most get both)

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What side of heart failure is this:
Pulmonary congestion → pulmonary edema
Dyspnea
Paroxysmal nocturnal dyspnea (increased venous return when flat)
Orthopnea
Crackles
Wheezes
Cough
Decreased flow to the kidneys = increased fluid retention
Edema
Hepatic congestion + ascites

left

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What are risk factors for HF?

Old age
Higher heart rate
HTN
CAD/previous MI
Valvular HD
Diabetes
Smoking
obesity

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What does this cause?
Poor pumping (systolic) or rigid/scarred/hypertrophic wall that resists filling (diastolic)

Most common cause = CAD, HTN

Chronic = long standing (months-years)

Due to pulmonary congestion

left sided HF

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What is NYHA class I?

asymptomatic

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What is NYHA class II?

slight limitation of physical activity, comfortable at rest but ordinary physical activity results in undue fatigue

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What is NYHA class III?

marked limitation of physical activity, comfortable at rest, but less than ordinary physical activity results in undue fatigue

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What is NYHA class IV?

unable to carry on any physical activity without discomfort

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What are candidates for thrombophilia workup if results will influence management?

patients <50 y of age
strong family history of VTE
clot in unusual locations
recurrent thromboses
women of childbearing age
suspicious for APS
VTE provoked by transient non major risk factor
VTE ass with pregnancy
VTE ass with oral contraceptives

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What type of HF:
Well nourished + comfortable at rest – dyspnea w/ minimal ex
High HR + P initially
Chronic = HR <70-75 + BP in normal-low range

mild/moderate HF

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What type of HF:
Sit upright + anxious, diaphoretic, dyspneic at rest
Pallor due to anemia
Duskiness (low output)
Cool extremities and peripheral cyanosis
HOTN, narrow pulse pressure, rapid/thready pulse

severe HF

What does this PE indicate:
Rales, crackles, wheezing, rhonchi (congestion)
pleural effusions (dullness to percussion, decreased breath sounds at base)
Displacement of apical impulse (down + left)
S3 or S4 gallop
*

What does this indicate:
BNP or NT-proBNP
Elevated
CBC: anemia and infection can exacerbate pre-existing HF
CMP: hyponatremia, renal impairment, electrolytes + renal function for meds, LFTs

heart failure

How can you dx HF?

CXR to differentiate echo (alone cannot diagnose/exclude) look at atrial/ventricular sizes

What are acute HF symptoms?

SOA and DOE Orthopnea Paroxysmal nocturnal dyspnea

What are chronic HF symptoms?

Fatigue Anorexia Abdominal distention Peripheral edema Dyspnea (less pronounced – due to w/d of activity)

Who are at risk for reduced HF EF?

Poor prognosis: older age, male sex, HF-related hospitalization (25% after single hospitalization)

Reduced EF HF

systolic HF MCC of death – CAD, valvular heart disease, myopathy, congenital heart disease, infection, autoimmune, chronic lung disease

reduced EF HF

What does this indicate EKG: abnormality (amyloid disease, A-fib/arrhythmia, acute MI/previous MI, LVH S3 gallop - systolic

HF w/ reduced EF

Criteria for diagnosis of reduced HFrEF

>/ 1 categories of high-specificity or >/ 3 of intermediate = diagnosis low specificity or 1-2 = exercise test and refer

How do you treat reduced HF EF?

all 4 pillars - starting dose + work up to goal dose

preserved HF EF

diastolic HF long standing HTN, valvular heart disease, CAD, cardiomyopathy, constrictive pericarditis, aging, endocardial fibroelastosis

What does this indicate: Precordial palpation often normal S4 gallop - diastolic

preserved EF HF

EF >/ 50% EKG normal

preserved EF HF

In order to diagnose HF EF preserved you need -

1+ symptoms of HF LVEF>/50% no apparent other cause score: H2 FPEF 0=unlikely 1-5=intermediate 6-9=highly likely

H2FPEF

H2 = heavy(BMI>/30), HTN (2), (1) F = A fib (3) P = pulmonary HTN (1) >35 E = elder (1) >60 F = filling pressure (1) velocity and pulm artery pressure >9 by echo

How do you treat preserved HF EF?

Cardiac rehab + diet = small improvements in exercise tolerance Diuretics for volume overload – loop + low salt diet Class II or III + elevated BNP = SGLT2 inhibitor + mineralocorticoid receptor antagonist Secondary medications: Sacubitril-valsartan ACEI/ARB Beta blocker

>50% EF

high output EF

When can holosystolic murmurs MR and TR be heard?

AHF hyponatremia on CMP

How do you treat advanced HF?

IV loop diuretics, fluid + sodium restriction All conventional therapies employed Referral to advance HF program Palliative care

What are short term devices for AHF?

Short term devices - intra-aortic balloon pump, percutaneous circulatory assist devices, extracorporeal membrane oxygenation (ECMO)

What are long term devices for AHF?

Long term devices - left ventricular assist devices (LVAD) - bridging time for transplant

What are severe treatments for AHF?

Cardiac transplant – Class IV, cardiogenic shock, not amenable to percutaneous or surgical revascularization, life-threatening arrhythmias unresponsible to therapy CIs: life expectancy <2 years, irreversible pulmonary HTN, severe cerebrovascular disease, substance use, inability to comply

What do these symptoms indicate: Rapid onset or worsening of symptoms -- Left sided: pulmonary symptoms, progressive dyspnea, cough, rales Right sided: systemic symptoms of abdominal and peripheral congestion

acute decompensated HF

What can contribute to acute decompensated HF?

Nonadherence to meds, dietary salt, usage of meds that exacerbate HF, arrhythmias, valvular heart disease, systemic infection, PE

What causes acute decompensated HF?

Acute HF – most from worsening of chronic HF but also can occur from ACS, acute valvular dysfunction, hypertensive urgency

What does this indicate: S3 sound and laterally displaced apex beat Lower extremity edema

acute decompensated HF

diagnosis of acute decompensated heart failure is based on

Signs and symptoms + supported by BNP(>100 or p-BNP >125), CXR, ECG, and doppler

What does this indicate: Troponin elevated Based on: Signs and symptoms + supported by BNP(>100 or p-BNP >125), CXR, ECG, and doppler CXR: cephalization of flow, Kerley B lines, bat wing appearance, cardiomegaly, pleural effusions, pulmonary edema

acute decompensated HF

How do you treat acute decompensated HF?

Start with IV loop diuretic (refractory, add thiazide) Decongestion occurred if: Change in weight Improvement in clinical symptoms Predischarge measurement of BNP Oxygen Vasodilators (IV nitroglycerin, sodium nitroprusside) Inotropic therapy (dopamine, dobutamine)

High = orthopnea, JVD, PND, S3, pulses alternans, displaced PMI, pulmonary edema, elevated BNP ECHO- <30% LVEF What are these high specificity for?

Heart failure with reduced ejection fraction — key for diagnosis