Heart Failure

Question 1

top 4 causes of heart failure

Answer 1

1. ischemic heart disease
2. rheumatic valvular disease
3. hypertension
4. COPD

Question 2

cardiac output =

Answer 2

heart rate x stroke volume

Question 3

heart rate influenced by

Answer 3

Sympathetic and parasympathetic

Question 4

stroke volume influenced by

Answer 4

preload
afterload
contractility

Question 5

normal adult cardiac output is ____

Answer 5

4.0-8.0 L/min

Question 6

In Heart Failure you have _____ preload

Answer 6

increased

Question 7

Frank Starling law

Answer 7

stretch of the myocardial fibers –> contractility

Question 8

RAAS in HF

Answer 8

stimulation of the RAAS in HF

Question 9

___ (hormone) is stimulated in HF

Answer 9

vasopressin

Question 10

which nerves system is activated in HF

Answer 10

SNS

Question 11

what increase in HF and acts as antagonist to angiotensin and adolsterone

Answer 11

natriuretic pepetides

Question 12

___ is used for diagnosis of HF

Answer 12

BNP

Question 13

classification of HTN

Answer 13

primary
secondary
drug induced

Question 14

examples of drugs causing HTN

Answer 14

NSAIDs
Prednisone, Hydrocortisone
OCP
Pseudoephedrine, Methylphenidate
Tegretol
Lithium
SNRIs (Venlafaxine)
Herbals: Ginseng, natural licorice
Substance Misuse: ETOH, Cocaine

Question 15

HTN is caused by increase in ___ and ____

Answer 15

cardiac output and peripheral resistance

Question 16

a goal in treating HTN is

Answer 16

prevent Target Organ Damage
cardiovascular disease
cerebrovascular disease
renal disease
peripheral arterial disease
hypertensive retinopathy

Question 17

causes of A fib

Answer 17

Genetics, Advancing age
Structural heart disease: CAD/ACS, HF, Valvular disease,
Congenital heart disease
HTN
Obesity, OSA
Increased ETOH use
Thyroid dysfunction

Question 18

A fib is ___

Answer 18

irregular and tachy

Question 19

classification of A fib

Answer 19

paroxysmal A fib (> 30 sec, < 7 days)
persistent A fib (> 7 days, < 1 year)
long standing persistent A fib (> 1 year(
permanent A fib

Question 20

pathophysiology of A Fib

Answer 20

Underlying cardiac disease creates a vulnerable atria
(HF, dilated left atrium, ↑ left atrial pressure)

Alters substrate or tissue of atria
In the LA, ectopic foci around ostia of pulmonary vein and SVC

Pulmonary veins have unique electrical characteristics (pacemaker cells)

A triggering event initiates AF in this ectopic foci
Abnormal handling of calcium – Ca2+ leaks from sarcoplasmic reticulum & activates a current; spontaneous depolarization of myocyte

Inflammatory signaling in the atria (i.e. cytokines IL-6, TNF-⍺) may also contribute to process of initiating and perpetuating AF

There is reentrant activity in the atria - electrical signal travels in a loop (circular), repeatedly exciting the atrial tissue causing an irregular heartbeat

Fibrosis and hypertrophy can initiate and maintain reentry impulses

AF alters cardiac hemodynamics:
Uncoordinated contraction with ventricles, loss of atrial kick, decreased ventricular filling
Decreased CO and SV

Turbulent blood flow within atria - increased risk of thrombus formation

Question 21

pediatric congenital heart disease: left-to-right shunting

Answer 21

Blood shunts from high pressure oxygenation left side, to low pressure deoxygenated right side

Results in increased pulmonary blood flow

Question 22

atrial septic defect (ASD)

Answer 22

Hole in the interatrial septum resulting in left to right shunting
Volume overload of the RA and RV, RV enlargement

Question 23

ventricular septal defect (VSD)

Answer 23

Defect in the interventricular septum, left to right shunt

LV volume overload – signs/symptoms of HF

Question 24

In a fetus, ______ resistance > _____ resistance; at birth when lungs expand there is a significant decrease in ______, which reaches a normal balance by age ______

Answer 24

In a fetus, pulmonary resistance > systemic resistance; at birth when lungs expand there is a significant decrease in pulmonary resistance, which reaches a normal balance by age 2-8 weeks

Question 25

patent ductus arteriosus (PDA)

Answer 25

PDA is a normal fetal artery connecting aorta and PA; in a fetus blood does not need to circulate to lungs for oxygenation PDA usually closes in term infants 12-72 hours after birth

Question 26

coarctation of the aorta (CoA)

Answer 26

Narrowing of a segment of the aortic lumen at site of ductus arteriosus

Question 27

HFrEF: Heart Failure with a reduced ejection fraction

Answer 27

Patients with a LVEF ≦ 40%

Question 28

HFmEF: Heart Failure with a mid-range ejection fraction

Answer 28

Patients with a LVEF 41-49%

Question 29

HFpEF: Heart Failure with preserved ejection fraction

Answer 29

Patients with a LVEF ≧ 50%

Question 30

Left-sided Heart Failure

Answer 30

If the heart is unable to pump appropriately there is an increase in pressure in the pulmonary vasculature (leading to pulmonary congestion) and poor systemic perfusion Most common cause of chronic HF

Question 31

Right-sided Heart Failure

Answer 31

Right sided heart failure is the inability of the right ventricle to perfuse the pulmonary circulation Systemic venous circulation pressures increase

Question 32

Recovered ejection fraction

Answer 32

Patients who previously had HFrEF but now have a LVEF > 40%

Question 33

clinical manifestations of HF

Answer 33

Tachycardia (HR > 100 bpm) Hypotension Decreased oxygen saturation Weight gain Increased JVP, positive HJR Pulmonary rales Displaced LV apex Extra heart sounds (S3, S4), murmurs Ascites, Hepatomegaly Peripheral edema Cool extremities

Question 34

____ sided failure can ________ pressures and lead to _____ sided failure.

Answer 34

Left sided failure can increase pulmonary pressures and lead to right sided failure.

Question 35

NYHA (New York Heart Association) Functional Class

Answer 35

NYHA I: Asymptomatic with no limitation in physical activity NYHA II: Mild symptoms and slight limitation with ordinary activity (dyspnea) NYHA III: Marked limitation in activity due to symptoms (walking a short distance of 20-100 m); comfortable only at rest NYHA IV: Severe limitation. Symptomatic even while at rest and patient may be bedbound.

Question 36

AHA Stages of Heart Failure

Answer 36

Stage A At risk for HF but do not yet have structural heart disease; Asymptomatic Stage B Structural heart disease but asymptomatic History of myocardial infarction, decreased LVEF or LV hypertrophy, asymptomatic vascular disease Stage C Structural heart disease and symptomatic Structural heart disease, symptoms of dyspnea and exercise intolerance Stage D Patients with end-stage HF Symptomatic at rest despite maximal medical therapy; recurrent hospitalizations

Question 37

Assessment, Work-up for Heart Failure

Answer 37

#1. Comprehensive Health History, Assessment of RF’s, Physical Exam #2. 2D Echocardiogram

Question 38

Diagnostics for Heart Failure

Answer 38

ECG CXR

Question 39

Kerley B Lines

Answer 39

fine horizontal opacified lines (~ 2cm); Represent fluid in the interstitial space

Question 40

_____ Gold standard biomarker in HF

Answer 40

Brain Natriuretic Peptide (BNP) 2 types of tests with different reference ranges: BNP and NT-proBNP

Question 41

BNP ranges

Answer 41

In acute setting: if BNP is < 100 pg/mL then HF is unlikely (NT-proBNP < 300 pg/mL) if BNP > 400 pg/mL then HF is very likely

Question 42

Obese patients have _____ BNP levels

Answer 42

Obese patients have lower BNP levels

Question 43

BNP is a hormone secreted by _____ ; Stored in ______

Answer 43

BNP is a hormone secreted by cardiomyoctes; Stored in ventricles