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Heart Failure Flashcards

1
Q

What is the global scope of heart failure as a health problem?

A

21 million people worldwide are affected.
50% die within 5 years of diagnosis.
It is the number 1 cause of hospitalization in individuals over 65 years.
Most patients have 3 or more comorbidities.

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2
Q

How is heart failure defined?

A

Heart failure is defined as insufficient oxygen delivery due to an imbalance between the body’s requirements and the heart’s ability to meet those needs.

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3
Q

How is heart failure classified based on ejection fraction (EF)?

A

HFrEF (Reduced EF): EF < 40%
HFmEF (Mildly Impaired EF): EF 40-49%
HFpEF (Preserved EF): EF ≥ 50%

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4
Q

What are the common etiologies of heart failure?

A

Ischemic heart disease
Toxic damage
Immune-mediated inflammatory damage
Infiltration
Metabolic derangements
Arrhythmias
Abnormal loading conditions (e.g., hypertension, volume overload)
Valve and myocardium structural defects

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5
Q

What is the pathophysiology of heart failure?

A

Heart failure occurs when the heart cannot pump sufficient blood to meet the body’s metabolic demands. It results from structural or functional cardiac disorders that impair filling or ejection of blood. Key mechanisms include:

Neurohormonal Activation: SNS and RAAS activation increase heart rate, vasoconstriction, and fluid retention.
Ventricular Remodeling: Chronic stress leads to hypertrophy and dilation, worsening heart function.
Increased Afterload and Preload: Persistent vasoconstriction and fluid retention raise the heart’s workload, leading to congestion (e.g., pulmonary or peripheral edema).

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6
Q

What is cardiac output (CO), and how is it calculated?

A

Cardiac Output (CO): The total volume of blood the heart pumps per minute.
Formula: CO = Stroke Volume (SV) × Heart Rate (HR).

Example: SV = 70 mL/beat, HR = 70 bpm → CO = 70 × 70 = 4900 mL/min (≈ 5 L/min).

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7
Q

What is ejection fraction (EF), and how is it calculated?

A

Ejection Fraction (EF): The percentage of blood ejected from the left ventricle during systole.
Formula: EF = (SV / EDV) × 100.

Example: SV = 70 mL, EDV = 110 mL → EF = (70/110) × 100 = 64% (normal).

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8
Q

What are the two primary types of left-sided heart failure?

A

Systolic Heart Failure (SHF): Impaired contraction, reduced EF (< 40%).
Diastolic Heart Failure (DHF): Impaired filling, preserved EF (≥ 50%) but stiff ventricles.

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9
Q

What are the main causes of systolic left-sided heart failure?

A

Ischemic heart disease → myocardial fibrosis → impaired contraction.
Hypertension → myocardial hypertrophy → increased oxygen demand.
Dilated cardiomyopathy → chamber enlargement → weakened myocardium.

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10
Q

What are the main causes of diastolic left-sided heart failure?

A

Hypertension → concentric hypertrophy → reduced filling space.
Aortic stenosis → hypertrophic cardiomyopathy.
Restrictive cardiomyopathy → decreased compliance → impaired filling.

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11
Q

What are the typical symptoms of heart failure?

A

Breathlessness
Orthopnea
Paroxysmal nocturnal dyspnea
Reduced exercise tolerance
Fatigue
Ankle swelling

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12
Q

What are the less typical symptoms of heart failure?

A

Nocturnal cough
Wheezing
Bloating
Loss of appetite
Palpitations
Syncope

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13
Q

What are the physical examination findings in heart failure?

A

Extremities: Diminished peripheral pulses, irregular pulse, pitting edema.
Signs: Elevated jugular venous pressure, hepatojugular reflux, third heart sound, laterally displaced apical impulse, weight gain (>2 kg/week), cardiac murmur, crepitations, tachycardia, tachypnea, Cheyne-Stokes respiration.

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14
Q

What are the first steps in managing heart failure?

A

Slow the heart rate to reduce pump effort.
Decrease hypertension using ACE inhibitors (ACE-I) or ARBs.
Administer diuretics if fluid overload is present.
Request an echocardiogram.
Refer the patient to a specialist as soon as possible.

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15
Q

Why is hypertension a significant risk factor for heart failure?

A

Hypertension is a common risk factor that aggravates heart failure because it is often under-treated or undiagnosed. It increases afterload, leading to ventricular hypertrophy and reduced compliance, which worsens heart function over time.

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16
Q

What is the natural history of heart failure?

A

Heart failure typically progresses from asymptomatic left ventricular dysfunction to symptomatic heart failure with worsening symptoms, frequent hospitalizations, and eventually end-stage heart failure with high mortality.

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17
Q

What are the complications of heart failure?

A

Pulmonary edema
Peripheral edema
Arrhythmias
Renal dysfunction
Cachexia (weight loss in advanced stages)
Increased risk of sudden cardiac death

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18
Q

What is the role of neurohormonal activation in heart failure?

A

Neurohormonal activation (e.g., sympathetic nervous system and renin-angiotensin-aldosterone system) is a compensatory mechanism in heart failure. It increases heart rate, contractility, vasoconstriction, and fluid retention to maintain perfusion. However, over time, these mechanisms become maladaptive, worsening cardiac function.

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19
Q

What is ventricular remodeling, and how does it contribute to heart failure?

A

Ventricular remodeling refers to structural changes in the heart (e.g., hypertrophy, dilation) in response to chronic stress. While initially compensatory, these changes eventually reduce cardiac efficiency, leading to worsening heart failure.

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20
Q

What is the difference between acute and chronic heart failure?

A

Acute Heart Failure: Sudden onset of symptoms, often due to a precipitating event (e.g., myocardial infarction, arrhythmia).

Chronic Heart Failure: Long-standing condition with gradual progression of symptoms and compensatory mechanisms.

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21
Q

What is the significance of ejection fraction (EF) in diagnosing heart failure?

A

Ejection fraction (EF) is a key diagnostic parameter:

EF ≤ 40%: Indicates systolic heart failure (HFrEF).

EF 40-49%: Mildly reduced EF (HFmEF).

EF ≥ 50%: Preserved EF (HFpEF), often seen in diastolic heart failure.

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22
Q

What are the common causes of right-sided heart failure?

A

Left-sided heart failure (most common cause).

Chronic lung diseases (e.g., COPD, pulmonary hypertension).

Pulmonary embolism.

Right ventricular infarction.

Congenital heart defects.

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23
Q

What are the key differences between left-sided and right-sided heart failure?

A

Left-Sided Heart Failure: Causes pulmonary congestion (e.g., dyspnea, pulmonary edema).

Right-Sided Heart Failure: Causes systemic congestion (e.g., peripheral edema, hepatomegaly, jugular venous distension).

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24
Q

What is the AHA classification of heart failure?

A

The AHA classifies heart failure into four stages:

Stage A: At risk for heart failure (e.g., hypertension, diabetes).

Stage B: Structural heart disease without symptoms.

Stage C: Structural heart disease with prior or current symptoms.

Stage D: Refractory heart failure requiring advanced interventions.

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25
What is the NYHA functional classification of heart failure?
The NYHA classification assesses symptom severity: Class I: No symptoms with ordinary activity. Class II: Mild symptoms with moderate activity. Class III: Symptoms with minimal activity. Class IV: Symptoms at rest.
26
What are the key hemodynamic changes in heart failure?
Increased Preload: Due to fluid retention and venous congestion. Increased Afterload: Due to vasoconstriction and hypertension. Reduced Cardiac Output: Due to impaired contractility or filling.
27
What are the common diagnostic tests for heart failure?
Echocardiogram: Assesses EF, chamber size, and valve function. BNP/NT-proBNP: Biomarkers elevated in heart failure. Chest X-ray: Shows cardiomegaly and pulmonary congestion. ECG: Detects arrhythmias or ischemic changes. Cardiac MRI: Provides detailed imaging of heart structure and function.
28
What is the role of BNP/NT-proBNP in heart failure diagnosis?
BNP (B-type natriuretic peptide) and NT-proBNP are biomarkers released in response to ventricular stretch. Elevated levels help diagnose heart failure and assess its severity.
29
What are the treatment goals for heart failure?
Relieve symptoms (e.g., dyspnea, edema). Improve quality of life. Slow disease progression. Reduce hospitalizations. Improve survival.
30
What medications are used to treat heart failure?
ACE Inhibitors/ARBs: Reduce afterload and prevent remodeling. Beta-Blockers: Slow heart rate and reduce myocardial oxygen demand. Diuretics: Relieve fluid overload. Aldosterone Antagonists: Reduce fibrosis and fluid retention. ARNI (Angiotensin Receptor-Neprilysin Inhibitors): Improve outcomes in HFrEF. SGLT2 Inhibitors: Recently shown to benefit heart failure patients.
31
What lifestyle modifications are recommended for heart failure patients?
Sodium and fluid restriction. Regular physical activity (as tolerated). Weight monitoring to detect fluid retention. Smoking cessation. Limiting alcohol intake.
32
What is the role of implantable devices in heart failure management?
ICD (Implantable Cardioverter-Defibrillator): Prevents sudden cardiac death in high-risk patients. CRT (Cardiac Resynchronization Therapy): Improves synchronization in patients with dyssynchrony and HFrEF. LVAD (Left Ventricular Assist Device): Used in advanced heart failure as a bridge to transplant or destination therapy.
33
What are the indications for heart transplantation in heart failure?
Heart transplantation is considered for patients with: Refractory end-stage heart failure. Severe symptoms despite optimal medical therapy. No contraindications (e.g., active infection, malignancy).
34
What are the complications of chronic heart failure?
Arrhythmias (e.g., atrial fibrillation, ventricular tachycardia). Thromboembolism (e.g., pulmonary embolism, stroke). Renal dysfunction (e.g., cardiorenal syndrome). Cachexia and muscle wasting. Depression and reduced quality of life.
35
What is cardiorenal syndrome in heart failure?
Cardiorenal syndrome refers to the bidirectional relationship between heart and kidney dysfunction. In heart failure, reduced cardiac output impairs renal perfusion, leading to fluid retention and worsening heart failure.
36
What is the significance of the third heart sound (S3) in heart failure?
The third heart sound (S3) is a sign of ventricular dysfunction and increased filling pressures. It is often heard in patients with systolic heart failure.
37
What is Cheyne-Stokes respiration, and why does it occur in heart failure?
Cheyne-Stokes respiration is a pattern of periodic breathing with alternating hyperventilation and apnea. It occurs in heart failure due to delayed circulation time and impaired respiratory control.
38
What is the role of palliative care in heart failure management?
Palliative care focuses on relieving symptoms, improving quality of life, and providing emotional support for patients with advanced heart failure. It is not limited to end-of-life care and can be integrated early in the disease course.
39
What is the prognosis of heart failure?
The prognosis varies based on severity and comorbidities: 50% of patients die within 5 years of diagnosis. Advanced heart failure has a 1-year mortality rate of up to 50%. Early diagnosis and treatment improve outcomes.
40
What are the key differences between systolic and diastolic heart failure?
Systolic Heart Failure (SHF): Reduced EF (< 40%), impaired contraction, dilated ventricles. Diastolic Heart Failure (DHF): Preserved EF (≥ 50%), impaired filling, stiff ventricles. Treatment: SHF responds well to ACE-I, beta-blockers, and ARNI. DHF focuses on controlling hypertension and fluid overload.
41
What is the role of the renin-angiotensin-aldosterone system (RAAS) in heart failure?
The RAAS is activated in heart failure to maintain blood pressure and perfusion. It causes vasoconstriction (via angiotensin II) and sodium and water retention (via aldosterone). While initially compensatory, chronic RAAS activation leads to increased afterload, fluid overload, and ventricular remodeling, worsening heart failure.
42
What is the significance of pulmonary edema in heart failure?
Pulmonary edema occurs when left-sided heart failure causes increased pressure in the pulmonary veins, leading to fluid leakage into the lungs. Symptoms include severe dyspnea, orthopnea, and crackles on lung auscultation.
43
What is orthopnea, and why does it occur in heart failure?
Orthopnea is difficulty breathing while lying flat. It occurs in heart failure because lying down increases venous return to the heart, exacerbating pulmonary congestion in patients with left-sided heart failure.
44
What is paroxysmal nocturnal dyspnea (PND), and why does it occur in heart failure?
PND is sudden shortness of breath that wakes the patient at night. It occurs due to fluid redistribution when lying down, increasing pulmonary congestion in patients with left-sided heart failure.
45
What is the role of beta-blockers in heart failure treatment?
Beta-blockers slow the heart rate, reduce myocardial oxygen demand, and improve ventricular remodeling. They are a cornerstone of treatment for HFrEF but must be started at low doses and titrated slowly.
46
What is the role of aldosterone antagonists in heart failure treatment?
Aldosterone antagonists (e.g., spironolactone, eplerenone) reduce fibrosis, fluid retention, and mortality in patients with HFrEF. They are particularly beneficial in advanced heart failure.
47
What is the role of SGLT2 inhibitors in heart failure treatment?
SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin) were initially developed for diabetes but have shown significant benefits in heart failure by reducing hospitalizations and improving outcomes, even in non-diabetic patients.
48
What is the significance of jugular venous distension (JVD) in heart failure?
JVD is a sign of increased right atrial pressure, often seen in right-sided heart failure. It indicates systemic venous congestion and is assessed by observing the jugular vein while the patient is at a 45-degree angle.
49
What is hepatojugular reflux, and how is it assessed?
Hepatojugular reflux is the increase in jugular venous pressure when pressure is applied to the liver. It is a sign of right-sided heart failure and indicates impaired venous return.
50
What is the significance of a third heart sound (S3) in heart failure?
The S3 sound is caused by rapid ventricular filling and is a sign of systolic heart failure. It is often described as a 'gallop' rhythm and indicates elevated left ventricular end-diastolic pressure.
51
What is the significance of a fourth heart sound (S4) in heart failure?
The S4 sound is caused by atrial contraction against a stiff ventricle and is a sign of diastolic heart failure. It is often heard in patients with hypertension or left ventricular hypertrophy.
52
What is the role of echocardiography in heart failure diagnosis?
Echocardiography is the gold standard for diagnosing heart failure. It assesses ejection fraction (EF), chamber size and wall thickness, valve function, and presence of pericardial effusion.
53
What is the significance of elevated BNP/NT-proBNP levels in heart failure?
Elevated BNP/NT-proBNP levels indicate ventricular stretch and are used to diagnose heart failure, assess severity, and differentiate cardiac from non-cardiac causes of dyspnea.
54
What is the role of diuretics in heart failure treatment?
Diuretics (e.g., furosemide) relieve symptoms of fluid overload (e.g., pulmonary congestion, peripheral edema) but do not improve survival. They are used as needed for symptom control.
55
What is the role of digoxin in heart failure treatment?
Digoxin improves symptoms and reduces hospitalizations in heart failure by increasing myocardial contractility and slowing the heart rate. However, it does not improve survival and requires careful monitoring for toxicity.
56
What are the signs and symptoms of digoxin toxicity?
Nausea, vomiting, and anorexia. Visual disturbances (e.g., yellow-green halos). Arrhythmias (e.g., bradycardia, atrial tachycardia). Confusion or delirium in elderly patients.
57
What is the role of ARNI (Angiotensin Receptor-Neprilysin Inhibitors) in heart failure treatment?
ARNI (e.g., sacubitril/valsartan) improves outcomes in HFrEF by enhancing natriuretic peptides (via neprilysin inhibition) and blocking angiotensin II (via ARB). It is recommended as a replacement for ACE-I/ARB in eligible patients.
58
What is the significance of weight monitoring in heart failure management?
Daily weight monitoring helps detect fluid retention early. A sudden weight gain of >2 kg in 3 days may indicate worsening heart failure and the need for diuretic adjustment.
59
What is the role of exercise in heart failure management?
Regular, moderate exercise improves functional capacity, quality of life, and symptoms in heart failure patients. It should be tailored to the patient’s tolerance and clinical status.
60
What is the significance of anemia in heart failure?
Anemia is common in heart failure and worsens symptoms by reducing oxygen delivery. It is often due to chronic disease, iron deficiency, or renal dysfunction. Treatment includes iron supplementation or erythropoiesis-stimulating agents.
61
What is the role of iron supplementation in heart failure?
Iron supplementation (e.g., intravenous ferric carboxymaltose) improves symptoms, functional capacity, and quality of life in heart failure patients with iron deficiency, even in the absence of anemia.
62
What is the significance of sleep apnea in heart failure?
Sleep apnea is common in heart failure and worsens outcomes by causing intermittent hypoxia, increased sympathetic activity, and elevated blood pressure. Treatment includes CPAP or adaptive servo-ventilation.
63
What is the role of anticoagulation in heart failure?
Anticoagulation is indicated in heart failure patients with atrial fibrillation or a history of thromboembolism. It reduces the risk of stroke but requires careful monitoring for bleeding.
64
What is the significance of hyponatremia in heart failure?
Hyponatremia is a marker of advanced heart failure and poor prognosis. It is often due to fluid overload and activation of the RAAS. Treatment focuses on fluid restriction and optimizing heart failure therapy.
65
What is the role of palliative care in advanced heart failure?
Palliative care focuses on symptom relief, emotional support, and improving quality of life in advanced heart failure. It includes managing dyspnea, pain, and depression, and facilitating end-of-life discussions.
66
What is the significance of cachexia in heart failure?
Cachexia is a syndrome of weight loss, muscle wasting, and weakness seen in advanced heart failure. It is associated with poor prognosis and is driven by chronic inflammation and metabolic changes.
67
What is the role of cardiac resynchronization therapy (CRT) in heart failure?
CRT improves symptoms and survival in patients with HFrEF and electrical dyssynchrony (e.g., wide QRS complex). It synchronizes ventricular contraction, improving cardiac output.
68
What is the role of implantable cardioverter-defibrillators (ICDs) in heart failure?
ICDs prevent sudden cardiac death in patients with HFrEF and significant ventricular dysfunction. They detect and treat life-threatening arrhythmias (e.g., ventricular tachycardia, fibrillation).
69
What is the significance of frailty in heart failure?
Frailty is common in elderly heart failure patients and is associated with worse outcomes. It includes physical weakness, fatigue, and reduced functional capacity, requiring tailored management.

Oolong (13 decks)

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