Heart Failure #2 Flashcards
(95 cards)
1
Q
When do you need to get an ECHO for BNP or pro-BNP?
A
Elevated (but not confirmed heart disease)
NT-proBNP >125
BNP > 35
ORDER ECHO if clinical presentation and rising BNP
2
Q
After ordering an echo from elevated BNP and you get an echo?
A
HfrEF <= 40%
HFmrEF 41-49%
HFpEF = => 50%
3
Q
What heart categories do you treat for CHF?
A
HfrEF <= 40%
HFmrEF 41-49%
manage symptoms of HFpEF = => 50%
4
Q
What is treatment of heart failure geared towards?
A
Treatment is aimed at relieving symptoms, improving functional status, and preventing death & hospitalizations
Evidence for clinical benefits most often limited to HFrEF
Treatment for HFpEF is focused on improving symptoms and managing comorbidities
5
Q
What type of HF is HFpEF = => 50%
A
Diastolic and right sided HF
6
Q
How to manage symptoms of HFpEF = => 50%
A
Reduce HF symptoms
Increase functional status (NYHA class)
Reduce hospitalization risk
This is done via
lifestyle modification (<2g Na+)
congestion control (loops - furosemide)
heart rhythm control (antiarryhthmics)
BP (anti-HTN)
comorbidity management
weight loss
potential Cath (not urgent)
No clear data on what you should focus on
7
Q
When should you have patients follow up for HFpEF management?
A
Ongoing evaluation and monitoring
Follow up visits every 1-6 months, depending on comorbid conditions, medication response, etc. (no clear guidelines)
HTN, CAD, CKD, obesity
Chronic disease management
Exercise, diet, weight loss, and cardiac rehab
8
Q
cardiac rehab for HFpEF
A
exercise, diet, lifestyle, while being watched by providers
6-8 week program and is SUPER helpful
9
Q
rule of 2s
A
No more than 2 L of fluid a day (including food with liquid)
No more than 2 g of sodium per day
No more than 2 pounds of weight gain a day or 5 pounds a week
10
Q
diuretics patient education for HFpEF
A
drink in morning so that you don’t pee at night
11
Q
What DM med should HFpEF be on?
A
SGLT2i
Jardiance, Farxiga
12
Q
HTN meds for HFpEF
A
May consider ACE inhibitors, ARBs, Thiazides, MRAs, possibly ARNis
Beta blockers (typically carvedilol) for HTN, HR, and rhythm control
13
Q
What is a class 1 medication be on with HFpEF?
A
Diuretics (thiazides/loops)
ONLY one
14
Q
What is a class 2 meds for HFpEF?
A
SGLT2i (Juardiance, Farxiga)
ANRi (Enestro)
MRA (Spironolatctone)
ARB (-sartans)
15
Q
Most effective means of symptomatic relief in patients with HFpEF?
A
Dietetics - INSTANT relief
Furosemide (lasix)
Hydrochlorothiazide
Metolazone
Chlorthalidone (IV)
Improves both dyspnea and fluid overload
16
Q
What needs to be checked with diuretics for HFpEF?
A
Both thiazides and loops
Renal function (overworking kidneys)
potassium (lose it)
17
Q
What diuretics do you use for mild vs severe fluid therapy for HFpEF
A
Thiazides = mild
Loops = severe
can combined if severe
18
Q
What is important for patients to monitor if diuretics? What do we monitor if we add/change a diuretic?
A
Daily weight to assess diuresis (should be losing weight)
BMP within one week of diuretic therapy initiation or dosage change
19
Q
What does SGLT2 inhibitors do for HFpEF?
A
Dapagliflozin
empagliflozin
Reduces the risk of cardiovascular death and hospitalization for heart failure, regardless of diabetes status
20
Q
HFrEF management goals
A
Clinical improvement, stabilization, and reduction in risk of morbidity and mortality
Extensive ACCF/AHA guidelines in place based on multiple clinical trials assessing outcomes of HFrEF with different management options
21
Q
What do you do for HFrEF meds titration?
A
Start low, go slow
22
Q
What is stage C or D for HFrEF?
A
Structural changes with symptoms
23
Q
If you have HFrEF stage C, what is the first step of management that is 1 recommendation.
A
ANRI in NYHA II-III, ACE or ARB in NYHA II-IV
BB
MRA
SGLT2i
Dieretics as needed
max these out typically before going to the next steps based on symptomology/ CI
24
Q
What is step 2 of stage C/D HFrEF with LVEF <40%
A
titrate dosing of the step 2 meds
25
What is step 3 managment
26
what is step 4 management
27
What loop dieurtics do you use for HFrEF
ACE-I specifically
Furosemide
Torsemide
Bumetanide
28
If a patient cannot tolerate ACE-I, what do you do?
ARB -sartan
29
what should a patient NEVER be on?
Class III (harmful) to add to ACE inhibitor and aldosterone antagonist!!!!
Class IIA indication to continue if pt already on an ARB at time of dx of HF
Class IIB indication to add to ACE inhibitor if aldosterone antagonist is contraindicated
30
What BBs do you need to be on for HFrEF
metorprolol succinate (has to be this)
carveidilol
bisoprolol
ANY OTHER is NOT a BB a patient should use
titrate and look out for
31
What are the aldosterone antagonists for HFrEF?
Spironolactone and Eplerenone
class I indication
32
What is the SE of aldosterone antagonist?
Increases K+ because you hold onto K+ and get rid of Na+
33
What is the CI of aldosterone antagonist?
Contraindicated in patients with potassium > 5 and eGFR < 30
34
MOA of entresto?
Combination sacubitril and valsartan
Sacubitril is a neprilysin inhibitor, which limits the breakdown of natriuretic peptides (ANP, BNP) lowering these values.
Stops excess
35
If you add enestro, what do you do?
discontinue ACEi for 36 hour washout period and then add enestro after this time
You need to wait because enestro has an ARB in it - because it might lead to angioedema
36
SE of enestro
Can lead to hypotension and hyperkalemia
37
CI of enestro
History of angioedema with an ACE
38
When do you add hydrazine nitrate?
Class I indication as addition to ACE inhibitor and beta blocker therapy for black patients
Hydralazine – Initiate at 25 mg TID and titrate to 75 to 100 mg TID
Isosorbide dinitrate (Isordil) – Initiate at 10 to 20 mg TID and titrate up to 40 mg TID
39
When do you add ivabradine?
stable patients with heart failure and heart rate of 70 beats per minute who are taking the maximally tolerated dose of beta-blockers or in patients in whom beta-blockers are contraindicated
Shown to reduce hospitalizations and cardiovascular death
class II
40
What ryhthm do patients have to be in with ivabradine?
sinus
41
MOA of Ivabradine
Inhibits the If channel in the sinus node → specifically slows sinus rate
42
When do you add digoxin?
Class IIA indication – can be beneficial to add to therapy after ACE inhibitor, beta blocker, and aldosterone antagonist
May improve HF symptoms and control ventricular rate in patients with afib
not common
43
What med do you need to use with caution?
CCB
44
What CCBs need to be avoided for HFrEF
Verapamil and Diltiazem (work centrally)
Amlodipine and Felodipine are ok, but not beneficial
45
What do you need to avoid with HFrEF?
Antiarrhythmics: Amiodarone, Dofetilide
NSAIDs: PRN for HA is ok (aspirin)
Thiazolidinediones: (-tazones) should switch to GLP2 inhibs
46
What NYHA class is cardiac rehab indicated?
stable NYHA class II to III HF
Lessens symptoms, increases exercise capacity, improves quality of life, reduces hospitalizations and improves survival
47
When do you use Cardiac resynchonization?
An effective therapy in patients with HF and ventricular dyssynchrony identified as a prolonged QRS
Can improve exercise tolerance, NYHA functional class, and reduce morbidity and mortality
LVEF < or = 35%, QRS > 120ms with NYHA class III or IV symptoms
Three wires that go to different chambers of the heart
48
What commonly leads to sudden cardiac arrest (SCA)?
Ventricular arrhythmias are common in patients with HF and cardiomyopathy
Asymptomatic PVCs to sustained VT or VF
49
how to prevent SCA?
implantable cardioverter defibrillator (ICD) vary based on etiology of cardiomyopathy and whether for primary or secondary prevention
50
indication of implantable cardioverter defibrillator (ICD)
For those who have not suffered SCD
After optimal medical therapy
51
Recommendation for implantable cardioverter defibrillator (ICD) in ischemic cardiomyopathy
ICD is recommended for LVEF < 35% with class II or III HF symptoms and > 40 days post-MI or revascularization
52
Recommendation for implantable cardioverter defibrillator (ICD) in non-ischemic cardiomyopathy
Nonischemic CM
LVEF < 35% with NYHA class II or III HF symptoms, more than 90 days post dx, and reasonable likelihood of > 1 yr survival
53
Recommendation for implantable cardioverter defibrillator (ICD) in secondary prevention
Patients with HF and cardiomyopathy who have survived an episode of SCD or have sustained VT without obvious reversible causes are recommended for ICD
54
Recommendation for implantable cardioverter defibrillator (ICD) in unexplained syncope
Patients with LVEF < 30% and unexplained syncope, recommend ICD
55
what to do while waiting 90 days for ICD
What to do while waiting the 90 days:
LifeVest – a wearable defibrillator
Indicated as a bridge to ICD during the waiting period
56
acute decompensated HF causes
A common and potentially fatal cause of acute respiratory distress
May be new HF or an exacerbation of chronic HF
Causes of acute decompensations include medication noncompliance, myocardial ischemia/infarction, tachyarrhythmias, excessive salt intake
Characterized by acute dyspnea with rapid accumulation of fluid
Requires rapid assessment and stabilization
57
Presentation of acute decompensated HF
Presents with acute pulmonary edema
Severe dyspnea, production of pink, frothy sputum
Diaphoresis and cyanosis are also likely present
Lung exam reveals inspiratory rales
Wheezes and rhonchi are also common
might have increased capillary refill
58
What do we need to order for acute decompensated HF
Echo (dilation, MI possibly)
CXR (pulmonary edema, patchy, cardiomegaly, curly B lines)
BNP
CMP (to check renal functions and liver for hepatic congestion)
Coag studies
Cardiac enzymes
CBC
EKG
59
How to stablize acute decompensted HF
Airway/oxygenation assessment
Vital signs
Cardiac monitoring
IV access
Diuretic therapy
Vasodilator therapy
Urine output monitoring (diuresis)
Provide if needed, NOT in the absence of hypoxia
O2 sat >94% is goal
Keep patient seated upright (gravity pulls fluid down)
Non-rebreather facemask with high-flow O2
Noninvasive positive pressure ventilation (NPPV) is preferred for respiratory distress, respiratory acidosis and/or hypoxia (CPAP or BPAP)
If fail NPPV or don’t tolerate, pt should be intubated and initiate mechanical ventilation
60
Treatment of acute decompensated HF
Mainstay of therapy due to fluid overload (dieresis!!)
Start as soon as possible
Intravenous recommended over oral because of greater
and more consistent drug bioavailability
Loop diuretics are first line
Furosemide (Lasix), Torsemide (Demadex), and Bumetanide (Bumex)
61
What do you need to monitor for acute decompensated HF diuretics
Vital signs
Fluid status
Daily weights (same protocol each time)
I’s/O’s
Renal function, electrolytes
Rule out other causes of AKI
If severely symptomatic, diuresis is indicated regardless of changes in GFR
Reduce dose or hold if elevation and signs of intravascular volume depletion
Cardiorenal Syndrome
Due to elevated venous pressure and reduced cardiac output
Renal function may actually improve with diuresis
62
What to do if they do not have adequate dieutic response with acute decompensated HF
Sodium restriction
Water restriction in patients with hyponatremia
Addition of a second diuretic
Chlorothiazide – only IV thiazide diuretic (500 to 1000 mg/day)
HCTZ – oral thiazide (25 to 50 mg bid)
Metolazone – oral diuretic addition of choice with renal failure (2.5 to 5 mg once or twice daily)
Inhibits reabsorption of Na in distal tubules, thereby increasing excretion of water, Na, K and H
Aldosterone antagonist (Spironolactone or Eplerenone) – enhances diuresis and minimizes potassium wasting (50 to 100mg daily)
63
When do you use vasodilator therapy in acute decompensated HF? What do you need to monitor
Recommended for patients without hypotension and severe symptomatic fluid overload
Frequent BP monitoring is required
Continuous IV infusion of Nitroglycerin or Nitroprusside, or morphine (tanks BP and RR)
NTG: Most commonly used vasodilator
Short half-life, well tolerated
Reduces LV filling pressures via venodilation (a lot of times it is because of an MI)
64
Nitroprusside and why NTG is typically used
Potent vasodilator with both venous and arteriolar effects
Used when pronounced afterload reduction is needed
HTN emergency, acute AR, acute MR
Metabolizes to cyanide, accumulation/toxicity can be fatal
May cause reflex tachycardia
May lead to rebound vasoconstriction upon discontinuation
Limit to 24 to 48 hrs, especially with renal failure
Initial dose is 5 to 10 mcg/min and titrate based on response
not used often
65
Nestiritide
Recombinant BNP
probably not a test question
66
Once a patient is stable from acute decompensated HF, what do you do?
ACE Inhibitors and ARBs
Beta Blockers (hold at first but add after definitely stable)
67
What are the inotropic agents
Milrinone and Dobutamine
pressors
68
MOA of milirone and dobutamine
Milrinone MOA: phosphodiesterase inhibitor (PDE3) with mostly inotropic properties, but also causes vasodilation
Dobutamine MOA: stimulates B1 receptors to increase BP, HR, but also has vasodilation effects
last ditch effort
69
SE of milirinone and dobutamine
May lead to hypotension (Milrinone), hypertension (Dobutamine), and tachyarrhythmias
70
Additional Therapy for acute decompensated HF
Venous Thromboembolism Prophylaxis
Hospitalized pts with ADHF are at increased risk for VTE
Heparin, LMWH (Lovenox) or Fondaparinux (Arixtra)
SCDs if A/C contraindicated
Mechanical Cardiac Assistance
Considered for pts in cardiogenic shock
Cardiac index (CI) less than 2.0 L/min per m2, systolic arterial pressure less than 90 mmhg, and a pulmonary capillary wedge pressure above 18 mmhg
2 major devices:
Intraaortic balloon counterpulsation
Internally implanted left ventricular assist device
71
What is ultrafiltration
AKA Continuous Renal Replacement Therapy (CRRT)
Effective method to remove excess fluid without major hemodynamic compromise and no effect on serum electrolytes
Uses peripheral venous access and small blood volume, compared to hemodialysis
Very tolerable for patients and easily adjustable
72
what is an intraaortic balloon counterpulsation?
mechanical means that monitor to support cardiac funciton when meds do not work
73
what is an Internally implanted left ventricular assist device (LVAD)
battery pack like a holster, there is an incision that goes to LV and helps for pumping
74
Cardiogenic shock is characterized by
reduced cardiac output and associated hemodynamic findings:
Clinical signs of reduced cardiac output
Cool extremities, weak distal pulses, altered mental status, and diminished urinary output (< 30 mL/h)
Hemodynamic findings include:
Hypotension (100% of the time)
A pulmonary capillary wedge pressure (PCWP) of > 15 mmHg which excludes hypovolemia
Cardiac index < 2.2 L/min/m2
need an arteriole line, pulmonary cath, lots of people on board
75
What is cardiac index?
Cardiac output per minute per square meter of body surface area
Provides info on left ventricular function
Normal CI ranges from 2.6 to 4.2 L/min/m²x
Basically CO/BSA
BSA = body surface area
76
what are the cardiogenic shock?
Acute valve rupture
arrythmia
cardiotoxic meds
direct insult to the HEART
MI
77
What is the pathophys of cardiogenic shock?
hypotension with evidence of end-organ hypoperfusion
78
classic cardiogenic shock patient
Classic cardiogenic shock patient → peripheral vasoconstriction (cool, moist skin) and tachycardia
look like there are on the way to passing away
79
What diagnostic test do you order for cardiogenic shock?
Elevated cardiac enzymes in presence of MI
Elevated CR, ALT, AST in renal and hepatic hypoperfusion
Coagulation abnormalities in hepatic congestion / hypoperfusion
Anion gap acidosis and / or serum lactate elevation
BNP for degree of fluid overload
Diagnostics
EKG for underlying cause (MI, arrhythmia)
Stat transthoracic echocardiogram
CXR for cardiomegaly, pulmonary congestion
80
What cath do you add for cardiogenic shock?
UA w/ insertion of foley catheter for UO measurement
+/- Pulmonary artery catheter placement
Consider if diagnosis is questionable, pt on inotropes/pressors, or patient not responding to treatment
+/- left heart catheterization (if heart attack)
81
Treatment of cardiogenic shock
Oxygen supplementation; intubation, ventilation
Vasopressors/inotropes; consider careful intravenous fluids, arterial line and pulmonary artery catheter insertion to guide management; correct underlying causes of acidemia
+/- Intra-aortic balloon pump (until we can take of underlying problem)
Suspected MI → ASA, Heparin, Urgent Cath, Revascularize (PCI, CABG, Fibrinolysis)
82
What is a pulmonary capillary wedge pressure?
Utilizes a Swan Ganz Catheter which is placed through a central line in the internal jugular, subclavian, or femoral veins
Invasive and associated with risks, so not always done
Provides an indirect estimate of left atrial pressure (LAP)
Normally 8 to 10 mmHg
If elevated, supports diagnosis of pulmonary edema
Video 1
Video 2
83
inotropic/vasopressor agent
Increase the contractility of the heart, the heart rate, and peripheral vascular tone
These agents also increase myocardial oxygen demand
β-agonists can precipitate tachyarrhythmias
α-agonists can lead to dangerous vasoconstriction and ischemia in vital organ beds
When using these agents, attention should be given to the patient as a whole rather than focusing solely on a desired arterial pressure
might lose fingers/toes
84
what is dopamine used for?
Endogenous catecholamine with qualitatively different effects at varying doses
85
What is dobutamine used for
Strong β1 and weak β2/α effects, which results in increased cardiac output, blood pressure, and heart rate, as well as decreased peripheral vascular resistance
86
Levofed
Levofed = leave them dead
strong beta-1 and 2
added to dopamine if still hypotensive
87
What iontropic vasopressor do we add?
Choose based on need, while looking at HR, MAP, and patient clinical status
Titrate single agent to max tolerated dose before adding additional agent
88
what devices do you add for cardiogenic shock
Intra-aortic Balloon
Pump (IABP)
Temporary support system
Patient’s must be anticoagulated with IV heparin due to risk of thrombosis
Benefits of decreased afterload without increases in myocardial demand
Left-Ventricular
Assist Device (LVAD)
Typically used as a bridge to cardiac transplant
89
Ethel is a 74-year-old female who presents with progressive dyspnea and lower extremity edema over the last 3 weeks. She denies previous history of similar symptoms. She states that her shortness of breath occurs with mild exertion, which has gradually worsened, prompting her to seek treatment. Her edema began with minimal swelling of her feet and has progressed to swelling all the way to her knees. She admits that it has been difficult to sleep the last week, requiring she sleep in her recliner in the living room, as sleeping upright is easier on her breathing. She denies waking up gasping for breath. She denies chest pain, but upon further questioning she admits to about 2 days of burning in her chest and dyspepsia, that occurred about 4 weeks ago. She attributed it to some bad chinese food and did not seek medical treatment.
1. what are red flags for HF?
She denies palpitations, dizziness, lightheadedness, confusion, vision changes, changes in urine output, changes in bowel movements, or N/V. She does not weigh herself regularly so she is not aware of any weight changes. She has a history of hypertension for which she takes Amlodipine 5 mg PO daily. She does not check her blood pressure at home but says it is usually on the borderline when seeing her primary care provider once a year. She also admits to tobacco use, about 1 ppd for 60 years. She denies history of CAD, hyperlipidemia, or DM. She states her family history is significant for several family members having heart disease, HTN, and DM.
2. what are the concerns
Vitals - HR 104 bpm, BP 158/94, RR 20, O2 88% on room air, Temp 98.6 F, Weight 85.2 kg
General - Mild distress, overweight, A&O x 3, appears older than stated age.
Neck - Trachea midline, + JVD at 90 degrees. Carotid upstroke normal with no bruits
noted.
Cardiovascular - Heart regular rhythm with slightly tachycardic rate. Normal S1 and S2
with S3 present. No murmurs or rubs noted. Chest wall nontender to palpation,
with no heaves, lifts or thrills. PMI is nondisplaced. Pedal pulses 1+. 2+ pitting
edema of the lower extremities to the knee bilaterally. No sacral edema.
Respiratory - Diminished breath sounds at bases with inspiratory rales noted throughout
remainder of lung fields. Dullness to percussion noted at bases. AP diameter 1:1
with normal chest wall expansion.
Abdomen - Soft, nontender, nondistended, with positive bowel sounds in all 4 quadrants.
No masses or hepatosplenomegaly noted. No bruits of the aorta or renal arteries
noted.
Skin/Nails - Tobacco staining on fingers and nails. Clubbing of fingers noted. Skin is cool
and dry to touch, with no areas of rash, excoriation, or lesions.
3. Concerns
1.
SOB laying flat
paroxysmal
worsening weight gain, edema
burning in chest (abnormal presentation in female)
2.
smoker
HTN
family history of CAD
3.
JVD at 90 degrees
HTN
S3 d/t systolic dysfunction
Pitting edema
Diminshed breath sounds a bases (fluid)
clubbing of nails
90
why do you check for sacral edema in female?
Same as why you check for scrotal edema
91
what do you need to order for this patient?
CXR
EKG
Echo
Cardiac enzymes
BNP
CBC
Coag studies
+/- glucose (FHx of DM) or lipids
TTE
92
EKG - Q waves inferior leads, sinus tach
CXR - diffuse patchy infiltrates, bilateral small effusions, central pulmonary vascular engorgement
Initial Troponin I - 0.08 → now what?
CBC - Hgb 15, otherwise normal
BNP - 2134
CMP - BUN 18, Cr 1.8; Glucose 180; LFTs normal
Coag studies - normal
Based on your results, what is the most likely diagnosis? What NYHA and Stage HF does this patient have?
Echo → EF 25%; wall hypokinesis & akinesis in places
inferior wall MI
Heart failure
tropnin 0.08 check for trend
BNP 2134 (would be mild if non-BNP)
Diagnosis = CHF secondary to IWMI
NYHA stage: III progressive symptoms on exertion (acute on chronic)
AHA = C
93
Are there any additional diagnostic studies for further evaluation?
A1C (8.2%); heart catheterization!
94
What is the most appropriate initial management for this patient?
Lasix! Potassium! Oxygen? NTG? Morphine? No BB in acute HF!
Lasix
Potassium
O2
NTG (if CP - not needed unless dyspepsia)
Morphine
ACEi
Get rid of CCB
NO BB until managed acute symptoms (never in acute)
95
Describe a long-term treatment plan for this patient?
Entresto! Beta Blocker! Glucose control? Life vest?
