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724: Medical Lectures > Heart Failure > Flashcards

Flashcards in Heart Failure Deck (119)
1

How many Americans have heart failure?

5 million

2

Heart failure is primarily a disease of ____.

aging

3

75% of new cases occur in individuals over __ years of age

65

4

The prevalence of heart failure rises from < 1% in individuals below 60 years to nearly 10% in those over __ years of age

80

5

What are the symptoms of left heart failure?

- dyspnea (predominant feature)
- low cardiac output
- elevated pulmonary venous pressure

6

What symptoms predominate in right heart failure?

fluid retention

7

What is the primary cause of right heart failure?

LV dysfunction

8

Approximately half of patients with heart failure have preserved left ventricular systolic function but have ______ dysfunction

diastolic

9

What is the common cause of systolic dysfunction?

Coronary artery disease (CAD) with resulting myocardial infarction and loss of functioning myocardium

10

Systolic function of the heart and resulting cardiac output is governed by what four major determinants?

- the contractile state of the myocardium
- the preload of the ventricle
- the afterload applied to the ventricles
- heart rate

11

What is the preload of the ventricle resultant of?

The end-diastolic volume and the resultant fiber length of the ventricles prior to onset of the contraction

12

What 2 things can cause an increased impedance to left ventricular ejection (afterload)?

- aortic stenosis
- severe HTN

13

What does elevated diastolic pressure in the left ventricle cause?

High-output heart failure

14

High-output heart failure patients have ____ systolic function.

normal

15

With time, the overload associated with high-output heart failure causes what?

systolic failure

16

What 5 diseases/disorders can cause high-output heart failure?

- thyrotoxicosis
- severe anemia
- arteriovenous shunting (including dialysis fistulas)
- Paget disease of bone
- thiamine deficiency (beriberi

17

What do chest images of high-output heart failure patients show?

An enlarged heart and pulmonary venous congestion

18

What is the most common cause of diastolic dysfunction?

left ventricular hypertrophy

19

The abnormal filling associated with diastolic dysfunction is due to what?

- impaired myocardial relaxation
- noncompliant chamber due to excessive hypertrophy or changes in the composition of the myocardium

20

In diastolic dysfunction diastolic pressures are elevated and cardiac output is ____

reduced

21

What does the decreased cardiac output associated with diastolic dysfunction cause?

- fluid retention
- dyspnea
- exercise intolerance

22

Diastolic dysfunction comprises about __% of all clinical heart failure and is especially common in the elderly

50%

23

HF leads to _____ stroke volume which leads to a(n) ______ in end-diastolic volume and pressure

decreased

increase

24

An increased end-diastolic volume leads to an increase in myocardial fiber length which results in _____ systolic shortening. Due to what law?

greater

Starling law of the heart

25

Chronic elevation of diastolic pressures will be transmitted to the atria and to the pulmonary and systemic venous circulation, resulting in what?

pulmonary or systemic edema

26

Reduced cardiac output can lead to reductions in arterial pressure and perfusion to what organs?

the kidneys

27

Reduced perfusion to the kidneys will activate what?

several neural and humoral systems

28

Increased sympathetic nervous system activity leads to _______ myocardial contractility, HR, and venous tone

increased

29

This increase in myocardial contractility, heart rate, and venous tone precipitates what?

ischemia (inadequate blood supply to the heart muscles)

30

Increased sympathetic nervous system activity leads to _______ peripheral vascular resistance

increased

31

Increased sympathetic nervous system activity initiates a series of myocellular events that contribute to what?

adverse ventricular remodelling and progressive ventricular dysfunction

32

What does an increased preload lead to?

worsened pulmonary congestion

33

Reduced cardiac output leads to a _____ in renal blood flow, which leads to _____ glomerular filtration rate, which leads to what?

reduction

decreased

sodium and fluid retention

34

Sodium and fluid retention leads to activation of what system?

Renin-angiotensin-aldosterone system

35

The renin-angiotensin-aldosterone system increases what 3 things?

- peripheral vascular resistance
- LV afterload
- sodium and fluid retention

36

Heart failure leads to _____ vasopressin levels which leads to what?

increased

vasoconstriction and inhibition of water excretion

37

Heart failure is characterized by _ hemodynamic derangements

2

38

Describe the first hemodynamic derangement associated with heart failure

A reduction in cardiac reserve, or in other words a reduction in the ability to increase cardiac output in response to increased demands imposed

39

Describe the second hemodynamic derangement associated with heart failure

Elevation of ventricular diastolic pressures

40

Elevated ventricular diastolic pressures is the primary derangement in _____ heart failure, but the secondary derangement in _____ heart failure.

diastolic

systolic

41

What 3 things can cause systolic heart failure?

- HTN
- Dilated or congestive cardiomyopathy
- Valvular heart disease

42

What 6 things can cause systolic heart failure?

- LVH
- Hypertrophic or restrictive cardiomyopathy
- Diabetes
- Pericardial disease
- Atrial fibrillation with or without rapid ventricular rate
- Aging

43

There are _ stages of heart failure

4 (A, B, C, and D)

44

Describe stage A heart failure

These are the people that are at a high risk for developing heart failure because of the presence of conditions that are strongly associated with the development of heart failure

45

What are some examples of stage A heart failure?

-systemic hypertension
- coronary heart disease
- diabetes mellitus
- history of cardiotoxic drug therapy or alcohol abuse

46

Describe stage B heart failure

These are the patients who have developed structural heart disease that is strongly associated with the development of heart failure but who have never shown symptoms or signs

47

What are some examples of stage B heart failure?

- left ventricular hypertrophy or fibrosis
- left ventricular dilation or hypocontractility
- asymptomatic valvular heart disease
- previous MI

48

Describe stage C heart failure

These are the patient who have current or prior symptoms of heart failure associated with underlying structural heart disease

49

What are some examples of stage C heart failure?

- dyspnea or fatigue due to left ventricular systolic dysfunction
- asymptomatic patients who are undergoing treatment for poor symptoms of heart failure

50

Describe stage D heart failure

These are the patients with advanced structural heart disease and marked symptoms of heart failure at rest despite maximal medical therapy and who require specialized interventions

51

What are the symptoms of left heart failure?

- SOB (exertional dyspnea)
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Rest dyspnea
- Cough that is worse in the recumbent position
- Nocturia
- Fatigue
- Exercise intolerance

52

What are the symptoms of right heart failure?

- Fluid retention (edema)
- Hepatic congestion
- Loss of appetite
- Nausea
- Ascites

53

Right heart failure is often indistinguishable from what?

cor pulmonale

54

What is cor pulmonae?

Enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs

55

What 7 things may cause an acute exacerbation of chronic stable heart failure?

- alterations in therapy (or patient noncompliance)
- excessive salt and fluid intake
- arrhythmias
- excessive activity
- pulmonary emboli
- intercurrent infection
- progression of the underlying disease

56

What is another classification of heart failure, but is rarely used due to its limitations in that patient reports are subjective and in that symptoms vary from day to day?

- class I (asymptomatic)
- class II (symptomatic with moderate activity)
- class III (symptomatic with mild activity)
- class IV (symptomatic at rest)

57

Some patients with heart failure may appear comfortable at rest while others appear what?

dyspneic during conversation or minor activity

58

How do patients with long standing severe heart failure appear?

Cachetic or cyanotic

59

What vital sign abnormalities are present in patients with heart failure?

- tachycardia
- hypotension
- reduced pulse pressure

60

These patients have increased ______ nervous system activity that presents as what?

sympathetic

cold extremities or diaphoresis

61

What are the pulmonary signs of heart failure?

- Crackles at the base of the lungs
- Pleural effusion that causes bibasilar dullness to percussion
- Expiratory wheezing and rhonchi

62

Patients with severe right heart failure have a positive hepatojugular reflux greater than 1 cm, what does this mean?

There is distension of the neck veins precipitated by firm pressure over the liver

63

What are the cardinal cardiac examination signs?

- parasternal lift
- enlarged and sustained LV impulse
- diminished first heart sound
- S3 gallop
- S4 in a diastolic heart failure patient

64

True or False

In chronic heart failure, many of the expected signs of heart failure may be absent despite markedly abnormal cardiac function and hemodynamic measurements

True

65

What 2 blood count findings have poor prognostic value in heart failure patients?

- anemia
- high RBC distribution width (RDW)

66

Chronic _____ disease is a poor prognostic factor in heart failure

kidney

67

What does hypokalemia increase the risk of?

arrhythmias

68

What does hyperkalemia limit the use of?

inhibitors of the renin-angiotensin system

69

What is hyponatremia an indicator of?

marked activation of the renin-angiotensin system

70

Thyroid tests should be assessed to detect what?

occult thyrotoxicosis or myxedema

71

Iron studies should be assessed to test what?

hemochromatosis

72

Why may a myocardial biopsy be required?

to rule out the diagnosis of amyloidosis

73

Serum ___ is a powerful prognostic factor that adds to clinical assessment in differentiating dyspnea due to heart failure and from noncardiac diseases

BNP (Brain Natriuretic Peptide)

74

When is BNP elevated?

when ventricular filling pressures are high

75

In what type of patients is BNP sensitive to?

patients with symptomatic heart failure

76

In what type of patients is BNP not sensitive to?

older patients, women, and patients with COPD

77

Elevation of serum _______ is common in both chronic and acute heart failure, and is associated with higher risk of adverse outcomes?

troponin

78

ECGs indicate what 6 things associated with heart failure?

- Secondary arrhythmias
- MI
- Low voltage
- Intraventricular conduction defects
- LVH
- Nonspecific repolarization changes

79

What is a poor prognostic factor found on chest radiographs?

cardiomegaly (abnormal enlargement of the heart)

80

Evidence of pulmonary venous hypertension includes what 4 things?

- relative dilation of the upper lobe veins
- perivascular edema (haziness of vessel outlines)
- interstitial edema
- alveolar fluid

81

True or False

Patients with chronic heart failure may show relatively normal pulmonary vasculature on chest radiograph despite markedly elevated pressures

True

82

What 2 stress imaging procedures are often indicated?

- dobutamine echocardiogram (most useful)
- perfusion scintigraphy

83

What does the echocardiogram reveal?

the size and function of both ventricles and of the atria

84

What does radionuclide angiography measure?

LV ejection fraction and permits analysis of regional wall motion

85

When is stress testing indicated?

when myocardial ischemia is suspected cause of LV dysfunction

86

What is cardiac catherterization helpful in defining?

the presence and extent of CAD

87

What are 3 reversible causes of heart failure?

- CAD
- HTN
- valvular lesions

88

What 4 drugs should be avoided because they may contribute to worsening heart failure?

- Calcium channel blockers (specifically verapamil or diltiazem)
- antiarrhythmic drugs
- thiazolidinediones
- nonsteroidal anti-inflammatory agents

89

What are 3 metabolic and infiltrative cardiomyopathies may be partially reversible, or their progression may be slowed?

- hemochromatosis
- sarcoidosis
- amyloidosis

90

What should be the initial treatment in most symptomatic patients with heart failure and reduced LV EF?

A combination of a diuretic and an ACE inhibitor with early addition of a beta-blocker

91

What are 6 pharmacologic treatment options?

- diuretic therapy
- inhibitors of the renin-angiotensin-aldosterone system
- beta-blockers
- digital glycosides
- vasodilators
- ivabradine

92

What are the most effective means of providing symptomatic relief to patients with moderate to severe HF?

Diuretics

93

What type of diuretic should be used when fluid retention is mild?

Thiazide diuretics (hydrochlorothiazide or Metolazone)

94

Patients with more severe HF should be treated with what type of diuretics?

oral loop diuretics (furosemide, bumetanide, and torsemide)

95

Oral _____-sparing agents are often useful in combination with the loop and thiazide diuretics

potassium

96

What do triamterene and amiloride (2 potassium-sparing agents) do?

Act on the distal tubule to reduce potassium secretion

97

What do spironolactone and eplerenone (2 potassium-sparing agents) do?

they inhibit aldosterone

98

What are 3 inhibitors of the renin-angiotensin-aldosterone system?

- ACE (angiotensin converting enzyme) inhibitors
- Angiotensin II receptor blockers
- aldosterone inhibitors

99

ACE inhibitors reduce mortality by approximately __% in patients with symptomatic heart failure and have been shown also to prevent hospitalizations, increase exercise tolerance, and reduce symptoms in these patients

20%

100

What is a significant concern when administering ACE inhibitors?

hypotension (systolic <100)

101

What are 4 types of ACE inhibitors?

- captopril
- enalapril
- ramipril
- lisinopril

102

Angiotensin II receptor blockers provide more complete blockade of the ___ receptor

AT1

103

What are 2 types of ARBs?

- candesartan
- valsartan

104

What are 2 aldosterone inhibitors?

- Spironolactone
- Eplerenone

105

What is a major concern of all inhibitors of the renin-angiotensin-aldosterone system?

hyperkalemia (high potassium in the blood)

106

What do beta blockers do?

produce consistent substantial rises in EF and reductions in LV size and mass

107

What are 3 examples of beta blockers?

- carvedilol
- metoprolol succinate
- bisoprolol

108

What type of heart failure patients should be treated with a beat-blocker?

stable patients

109

What are 2 adverse side-effects of beta blockers?

dizziness and hypotension

110

Digitalis glycosides work as inhibitors of what?

the sodium-potassium pump

111

What 4 drugs increase levels of digoxin?

- amiodarone
- quinidine
- propafenone
- verapamil

112

What do vasodilators do to help treat HF?

Reduce cardiac preload and afterload by achieving both venous and arterial vasodilation

113

What are 2 types of vasodilators used for HF patients? What vascular structure does each dilate?

- Hydralazine: dilates arteries
- Nitrates: dilates veins

114

In patients with atrial fibrillation or who have large recent anterior myocardial infarction, should generally be anticoagulated with what drug for 3 months following the myocardial infarction.

warfarin

115

What are 5 nonpharmacologic treatment options for patients with HF?

- Implantable cardioverter defibrillators
- Biventricular pacing (resynchronization)
- Case management, diet and exercise training
- Coronary revascularization
- Cardiac transplantation

116

The 1 year survival rate for heart transplant patients is __-__% and the 5 year survival is __%

80-90

70

117

What is the 5 year mortality rate for patients with heart failure?

50%

118

Mortality rates vary from less than _% per year in those with no or few symptoms to greater than __% per year in those with severe and refractory symptoms

5

30

119

Higher mortality rates are related with what?

- older age
- lower LV EF
- more severe symptoms
- chronic kidney disease
- diabetes