Flashcards in Heart Failure Deck (56):
What are two classifications of HF?
systolic heart failure = reduced ejection fraction
diastolic heart failure = preserved ejection fraction
What could cause high output heart failure?
a lot of CO
What is the most common reason for right sided HF?
left sided heart failure
What are some causes of right sided HF?
left sided heart failure
pulmonic valve stenosis
right ventricular infarction
interstitial lung disease
adult respiratory distress syndrome
chronic lung infection or bronchectasis
primary pulmonary hypertension
What is the NYHA Classification of heart failure?
Class I - asx
Class II - sx with moderate exertion
Class III - sx with minimal exertion
Class IV - sx at rest
What are some causes of heart failure with reduced ejection fraction (systolic dysfunction)?
- CAD (MI or transient myocardial ischemia)
- chronic volume overload (MR, AR)
- advanced AS
- uncontrolled severe Htn
What are some causes of heart failure with preserved ejection fraction (diastolic dysfunction) ?
Impaired diastolic filling:
- myocardial fibrosis
- transient myocardial ischemia
- pericardial constriction or tamponade
What is the effect of the activation of RAAS in heart failure? Why is it activated?
dec renal perfusion --> kidneys secrete renin
effect of RAAS --> vasoconstriction --> detrimental in CHF! now we have inc afterload which further dec SV
What are sx of HF?
What are signs of HF?
positive abdominojugular reflex
hypoxia, tachypnea (decomp)
tachycardia, arrhythmia (decomp)
poor urine output (decomp)
cool extremities above the hands and feet (decomp)
lower extremity edema
GI sx from bowel edema (decomp)
cold intolerance (decomp)
What is the most specific sign of heart failure?
What are findings on CXR in HF?
cephalization of vessels
Kerley B lines
hilar vascular congestion
interstitial/alveolar edema (decomp)
pleural effusion (decomp)
fluid in subpleural space
What is the EF in a pt with HF usually?
EF < 40%
How does the EF relate to severity of left ventricular dysfunction?
none EF > 50%
mild EF 35-49%
severe EF < 25%
What level of BNP can be used to diagnose heart failure? What level excludes it? What else can BNP be used for?
BNP < 100 is not HF
BNP > 400 is HF
good prognostic indicator
What conditions (other than HF) can affect BNP and how?
PE - inc
pulmonary Htn - inc
infection - inc
AF - high baseline BNP
overweight - lower BNP
renal failure/insufficiency - inc BNP
NT Pro-BNP - inc with age
some chronic HF pts may have persistent elevations
What is the single most useful diagnostic test for HF?
What is involved in non-pharmacological management of HF?
salt restriction <2g/day
daily morning weight
restriction of daily fluid intake
What is the pharmacological treatment of HF? When do you use each agent?
ACE-I and beta blockers
Start adding Spirnolactone, DIgoxin & nitrates if sx
oxygen, positive pressure ventilation
the most common indication for starting an inotrope is worsening renal function (indicative of poor CO) & prolonged hypotension = "cardio renal syndrome"
True or False: CHF can be worsened by the use of a Cox-2 inhibitor. Why?
True. NSAIDs can cause fluid and sodium retention and high blood pressure --> exacerbate HF.
What are examples of beta blockers used in Rx of HF?
Carvedilol * - both inotropic effect & vasodilator
Bisprolol - vasodilator
Metoprolol - vasodilator
What factors make a patient not candidates for a beta blockade?
bronchospastic disease (true asthma)
advanced heart block
pts with acutely decompensated HF: fluid retention requiring intensive diuresis, receiving IV therapy for HF, re-evaluate for beta-blockage therapy later
What would you give a HF pt if they are unable to tolerate ACE-Is and ARBs?
nitrates + hydralazine
What are the major s/e of Spirnolactone? of Eplerenon?
hyperkalemia for both
gynecomastia for Spirnolactone
When do you consider ICDs and CRTs (BiVAD) in pts with HF?
ICDs: EF 30-35%, CAD, Class II and III HF
BiVAD: dyssynchronous heart, moderate to severe HF that failed medical therapy, EF <30%, evidence of LBBB
What surgical options are available for pts with HF?
What are indicators for ventricular support? What options are available?
decompensated end stage chronic CHF, post-surgical shock, acute myocarditis, post AMI cardiogenic shock
*if someone is not a transplant candidate in Canada, they will not get a device
What are indications for heart transplantation in HF? In general?
severe sx heart disease despite adequate med therapy
unacceptable risk of cardiac death
EF < 70
What are exclusion criteria for heart transplantation?
- primary systemic disease
- malignancy (eg skin)
- liver or renal dysfunction
- sign obstructive pulmonary disease
- pulmonary htn
- active infection
- age >72 yo
- active PUD
- DM with end-organ damage
- significant peripheral or cerebrovascular disease
- sx carotid stenosis
- morbid obesity
- marked cachexia
- difficult to control Htn
- irreversible neurological or neuromuscular disorder
- mental illness/psychosocial issues
- drug/tobacco/alcohol abuse
- heparin-induced thrombocytopenia
- technical issues
- documented noncompliance
- osteoporosis ?
What is the overall 5-year mortality for pts with HF?
How much more likely are pts with HF to develop sudden cardiac death?
6-9 times more likely
What are some precipitants of acute heart failure exacerbations?
patient factors: nonadherence to meds or lifestyle, excessive salt intake, stress, cardiac toxins
acute cardiac events: arrythmias, AF with rapid ventricular response, v-tach, bradycardia, conduction abnormalities, uncontrolled htn, acute MI, myocardial ischemia, valvular disease (progressive MR)
acute noncardiac events: PE, anemia, bleeding, systemic infection, thyroid disorders
adverse effects of meds: cardiac depressants/salt-retaining drugs
At low doses, IV nitro is a ___ and at higher doses is a ___
venodilator at lower doses
arteriodilator at higher doses
How does nitroprusside work? What are adverse effects?
venous & arterial vasodilator
can cause "coronary steal syndrome" - can "steal" blood from coronary arteries and cause MI
How long should inotropes be used for?
short term use only
chronic administration is associated with increased mortality
What is the MOA of dobutamine? What are s/e?
pulmonary vasodilator, mild arterial vasodilator
beta-1, beta-2 and alpha-1 agonist
inc cAMP by upregulating adenylyl cyclase inc contractility
minimal vascular actions as alpha-1 causes vasoconstriction and beta-2 causes vasodilation
s/e: tachycardia, tachyarrythmias, tachyphlyaxis
What is the MoA of Milrinone? What are the s/e?
inhibits PDE III - prevents breakdown of cAMP
cardiac myocytes: inc cAMP --> inc contractility
vascular smooth muscle: inc cAMP --> inhibit MLCK --> vasodilation
lungs: pulmonary vasodilator
s/e: use caution in pts with renal insufficiency, as drug as a long half-life; may cause sustained hypotension and ventricular arrythmias & AF
What is the MoA of dopamine and how does it relate to dosing? What are the s/e?
beta-1, alpha-1 and D1 agonist
at low doses, D1 stimulation in renal and mesenteric vascular beds inc cAMP - inhibits MLCK - vasodilation - inc excretion of sodium and water - dec plasma volume
at medium doses, inotropic effect - stimulates beta-1 receptors and promotes release of NE - chronotropic effect
at higher doses, beta-1 and alpha-1 receptor stimulation predominates - this is predominantly "oppressive" as it causes an inc in contractility (beta-1) and inc in vasoconstriction (alpha-1) at the same time --> tachycardia
s/e: nausea, tachycardia
What is the most common indicator of someone requiring inotropes?
patients with worsening renal function indicative of low CO
"cardio renal syndrome"
What are triggers for heart failure exacerbation (--> decomp)?
progression of disease
concurrent medical condition (eg infection)
What is the MoA of Isoproterenol? In what group of pts should it not be used?
synthetic analog of NE; action on both beta-1 and beta-2 receptors
inc cardiac contractility
inc HR (chronotropic effect)
vasodilation within periphery
contra: shouldnt be given to individuals with myocardial ischemia bc it has been shown to inc oxygen demand on heart
Which inotropic agent can be used to treat hypotensive shock?
acts on alpha-1 receptors in vasculature --> vasoconstriction
Why are narcotics used in the Rx of HF?
venodilate & provide relief from sensation and SOB
What are signs of low perfusion ?
low urine output
altered mental status
inadequate response to IV diuretic
What are signs of congestion?
recent weight gain
What are the four classifications of acute heart failure and which is the most common? How do you treat each presentation?
wet and warm * - volume overload, preserved forward flow - Rx: diuretics +/- vasodilators +/- sodium and fluid restriction; may require ultrafiltration
wet and cold - high pressures, low output - Rx. vasodilators - if unresponsive, try inotropes
dry and cold - end-stage - we might have caused this by over-diuresing - Rx: vasodilators
dry and warm - stable chronic HF
What is a PA catheter used for?
to monitor filling pressure
What is ECMO?
extra corporal membrane oxygenation
bridge to recovery or candidacy
What are the physiological effects of BNP?
inhibition of Aldo
inhibition of Renin
causes natriuresis and red of intravascular volume
What are some drugs that should be used with caution or avoided when co-prescribed with any heart failure treatment?
Class I antiarrythmics
What are some complications of chronic heart failure?
acute pulmonary edema
s/e from meds
leg venous stasis and ulcers
What are two causes of warm and dry HF?
What are causes of cold and dry HF?
acute right heart failure
What are causes of warm and wet HF?
What are causes of cool and wet HF?