Heart Failure Flashcards by Kellie Wheeler

When the heart cannot pump blood fast enough to meet the requirements of metabolizing tissues or can only do so from an abnormally elevated diastolic pressure/volume

Heart failure

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How many patients in the US have heart failure?

5 million

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Why are numbers of heart failure deaths increasing despite advances in medications?

Increased salvage of patients with acute MI

Numbers rising as baby boomers age

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What are the different etiologies of heart failure?

Coronary heart disease
Primary pump failure
Valvular heart disease
Congenital heart disease
Long standing, uncontrolled HTN

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MI’s or ischemia superimposed on prior infarction(s) make up ___% of all HF cases

(This is coronary heart disease) 75%

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Cardiomyopathies and viral myocarditis are examples of?

Primary pump failure

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What causes heart failure?

Progressive weakening of the myocardium and consequences from the weakness lead to heart failure

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Primary contraction abnormality causing inadequate delivery of O2 to tissues; issue with ejecting the blood from the heart to the rest of the body

Systolic heart failure

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Elevation of ventricular filling pressures and associated symptoms; When the heart has a decreased ability to fill with blood correctly

Diastolic heart failure

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Do systolic and diastolic failure occur together in heart failure?

Often

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Inadequate cardiac output to the body with pulmonary congestion and related symptoms (post MI, aortic/mitral valve disease)

Left heart failure

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Inadequate flow of blood to the pulmonary system due to COPD/pulmonary hypertension, pulmonic stenosis, etc.

Associated with peripheral edema and hepatic congestions

Right heart failure

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What is the most common cause of right heart failure?

Left heart failure!

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Dyspnea, cough, orthopnea, and PND are all symptoms of which type of heart failure?

Left sided heart failure - left side fails and fluid backs up into lungs causing all of these symptoms

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Peripheral edema, increased liver size, and ascites are all symptoms of which type of heart failure?

Right sided heart failure - Right side fails and backs fluid up to the body (limbs, liver, etc.)

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Inadequate ventricular emptying; pressures in the atrium and venous system behind the failing ventricle rise resulting n transudation of fluid into interstitial spaces

Backward failure

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Inadequate forward cardiac output; Na and water retention result from diminished renal perfusion and activation of renin-antiogensin-aldosterone system

Forward failure

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What are some compensatory mechanisms for the body to overcome heart failure?

Redistribution of cardiac output to vital organs (less blood flow to skin and muscle)

Sodium and water retention

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What mediates the redistribution of cardiac output to vital organs?

Adrenergic nervous system - primarily sympathetic nervous system with norepinephrine release

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Why would the body want to retain Na and water?

Helps maintain CO

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How does Na and water retention help maintain CO?

Starling mechanism

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What is the cost of Na and water retention?

Volume overload from accumulation of fluid and increased afterload from increased SVR

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Is the adrenergic system beneficial or harmful?

Both!

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Increased levels of norepinephrine result in an increase in ???

HR, contractility, and SVR

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Increased levels of norepinephrine helps maintain?

Arterial perfusion pressure (BP) in presence of decreased CO

What is the cost of elevated SVR?

Increased after load | Increased O2 requirements of the failing ventricle

Long term elevation of _______ leads to progressive myocardial damage and fibrosis

Catecholamines

Where and when is Renin released?

Released by kidneys with decreased perfusion or decreased BP

What converts angiotensinogen to angiotensin I?

Renin

What converts angiotensin I to angiotensin II? Where does this occur?

Angiotensin converting enzyme in LUNGS

What is the problem with angiotensin II?

Very potent vasoconstrictor! Increases SVR and RAISES BP!!

What does Angiotensin II stimulate in the adrenal glands?

Aldosterone

What does aldosterone do?

Increases renal Na and H2O reabsorption - causes edema!

What does long term activation of angiotensin II and aldosterone lead to?

Myocardial thinning and fibrosis

No limitation of physical activity; no symptoms of SOB, CP, dizziness, etc.

Stage 1 HF

Slight limitation of physical activity. Some (ordinary) activities (exercise, exertion, etc) cause symptoms.

Stage 2 HF

Marked limitation of physical activity. Less than ordinary activities (walking, dressing, etc.) cause symptoms.

Stage 3 HF

Symptomatic at rest or minimal activity; unable to engage in any physical activity.

Stage 4 HF

What are the 3 major clinical manifestations of HF?

Dyspnea, orthopnea, PND

Initially occurs with activity, then at rest; due to elevation of pulmonary venous pressure

Dyspnea

Dyspnea in recumbent position; redistribution of fluid from abdomen and lower extremities into chest

Orthopnea

Attacks of severe SOB, coughing and wheezing awakening patient from sleep

PND

What is a classic sign of HF that results from sodium and water retention?

Unexplained weight gain and swelling of legs

What causes cerebral symptoms in patients with HF?

Decreased perfusion to the brain

Severe dyspnea at rest as pulmonary congestion preogresses; elevation of PCP leading to interstitial then alveolar edema

Acute pulmonary edema

Acute pulmonary edema is considered a ___?

Medical emergency!

PCW greater than 20mmHg

Interstitial edema

PCW greater than 25mmHg

Alveolar edema

How do you measure PCP?

Right heart cath

Common PE findings in patient with HF

JVD! Tachycardia Cyannosis (hypoxemia) Patient uncomfortable lying flat

What might you hear on lung auscultation of a patient with HF?

Moist inspiratory crackles that begin at bases and progress upwards through the lungs

What might you hear when auscultating a patients heart in a patient with HF?

S3 gallop: Low pitched sound in early diastole

Hepato-jugular reflex in a HF patient will be ?

What might you find when palpating the liver of a HF patient?

Congestive hepatomegaly

"wasted appearance" - weight loss, anorexia, nausea

Cardiac cachexia

What causes cardiac cachexia?

Increased levels of cytokines (tNF)

What might you find on CXR of a patient with HF?

Cardiomegaly; distention of pulmonary veins; venous redistribution to apices; Pleural effusions; interstitial or alveolar edema

What is the best *non-invasive* tool for assessing HF?

Echo-doppler

What will an echo-doppler identify in a patient with HF?

Ventricular dysfunction and EF

What is a common ECG finding of a patient with HF?

LVH

What is a good blood test to check for acute ventricular dysfunction leading to symptomatic heart failure? Why?

BNP - hormone produced by ventricle in response to wall stress

What is a common BNP result in patients with HF? What is normal?

Normal is less than 50 HF usually greater than 100

What drugs help decrease preload in patients with HF?

Diuretics and venodilators (nitrates)

What drugs help with excess Na retention with edema in HF patients?

Diuretics

What drugs help decrease after load in patients with HF?

Vasodilator therapy (ACEIs and ARBs)

What drugs improve cardiac contractility?

Digoxin

What drugs slow progression of cardiac deterioration by preventing remodeling?

ACEIs Beta blockers Spironolactone

Once your patient with HF is symptomatic, what is their prognosis?

Poor

What are the goals of drug therapy to *control the HF state*?

Reduction of cardiac workload | Control of excessive Na/water retention

What drug therapy do you want to initiate EARLY for patients with HF?

ACEI/ARB

What should you add to ACEI/ARB in the black population?

Hydralazine and nitrates

What are the general goals of therapy in HF?

Remove precipitating factors Treat underlying cause Control HF state Enhance cardiac contractility

How can you reduce the cardiac workload? (Non-pharm and pharm)

Decrease/limited activity Elastic stockings Anxiolytic therapy Control dietary sodium

Ideal diet for a patient with HF?

No added salt, no salt in preparation of foods, AVOID FOODS WITH HIGH SODIUM CONTENT 4gm Na or LESS!

Most potent diuretics and cornerstone of diuretic Rx in CHF

Loop diuretics

Side effects of loop diuretics

Hyperkalemia Hyperuricemia Metabolic alkalosis

What is always elevated in heart failure? Why?

LV afterload Constricuted vascular bed and increased SVR

What is increased due to Na/H2O retention?

Preload

Treatment with vasodilators results in?

Decreased SVR Increased CO Decreased PCW Relief of symptoms Decreased mortality!

What do ACEI's do?

Reduce after load and preload

How do ACEIs reduce preload?

Decreasing production of angiotensin II and aldosterone

What is the equation for cardiac output using BP and SVR?

CO = BP/SVR

ACEIs decrease remodeling of the ____ How?

LV Reducing wall thinning, fibrosis, and by interfering with apoptosis

ACEIs are less effective in which population?

Black

If an ACEI is needed in a black patient, what should you add?

Hydralazine + long acting nitrate BiDil!!

What must you monitor on your patient taking an ACE?

Renal function

What causes the cough that is a side effect of ACEIs?

Bradykinin

Which medication used to be contradicted in HF, but is now proven to reduce mortality and improve cardiac function?

Beta blockers

When do you begin a patient with HF on beta blocker therapy?

Once patient is stable and euvolemic (normal blood volume)

Beta blocker DOC in patients with HF?

Carvedilol

By blocking aldosterone, spironolactone should be considered as a ______ antagonist rather than narrowly as a K sparing diuretic.

neurohumonal

______ mediates some of the deleterious effects of renin-angiotensin-aldosterone system activation, such as myocardial remodeling and fibrosis.

Aldosterone

Why do you need to monitor potassium levels in a patient on spironolactone or aldosterone?

Hyperkalemia

Digoxin improves CHF symptoms but not ____

Mortality

If QRS > 120ms (.12s) and severe refractory CHF, _______ (CRT*) improves symptoms and quality of life. Improves EF.

Synchronized biventricular pacing

When should you suggest an Implantable Cardioverter Defibrillator to your patient?

If your patient was resuscitated from cardiac arrest/Vfib or are in hemodynamically unstable vtach If your patients EF is less than 3.5 with mild to moderate HF symptoms

What can you recommend to your patient for end-stage HF?

LVAD (LV assist devices) Decreases workload of native heart and buys time to heart transplant

What is the problem with cardiac transplantation?

Not enough donor hearts