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Flashcards in Heart Failure - Brown Deck (30)
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Pitting Edema

  • 1+:  slight pitting, no visible distortion, disappears  rapidly.
  • 2+:  somewhat deeper pit than 1+, disappears in 10- 15 seconds.
  • 3+:  pit is noticeably deep, lasts more than 1 minute,  the dependent extremity looks full and swollen
  • 4+:  pit is very deep, lasts 2-5 minutes, extremity is  grossly distorted.





Diagnostic Studies in Heart Failure Patients


  • existence and extent of LV dysfunction
  • valvular or pericardial disease
  • amyloidosis

differentiate systolic versus diastolic heart failure

distinguish regional from global LV dysfunction


Stages of Heart Failure - C

Patients who have current or prior symptoms of HF associated with underlying structural heart disease


Prognosis of Heart Failure

  • five year survival < 50%
  • mortality rate in stage d > 30%/year
  • men have poorer prognosis
  • slight improvement due to use of ACE inhibitors and beta-blockers


Diagnostic Studies in Heart Failure Patients

  • Chest X-ray
  • EKG
  • LAB: BNP
  • Echocardiogram
  • Cardiac catheterization


Systolic Heart Failure: Low Output


Classification of Heart Failure

  • present with fatigue and loss of mean muscle mass
  • present with dyspnea


Stages of Heart Failure - B

Patients who have developed structural heart disease that is strongly associated with the development of HF but who have  never shown signs or symptoms of HF.


Systolic Heart Failure


Classification of Heart Failure

  • most common form
  • impaired myocardial contractility and low ejection fraction
  • assoicated with: CAD, MI, idiopathic dilated cardiomyopathy, HTN, valvular disease


Physical Exam in Heart Failure Patients

not highly sensitive nor highly specific, most sensitive signs:

  • S3 (systolic heart failure)
  • distended jugular veins
  • laterally displaced PMI
  • pulmonary crackles that do not clear with cough
  • peripheral edema

determining the severity of disease and etiology:

  • narrow pulse pressure
  • hypotension with cool extremeties
  • pulsus alternans (regular rhythm but alternating strong and weak peripheral pulses)


Physical Exam in Heart Failure Patients

See chart below:


pathophysiology of heart failure

Compensatory Mechanisms: activated when CO falls maintain BP and perfusion to vital organs via
  • Frank-Starling Mechanism
  • Myocardial hypertrophy
  • neurohormonal activation
    • SNS
    • Renin-Angiotensin-Aldosterone System
    • Hormones
      • vasopressin
      • endothelium-derived relaxing factor (nitric oxide)
      • natriuertic peptides
      • cytokines
      • endothelin
      • prostaglandins


Systolic Heart Failure: Biventricular Failure


Classification of Heart Failure

  • both systemic and pulmonary congestion present
  • bilateral reduced contractility


Diastolic Heart Failure


Classification of Heart Failure

  • compromised myocardial relaxation with NORMAL contractility and ejection fraction
  • associated with: CAD, HTN, aging, infiltrative cardiomyopathy


Systolic Heart Failure: High Output


Classification of Heart Failure

  • demand for blood exceeds capacity of a normal heart to meet demand
  • anemia
  • hyperthyroid




Diagnostic Studies in Heart Failure Patients

Evaluate for:

  • old arrhythmias
  • old MI's
  • conduction delays
  • left ventricular hypertrophy
  • repolarization abnormality


define heart failure:

Complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.


Pathophysiology - factors that worsen heart failure

  • increased metabolic demand
  • increased afterload or preload
  • drugs
    • negative inotropic drugs
    • disopyramide
    • Ca blockers
  • arrhythmias
  • toxins
  • hypothyroidism
  • lack of compliance


Stages of Heart Failure - D

Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical  therapy and who require specialized  interventions.


Systolic Heart Failure: Right Heart Failure


Classification of Heart Failure

  • Most common cause of right heart failure is left heart failure
  • secondary to long-standing increase in pulmonary pressure caused by LV failure
  • signs: peripheral edema 
  • other cuases
    • mitral stenosis
    • COPD
    • sleep apnea
    • pulmonary emboli
    • pulmonary hypertension


B-Type Natriuretic Peptide (BNP)


Diagnostic Studies in Heart Failure Patients

  • < 50 pg/mL HF is unlikely
  • >150 pg/mL moderately helpful
  • helps diagnose cardiac vs. non cardiac shortness of breath
  • screening for asymptomatic LV dysfunction
  • risk stratification and prognosis
  • monitoring treatment


Goals of Heart Failure Treatment

  • improve symptoms
  • prolong survival
  • halt progression of myocardial dysfunction
  • reverse myocardial process


Systolic Heart Failure: Left Heart Failure


Classification of Heart Failure

  • reduced left-sided contractility
  • pulmonary congestion resulting in dyspnea
  • etiology
    • CAD
    • HTN
    • idopathic dilated cardiomyopathy
    • toxin (alcohol, cocaine, meth)
    • valvular heart disease
    • congenital heart disease
    • viral cardiomyopathy (coxsackie, HIV, CMV)
    • obesity
    • peri-partum cardiomyopathy
    • vitamin/mineral deficiency


Stages of Heart Failure

At Risk for Heart Failure

  • A: high risk of developing HF
  • B: asymptomatic LV dysfunction

Heart Failure

  • C: past or current symptoms of HF
  • D: end-stage HF

emphasize the preventability of heart failure

can only move A to D due to cardiac remodeling



History in Heart Failure Patients

History is important to help

  • establish HF as the cause of symtpoms
  • determine etiology
  • establish severity and functional class


Functional Classification of Heart Failure

NYHA Classification of HF

Class I: No limitation of physical activity

Class II: Slight limitation of activity. Dyspnea and fatigue with moderate activity (walking up stairs quickly)

Class III: Marked limitation of activity. Dyspnea with minimal activity (slowly walking up stairs)

Class IV: Severe limitation of activity.  Symptoms are present even at rest

can move bi-directionally


Cardiac Catheterization

indicated if further evaluation of cardiac function is necessary - extent of vascular disease, CAD and possible revascularization


Thearpy for Heart Failure

cardiac surgery with ischemic cardiomyopathy

eliminate/correct reversible causes and/or aggrevating factors

  • ischemia
  • HTN
  • arrhythmias
  • thyroid disease
  • anemia
  • vitamin deficiency
  • sleep apnea
  • drugs with negative inotropic effect
  • NSAIDs
  • alcohol
  • obesity

restrict Na intake < 2 grams/day


Stages of Heart Failure - A

Patients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. 

Such patients have no identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves and have never shown signs or symptoms of HF.


Chest X-Ray


Diagnostic Studies in Heart Failure Patients

  • information on size and shape of cardiac silhouette
  • cardiomegaly
  • evidence of pulmonary venous hypertension
    • dilation of veins
    • perivascular edema
    • interstitial edema
  • pleural effusions


Jugular Venous Pressure

  • indicator of volume and pressure in the right side of the heart
  • pulsations absent when patient is upright