Heart Failure Continuum of Care Flashcards
(100 cards)
1
Q
Co-morbidities with Heart Failure in WOMEN
A
HTN Valvular disease Thyroid function Less obstructive CAD DM LVH (increased mortality)
2
Q
Define Heart Failure
A
Complex, heterogeneous & progressive syndrome characterized by structural and/or functional abnormalities in cardiac contraction, consequent adverse euro-hormonal adaptations & remodeling & co-morbidities that collectively alter myocardial function, fluid regulation, respiration, & perfusion & overall hemodynamic stability
3
Q
Unusual Causes of Cardiomyopathy
A
Hypertrophic obstructive cardiomyopathy (HCM) AL amyloid cardiomyopathy Myocarditis Tachycardia-induced cardiomyopathy (TIC) Takotsubo cardiomyopathy (TTC) Peripartum cardiomyopathy (PPCM)
4
Q
Co-Morbid Conditions in Heart Failure
A
Anemia: of chronic disease Gout: thiazides contribute HTN Renal dysfunction: murderous marriage with the heart Lung disease; sleep-disordered breathing Rapid or irregular dysrhythmias DM Thyroid disorders
5
Q
Types of Remodeling in Heart Failure
A
Hypertrophy (preserved EF HF)
Dilation (reduced EF HF)
6
Q
Clinical Features of Heart Failure with Preserved Ejection Fraction
A
Volume overload
Decreased activity tolerance
QOL similar to low EF patients
7
Q
Heart failure with preserved ejection fraction is associated with what kind of dysfunction?
A
Diastolic dysfunction
8
Q
Signs/Symptoms of Diastolic Dysfunction
A
Increased LV wall stiffness
Decreased compliance/impaired relaxation
Decreased cardiac output
9
Q
3 Stages of Diastole
A
Isovolemic (active) relaxation & rapid early filling
Diastasis (passive) filling
Active filling during atrial contraction
10
Q
Define Grade 1 Diastolic Heart Failure
A
Impaired relaxation
11
Q
Define Grade 2 Diastolic Heart Failure
A
Pseudonormal
Concomitant LA enlargement, LV hypertrophy and/or decreased LV ejection fraction
12
Q
Define Grade 3 Diastolic Heart Failure
A
Restrictive/constrictive Difference is reversibility Impaired LV relaxation Increased LV stiffness Increased LA pressures
13
Q
Define Dilation
A
Compensate for poor cardiac output, ventricle dilates, becomes thinned & weakened
14
Q
Heart failure with reduced ejection fraction is associated with what kind of dysfunction?
A
Systolic dysfunction
15
Q
Clinical Features of Reduced Ejection Fraction Heart Failure
A
Impairment of LV contraction EF less than 40% Decreased stroke volume Decreased cardiac output Engorgement of systemic veins Decreased perfusion to vital organs
16
Q
Atrial Fibrillation in Heart Failure
A
Lead to an acute decompensated state
17
Q
Common Symptoms of A-fib in Heart Failure
A
Fatigue
Dyspnea
Especially in preserved HF
18
Q
Factors that Contribute to HF
A
Cardiac chamber enlargement Conduction system & anatomical heart abnormalities Adaptations of SNS Adverse responses to medications Electrolyte abnormalities
19
Q
Functional Classification of HF
A
Class 1 (Minimal): no limitations Class 2 (Mild): no strenuous activity Class 3 (Moderate): activity limited to ADLs Class 4 (Severe): symptoms with any physical activity
20
Q
2 Parts of a Cardiovascular Assessment
A
Wet or dry: assessing fluid status & congestion
Warm or cold: assessing indicators of perfusion
21
Q
No Low Perfusion or Congestion at Rest
A
Warm & dry
22
Q
Congestion at Rest but No Low Perfusion at Rest
A
Warm & wet
23
Q
Low Perfusion at Rest & No Congestion at Rest
A
Cold & dry
24
Q
Lower Perfusion & Congestion at Rest
A
Cold & wet
25
Possible Evidence of Low Perfusion
```
Narrow pulse pressure
Sleepy/obtunded
Low serum sodium
Cool extremities
Hypotension with ACE inhibitor
Renal dysfunction
```
26
Signs/Symptoms of Congestion
```
Orthopnea/PND
JV distension
Ascites
Edema
Rales (rare)
S3
Hepato-jugular reflex
```
27
Follow Up Questions with SOB
Occurring at rest or with exertion
Awaken patient from sleep
Occur when walking on a flat surface; worse with stairs/carrying items
Increasing with daily activities now as opposed to 1 & 6 months ago
Ask family if patient looks more SOB than normal
28
Follow Up Questions with Cough
Productive, non-productive, blood tinged sputum
Worse with exertion or when lying down
Patient taking any new medication
29
Follow Up Questions with Chest Pain
```
Description
Accompanied by diaphoresis, SOB, N/V
Alleviating or aggravation factors
With or without exertion
Awaken patient from sleep
```
30
Follow Up Questions with Palpitations
Circumstances when symptoms occur
Duration & description
Accompanied by dizziness, loss of consciousness, shock from ICD
31
Follow Up Questions with Dizziness, Lightheadedness, Syncope
Occur with position changes, while bending over
Accompanied by palpitations
Loss of consciousness (alone or witnessed)
32
Follow Up Questions with Abdominal Fullness
Weight change in the past week, month
Presence of nausea, early satiety, abdominal bloating
Clothes feel tight (pants, belt)
Experiencing RUQ tenderness, feelings of pressure in abdomen
33
Follow Up Questions with Dietary Habits
Table salt added while cooking or eating
Consuming frozen processed meals, canned foods, eating in restaurants
Foods high in fat/cholesterol
34
Follow Up Questions with Edema
Presence in feet, ankles, calf, knees, back
Resolve overnight
Skin painful or seeping
35
Follow Up Questions with Sleep
Awaken during the night with SOB
| Able to lay flat, sleep propped up in bed, on a sofa, recliner, or sit at the edge of the bed
36
Follow Up Questions with Mentation
Difficulty thinking, staying awake, concentrating or understanding written/verbal communication
Does family notice whether patient's mind drifts or not paying attention
Falling asleep while talking to someone in person or on the phone
37
Follow Up Questions with Substance Abuse
Smoking
Illicit drugs
Alcohol
38
Follow Up Questions with Past Disease/Treatment
```
Recent infections
Symptoms
Treatment
Rheumatic fever
Chemo: type & year
```
39
Clues for Identifying Patients with Advanced HF
Repeated hospitalizations or ED visits for HF in past year
Progressive deterioration in renal function
Weight loss without other cause
Intolerance to ACE inhibitors due to hypotension and/or worsening renal function
Intolerance to beta blockers due to worsening HF or hypotension
Frequent systolic blood pressure
40
Diagnostic Testing for HF
```
CXR
Lab: include biomarkers
ECG
ECHO, MUGA, MRI
Risk stratification for CAD
Risk stratification for HF
```
41
Non-invasive Imaging for Risk Stratification for CAD
Nuclear stress test
| Stress echo
42
Invasive Imaging for Risk Stratification for CAD
Cardiac cath
43
Initial Lab Testing & as Indicated
```
CBC without diff
CMP
A1C
BNP
TSH
Lipid panal
UA: proteinuria, RBCs
Uric acid
CXR (new/suspected HF)
```
44
Diuretic Guidelines
Used in symptomatic patients to reduce fluid
Increase initial dose as necessary to relieve congestion
Torsemide & bumetanide can be effective in patients with poor absorption of oral meds or erratic diuretic effect, esp. RHF
IV diuretics may be pessary to relieve congestion
Avoid chlorthiadone or metolazone when high-dose loop diuretic therapy not effective
Education to adjust daily dose of diuretic in response to weight gain from fluid overload
Diuretic refractoriness may represent patient non-adherence
Observe for SE
45
SE of Diuretic Therapy
Electrolyte abnormalities
Symptomatic hypotension
Renal dysfunction
Worsening renal function
46
MOA of ACE Inhibitors
Inhibits conversion of angiotensin I to II
Dilates blood vessels
Decreases systemic vascular resistance & blood pressure
47
Effect of ACE Inhibitors
Reduces morbidity & mortality
| Improves cardiac function, symptoms, & clinical status
48
Contraindications for ACE Inhibitors or ARBs
```
Hx of intolerance
Pregnancy
Serum K+ >5 mEq/L
Symptomatic hypotension
Caution: patients with Cr >3.0 mg/dL
```
49
Surveillance with ACE Inhibitors & ARBs
BP
Renal function
Potassium
50
ACE Inhibitors in HF
Captopril
Enalapril
Lisinopril
Ramipril
51
Beta-blockers in HF
Metoprolol XL
Carvedilol
Bisoprolol
52
When to start beta-blockers?
When patient is NOT significantly congested
53
Beta-Blocker Effects
```
Increased LVEF
Global symptom improvement
Decreased hospitalizations & mortality
Decreased sympathetic stimulation
Stable HF & LVEF less than 40%
Beneficial in DM2 or CAD
Ok with COPD, PAD
```
54
Managing Vasodilator SE of Beta-Blocker Up-Titration
Temporary
Separate dosing of Beta-blocker & ACEI
Persistent: reduce vasodilators
55
Managing Fluid Retention in Beta-Blocker Up-Titration
Increase diuretic to restore baseline weight
| Delay up-titrating until weight is at baseline
56
Managing Bradycardia/AV Block in Beta-Blocker Up-Titration
Check digoxin level
| Persistent: cardiac pacing
57
Patient Selection for Aldosterone Antagonists
On ACEI/ARB & beta-blocker therapy
K+ less than 5.0
Creatinine less than 2.5 in men & 2.0 in women
58
When is an aldosterone antagonist not recommended?
Absence of a concomitant loop diuretic
59
New HF Drugs
Entresto (Sacubitril/valsartan)
| Corlanor (Ivabradine)
60
MOA of Entresto (Sacubitril/valsartan)
Sacubitril: inhibits breakdown of vasoactive peptides including BNP, bradykinin; results in natriuresis & diuresis
Valsartan: ARB, antagonizes angiotensin II at ATI receptor; decreases AT II dependent aldosterone release, increases vasodilation
61
Monitoring with Entresto (Sacubitril/valsartan)
```
BP
Volume status
BUN/Cr
K+
BNP: may impact
```
62
SE of Entresto (Sacubitrli/valsartan)
```
Decreased BP
Hyperkalemia
Cough
Dizziness
Acute renal failure
Angioedema
```
63
MOA of Corlanor (Ivabradine)
Reduces the slow diastolic depolarization phase
64
Indications for Corlanor (Ivabradine)
Reduce risk of hospitalization for worsening HFrEF
| Slow releasing with HR resting >70 bp on maximum beta-blocker or contraindicated for beta-blocker use
65
Contraindications for Corlanor (Ivabradine)
```
Acute decompensated heart failure
BP less than 90/50
Sick sinus syndrome
SA block
Complete heart block
Resting heart rate less than 60 bpm
Severe hepatic impairment
Pacemaker dependent
```
66
Relative Contraindications for Corlanor (Ivabradine)
```
Negative chronotropes (amiodarone, digoxin)
Increased bradycardia
```
67
SE of Corlanor (Ivabradine)
```
Bradycardia
HTN
Dizziness
Fatigue
Complete heart block
A-fib
```
68
Interactions with Corlanor (Ivabradine)
Not for patients with a demand pacemaker set to a rate of >60 bpm
Delayed absorption with food
Increased plasma exposure
69
Monitoring Parameters
```
HR (50-60 bpm)
Signs/symptoms of improvement in HF
Cardiac rhythm
BP
HR
```
70
Other Medical Treatments for HF
```
Vasodilators: nesiritide, nitroglycerine, nipride)
Inotrope infusion: dobutamine, dopamine
Milrinone (Primacor) "inodilator)
Anticoagulation
Dysrhythmics
Lipid management
Screen for sleep disordered breathing
```
71
MOA of Dobutamine
Stimulates beta-adrenergic receptors
| Can not be used with beta-blockers
72
MOA of Dopamine
Norepinephrine release
| Promotes diuresis
73
MOA of Milrinone (Primacor) "inodilator"
Decreases systemic vascular resistance & peripheral vascular resistance
Increase cardiac output
Can be used with beta-blockers
74
Treatment Strategies for HF preserved EF`
Manage comorbidities: BP, a-fib, myocardial ischemia, DM
Block neuro-hormonal activation
Improve left ventricle relaxation
Screen for/treat sleep disordered breathing
Sodium restriction
75
Treatment Strategies for Right Sided HF
```
Oxygen therapy
Inhalers, CPAP if indicated
Digoxin: rhythm problems
Diuretics
Pulmonary HTN
Accompanied with preserved LV HF
```
76
Medications that May Hurt a HF Patient
```
Most CCBs
Amlodipine
Felodipine
Anti-arrhythmic drugs
Megestrol acetate
NSAIDs
Corticosteroids
```
77
Surgeries & Medical Devices to Treat HF
```
CABG
TAVR
Cardiac tranplantation
CRT: cardiac resynchronization therapy (bi-ventricular pacing)
ICD
LVAD
```
78
Indications for ICD Placement
LVEF less than 35%
QRS >120 ms
NYFC III-IV
79
Ventricular Assistive Devices (VADs)
```
Type of mechanical circulatory support device sufficient to replace/assist pumping function of the LV
Durable
Expensive: $75K-125K
Narrowed/no pulse pressure
No valves: constant flow
```
80
VADs & Emergencies
```
Do not interfere with ICD/pacemaker
Can exercise like everyone else
Patient responsive?
LVAD pumping?
Get LVAD running?
CPR only if LVAD not running
Defibrillation can be done
```
81
Complications of LVADs
```
Arrhythmias: stable vs. unstable
Right heart failure
Hypovolemia
Bleeding
Infection (drive line)
Thrombus/stroke (embolic/hemorrhagic)
```
82
Non-Pharmacologic Recommendations for Heart Failure Patients
```
Sodium restrictions
Fluids
Sleep disordered breathing
Weight
Exercise
Education/self-care
```
83
Risk Factors for OSA
```
Obesity
Male
Post-menopausal women
Men neck >16"
Women neck >15"
```
84
Risks with having OSA
```
Exacerbate myocardial ischemia
Increased risk for arrhythmias
Fatigue
Excessive daytime sleepiness
Mood disturbance
Decrease QOL
```
85
Benefits of CPAP
```
Improve heart function & functional status in HF patients
Decreased apnea-hypopnea index
Increased nocturnal O2
Increased LVEF
Decreased norepinephrine levels
Increased 6 minute walk distance
```
86
Weight Management & HF
BMI: 18-30 ideal
| Cachexia
87
Cachexia & HF
Predicts worse prognosis
| Weight loss >5% in 12 months or BMI
88
Exercise & HF
Recommended as safe/effective for patients who are able to improve functional status
Cardiac rehab can improve functional capacity, exercise duration, QOL, & mortality
89
When should a HF patient stop exercise?
```
Rapid pulse
CP/pressure
Unusual SOB
Irregular or slow HR
Weakness
Faintness or dizziness
Extreme fatigue
```
90
Define Self-Care
Process whereby individuals and/or their caregivers perform the daily activities that serve to maintain health, well-being, prevent illness, manage chronic illness or restore health
91
Mechanisms Through Which HF Self-Care Influences Health outcomes
Neuro-hormonal deactivations
Limited inflammation
Avoidance of pharmacology
Limited myocardial hibernation
92
Self-Care Activities in HF
```
Medications: take as prescribed
Follow a lower sodium diet
Monitoring symptoms of worsening HF
Daily weighing
Physical activity
Alcohol, smoking, fluid intake
```
93
Hospitalization Requirements for HF Patients
Worsened congestion without dyspnea
S/S of pulmonary or systemic congestion even in absence of weight gain
Major electrolyte disturbance
Associated co-morbid conditions
Symptoms suggestive of TIA or stroke
Repeated ICD firings
Previously undiagnosed HF with S/S of systemic or pulmonary congestion
94
Guiding the HF Patient out the Door
```
Near optimal volume
Stable after transition from IV to oral diuretics for 24 hours
Exacerbating factors addressed
LV EF documented
Near-optimal medical therapy
Patient & family education initiated
FU clinic visit scheduled within 7 days
```
95
Risk Factors for Highest Risk of Readmission
Advanced age
Co-morbidities: renal disease, DM2, COPD, HF severity, psychiatric disease, frailty
Low education/literacy levels
Prior admission for HF
Patient behaviors: lacking self-care skills, adherence issues, substance abuse
Not ready for discharge
Absence of family, friend, religious, social, & financial support & access to transportation
96
3 Phases of Progressive HF
Chronic disease management
Supportive & palliative care phase
Terminal care phase
97
Parts of Chronic Disease Management
Diagnosis
Focus on extended survival
Concurrent palliation of symptoms
Promoting self care
98
Parts of Supportive & Palliative Care Phase
Appropriate when patients require recurrent hospitalizations
Focus on promoting comfort & QOL
Palliation of symptoms & advanced care planning
99
Barriers to the Use of Palliative Care
Traditional model of medicine: cure & comfort are mutually exclusive
Proposed integrated model of palliative care
100
Define Hospice Care
A deploy of a team of doctors, nurses, chaplains, & social workers to help people with fatal illness to have the fullest possible lives now
