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Flashcards in Heart Failure Continuum of Care Deck (100)
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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
Q

Possible Evidence of Low Perfusion

A
Narrow pulse pressure
Sleepy/obtunded
Low serum sodium
Cool extremities
Hypotension with ACE inhibitor
Renal dysfunction
26
Q

Signs/Symptoms of Congestion

A
Orthopnea/PND
JV distension
Ascites
Edema
Rales (rare)
S3
Hepato-jugular reflex
27
Q

Follow Up Questions with SOB

A

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
Q

Follow Up Questions with Cough

A

Productive, non-productive, blood tinged sputum
Worse with exertion or when lying down
Patient taking any new medication

29
Q

Follow Up Questions with Chest Pain

A
Description
Accompanied by diaphoresis, SOB, N/V
Alleviating or aggravation factors
With or without exertion
Awaken patient from sleep
30
Q

Follow Up Questions with Palpitations

A

Circumstances when symptoms occur
Duration & description
Accompanied by dizziness, loss of consciousness, shock from ICD

31
Q

Follow Up Questions with Dizziness, Lightheadedness, Syncope

A

Occur with position changes, while bending over
Accompanied by palpitations
Loss of consciousness (alone or witnessed)

32
Q

Follow Up Questions with Abdominal Fullness

A

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
Q

Follow Up Questions with Dietary Habits

A

Table salt added while cooking or eating
Consuming frozen processed meals, canned foods, eating in restaurants
Foods high in fat/cholesterol

34
Q

Follow Up Questions with Edema

A

Presence in feet, ankles, calf, knees, back
Resolve overnight
Skin painful or seeping

35
Q

Follow Up Questions with Sleep

A

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
Q

Follow Up Questions with Mentation

A

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
Q

Follow Up Questions with Substance Abuse

A

Smoking
Illicit drugs
Alcohol

38
Q

Follow Up Questions with Past Disease/Treatment

A
Recent infections
Symptoms
Treatment
Rheumatic fever
Chemo: type & year
39
Q

Clues for Identifying Patients with Advanced HF

A

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
Q

Diagnostic Testing for HF

A
CXR
Lab: include biomarkers
ECG
ECHO, MUGA, MRI
Risk stratification for CAD
Risk stratification for HF
41
Q

Non-invasive Imaging for Risk Stratification for CAD

A

Nuclear stress test

Stress echo

42
Q

Invasive Imaging for Risk Stratification for CAD

A

Cardiac cath

43
Q

Initial Lab Testing & as Indicated

A
CBC without diff
CMP
A1C
BNP
TSH
Lipid panal
UA: proteinuria, RBCs
Uric acid
CXR (new/suspected HF)
44
Q

Diuretic Guidelines

A

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
Q

SE of Diuretic Therapy

A

Electrolyte abnormalities
Symptomatic hypotension
Renal dysfunction
Worsening renal function

46
Q

MOA of ACE Inhibitors

A

Inhibits conversion of angiotensin I to II
Dilates blood vessels
Decreases systemic vascular resistance & blood pressure

47
Q

Effect of ACE Inhibitors

A

Reduces morbidity & mortality

Improves cardiac function, symptoms, & clinical status

48
Q

Contraindications for ACE Inhibitors or ARBs

A
Hx of intolerance
Pregnancy
Serum K+ >5 mEq/L
Symptomatic hypotension
Caution: patients with Cr >3.0 mg/dL
49
Q

Surveillance with ACE Inhibitors & ARBs

A

BP
Renal function
Potassium

50
Q

ACE Inhibitors in HF

A

Captopril
Enalapril
Lisinopril
Ramipril

51
Q

Beta-blockers in HF

A

Metoprolol XL
Carvedilol
Bisoprolol

52
Q

When to start beta-blockers?

A

When patient is NOT significantly congested

53
Q

Beta-Blocker Effects

A
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
Q

Managing Vasodilator SE of Beta-Blocker Up-Titration

A

Temporary
Separate dosing of Beta-blocker & ACEI
Persistent: reduce vasodilators

55
Q

Managing Fluid Retention in Beta-Blocker Up-Titration

A

Increase diuretic to restore baseline weight

Delay up-titrating until weight is at baseline

56
Q

Managing Bradycardia/AV Block in Beta-Blocker Up-Titration

A

Check digoxin level

Persistent: cardiac pacing

57
Q

Patient Selection for Aldosterone Antagonists

A

On ACEI/ARB & beta-blocker therapy
K+ less than 5.0
Creatinine less than 2.5 in men & 2.0 in women

58
Q

When is an aldosterone antagonist not recommended?

A

Absence of a concomitant loop diuretic

59
Q

New HF Drugs

A

Entresto (Sacubitril/valsartan)

Corlanor (Ivabradine)

60
Q

MOA of Entresto (Sacubitril/valsartan)

A

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
Q

Monitoring with Entresto (Sacubitril/valsartan)

A
BP
Volume status
BUN/Cr
K+
BNP: may impact
62
Q

SE of Entresto (Sacubitrli/valsartan)

A
Decreased BP
Hyperkalemia
Cough
Dizziness
Acute renal failure
Angioedema
63
Q

MOA of Corlanor (Ivabradine)

A

Reduces the slow diastolic depolarization phase

64
Q

Indications for Corlanor (Ivabradine)

A

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
Q

Contraindications for Corlanor (Ivabradine)

A
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
Q

Relative Contraindications for Corlanor (Ivabradine)

A
Negative chronotropes (amiodarone, digoxin)
Increased bradycardia
67
Q

SE of Corlanor (Ivabradine)

A
Bradycardia
HTN
Dizziness
Fatigue
Complete heart block
A-fib
68
Q

Interactions with Corlanor (Ivabradine)

A

Not for patients with a demand pacemaker set to a rate of >60 bpm
Delayed absorption with food
Increased plasma exposure

69
Q

Monitoring Parameters

A
HR (50-60 bpm)
Signs/symptoms of improvement in HF
Cardiac rhythm
BP
HR
70
Q

Other Medical Treatments for HF

A
Vasodilators: nesiritide, nitroglycerine, nipride)
Inotrope infusion: dobutamine, dopamine
Milrinone (Primacor) "inodilator)
Anticoagulation
Dysrhythmics
Lipid management
Screen for sleep disordered breathing
71
Q

MOA of Dobutamine

A

Stimulates beta-adrenergic receptors

Can not be used with beta-blockers

72
Q

MOA of Dopamine

A

Norepinephrine release

Promotes diuresis

73
Q

MOA of Milrinone (Primacor) “inodilator”

A

Decreases systemic vascular resistance & peripheral vascular resistance
Increase cardiac output
Can be used with beta-blockers

74
Q

Treatment Strategies for HF preserved EF`

A

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
Q

Treatment Strategies for Right Sided HF

A
Oxygen therapy
Inhalers, CPAP if indicated
Digoxin: rhythm problems
Diuretics
Pulmonary HTN
Accompanied with preserved LV HF
76
Q

Medications that May Hurt a HF Patient

A
Most CCBs
Amlodipine
Felodipine
Anti-arrhythmic drugs
Megestrol acetate
NSAIDs
Corticosteroids
77
Q

Surgeries & Medical Devices to Treat HF

A
CABG
TAVR
Cardiac tranplantation
CRT: cardiac resynchronization therapy (bi-ventricular pacing)
ICD
LVAD
78
Q

Indications for ICD Placement

A

LVEF less than 35%
QRS >120 ms
NYFC III-IV

79
Q

Ventricular Assistive Devices (VADs)

A
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
Q

VADs & Emergencies

A
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
Q

Complications of LVADs

A
Arrhythmias: stable vs. unstable
Right heart failure
Hypovolemia
Bleeding
Infection (drive line)
Thrombus/stroke (embolic/hemorrhagic)
82
Q

Non-Pharmacologic Recommendations for Heart Failure Patients

A
Sodium restrictions
Fluids
Sleep disordered breathing
Weight
Exercise
Education/self-care
83
Q

Risk Factors for OSA

A
Obesity
Male
Post-menopausal women
Men neck >16"
Women neck >15"
84
Q

Risks with having OSA

A
Exacerbate myocardial ischemia
Increased risk for arrhythmias
Fatigue
Excessive daytime sleepiness
Mood disturbance
Decrease QOL
85
Q

Benefits of CPAP

A
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
Q

Weight Management & HF

A

BMI: 18-30 ideal

Cachexia

87
Q

Cachexia & HF

A

Predicts worse prognosis

Weight loss >5% in 12 months or BMI

88
Q

Exercise & HF

A

Recommended as safe/effective for patients who are able to improve functional status
Cardiac rehab can improve functional capacity, exercise duration, QOL, & mortality

89
Q

When should a HF patient stop exercise?

A
Rapid pulse
CP/pressure
Unusual SOB
Irregular or slow HR
Weakness
Faintness or dizziness
Extreme fatigue
90
Q

Define Self-Care

A

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
Q

Mechanisms Through Which HF Self-Care Influences Health outcomes

A

Neuro-hormonal deactivations
Limited inflammation
Avoidance of pharmacology
Limited myocardial hibernation

92
Q

Self-Care Activities in HF

A
Medications: take as prescribed
Follow a lower sodium diet
Monitoring symptoms of worsening HF
Daily weighing
Physical activity
Alcohol, smoking, fluid intake
93
Q

Hospitalization Requirements for HF Patients

A

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
Q

Guiding the HF Patient out the Door

A
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
Q

Risk Factors for Highest Risk of Readmission

A

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
Q

3 Phases of Progressive HF

A

Chronic disease management
Supportive & palliative care phase
Terminal care phase

97
Q

Parts of Chronic Disease Management

A

Diagnosis
Focus on extended survival
Concurrent palliation of symptoms
Promoting self care

98
Q

Parts of Supportive & Palliative Care Phase

A

Appropriate when patients require recurrent hospitalizations
Focus on promoting comfort & QOL
Palliation of symptoms & advanced care planning

99
Q

Barriers to the Use of Palliative Care

A

Traditional model of medicine: cure & comfort are mutually exclusive
Proposed integrated model of palliative care

100
Q

Define Hospice Care

A

A deploy of a team of doctors, nurses, chaplains, & social workers to help people with fatal illness to have the fullest possible lives now