HF lecture

Question 1

A pathophysiologic state in which an abnormality of cardiac function is responsible for failure of the heart to pump blood at a rate commensurate with the requirements of the metabolizing tissues and/or can do so only from an abnormally elevated diastolic volume/pressure.

Answer 1

Heart failure

Question 2

Coronary heart dz
Primary pump failure
Valvular heart dz
Congenital heart dz
Uncontrolled HTN

can all cause…

Answer 2

Heart failure

Question 3

Primary contraction abnormality; inadequate delivery of O2 to tissues and associated symptoms; e.g: large or multiple MI(s), dilated cardiomyopathy, chronic AR, MR.

Answer 3

Systolic failure (or dysfunction)

Question 4

Impaired ventricular relaxation- elevation of ventricular filling pressures and associated symptoms; e.g: long standing hypertension (with LVH), hypertrophic cardiomyopathy, acute ischemia, prior infarcts, restrictive cardiomyopathy.

Answer 4

Diastolic failure (or dysfunction)

Question 5

Can diastolic and systolic failure occur together?

Answer 5

YES

Question 6

Most common cause of R sided failure?

Answer 6

L sided failure/dysfunction

Question 7

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

Answer 7

Backward failure

Question 8

Inadequate forward CO; Na and water retention result from diminished renal perfusion and activation of renin-angiotensin-aldosterone system.

Answer 8

Forward failure

Question 9

Compensatory mechanisms of HF?

Answer 9

• Redistribution of CO

- Na and H20 retention

Question 10

Increase levels of norepinephrine result in increase HR, contractility and SVR- helps maintain arterial perfusion pressure (BP) in presence of decreased CO.

Answer 10

Adrenergic Nervous System

Question 11

Long term elevation of catecholamines leads to progressive myocardial damage and….

Answer 11

fibrosis

Question 12

extremely potent vasoconstrictor- leads to arteriolar constriction and increase in SVR, raising BP.

Answer 12

Angiotensin II

Question 13

Angiotensin II stimulates adrenal gland to secrete…

Answer 13

Aldosterone

Question 14

a mineralocorticoid hormone that ↑’s renal Na and H2O reabsorption; contributes to edema formation.

Answer 14

Aldosterone

Question 15

Long term activation of angiotensin II and aldosterone lead to myocardial thinning and..

Answer 15

fibrosis (remodeling)

Question 16

Which NYHA classification of Heart dz:

No limitation of physical activity. No symptoms of SOB, CP dizzyness, etc.

Answer 16

I

Question 17

Which NYHA classification of Heart dz:

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

Answer 17

II

Question 18

Which NYHA classification of Heart dz:

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

Answer 18

III

Question 19

Which NYHA classification of Heart dz:

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

Answer 19

IV

Question 20

3 common manifestations of HF

Answer 20

Dyspnea
Orthopnea
Paroxysmal Nocturnal Dyspnea

Question 21

Severe dyspnea at rest as pulmonary congestion progresses; accompanied by marked elevation of pulmonary capillary pressure (PCP) leading to interstitial, then alveolar edema. A medical emergency usually addressed in ED.

Answer 21

Acute pulmonary edema

Question 22

How can you measure pulmonary pressure?

Answer 22

Right heart cath

can get Capillary Wedge pressure

Question 23

PCW greater than 20 mmHg

Answer 23

Interstitial edema

Question 24

PCW greater than 25 mmHg

Answer 24

Alveolar edema

Question 25

moist inspiratory crackles, begin at bases and progress upwards through the lungs; wheezes occasionally heard.

Answer 25

Crackles

Question 26

* Increased systemic venous pressure; JVD reflects ↑JVP * Hepato-Jugular Reflux. * Congestive hepatomegaly- enlarged, tender, pulsatile liver.

Answer 26

Acute pulmonary edema

Question 27

“Wasted appearance” occurs with severe chronic heart failure→weight loss, anorexia, nausea; correlates with increased levels of cytokines like circulating tumor necrosis factor.

Answer 27

Cardiac cachexia

Question 28

findings unique to pathology responsible for HF; best non-invasive tool. Identifies ventricular dysfunction and EF.

Answer 28

Echo-doppler

Question 29

hormone produced by heart (ventricle) in response to wall stress- marker of decompensated heart failure in blood

Answer 29

beta-type natriuretic peptide (BNP)

Question 30

* Blood test for acute ventricular dysfunction → symptomatic heart failure. * Useful in diagnosis of HF in patients presenting with SOB of uncertain (Cardiac vs Pulm) etiology and confirming HF when suspected clinically.

Answer 30

BNP

Question 31

``` Has vasodilator (a&v) and diuretic properties. Normal is 100pg/ml common with HF. ```

Answer 31

BNP

Question 32

What do you want to start right way in HF patients?

Answer 32

ACEi/ARBs

Question 33

Must monitor renal function (BUN, Cr.) serum electrolytes (esp. K), uric acid and glucose **can cause hypokalemia, and hyperuricemia as well as metabolic alkalosis.

Answer 33

Loop diuretics

Question 34

Which drugs decrease remodeling of the LV post MI and in HF by reducing wall thinning, fibrosis and interfering with programmed cell death (apoptosis) result is ↓ mortality

Answer 34

ACE inhibitors

Question 35

Do ARBs increase bradykinin (and therefor cause a cough)?

Answer 35

NO!

Question 36

Drug class of Valsartan

Answer 36

ARB

Question 37

MUST!!! check K levels in these patients, because this drug is potassium sparing

Answer 37

Aldosterone Antagonist

Question 38

Prolongs refractory period of AV node (vagal tone increased): slows rate of Atrial fibrillation and flutter. Modest improvement in cardiac function in patients with LV dilatation and dysfunction. Falling out of favor for Rx of CHF; improves symptom but not mortality.

Answer 38

Digoxin

Question 39

Sympathomimmetic amines are given via...

Answer 39

IV

Question 40

Potent inotropes administered IV for...

Answer 40

short term use

Question 41

- Secondary: Rescusitated cardiac arrest/Vfib or hemodynamically unstable Vtach - Primary: EF ≤ .35 + mild to moderate HF symptoms indications for....

Answer 41

implantable cardioverter defibrillators (ICD)

Question 42

low pitched sound in early diastole.
(best heard with the bell bc it is low pitched)

Answer 42

S3 gallop

Question 43

Useful in diagnosis of HF in patients presenting with SOB of uncertain (Cardiac vs Pulm) etiology and confirming HF when suspected clinically.

Answer 43

BNP

Question 44

ACE inhibitors Beta blockers Spironolactone all prevent...

Answer 44

Remodeling

Question 45

Once HF is symptomatic, prognosis is..

Answer 45

poor

Question 46

severe failure (class IV) has ____% mortality in 12 months

Answer 46

40-50%

Question 47

Moderate failure (class III)- 40-50% mortality in...

Answer 47

3-4 years

Question 48

30-40% of HF patients die suddenly due to...

Answer 48

an arrhythmia

Question 49

ow many grams of Na should you try to stay under with a low sodium diet

Answer 49

4 gm

Question 50

Cramping and constipation could be indicative of...

Answer 50

HYPOkalemia

Question 51

In patients with acute and chronic HF, treatment with _______ results in: decreasing SVR, increasing CO, decreasing PCW, and relief of symptoms; also decreases mortality.

Answer 51

vasodilators

Question 52

Reduce mortality by >25%. | Long term, has natriuretic effects resulting in improved diuresis (↓ production of aldosterone).

Answer 52

ACE inhibitors

Question 53

these decrease remodeling of the LV post MI and in HF by reducing wall thinning, fibrosis and interfering with programmed cell death (apoptosis) result is ↓ mortality.

Answer 53

ACE inhibitors

Question 54

Elevation of _____ from ACE inhibition may also have beneficial effects on hemodynamics (vasodilation) and remodeling

Answer 54

kinins

Question 55

increased levels of prostaglandins and nitric oxide may lead to...

Answer 55

vasodilation

Question 56

Drug related persistent cough resulting from elevated bradykinin levels; occurs in up to 15-20% of patients, but only 5% need to DC the drug.

Answer 56

ACE inhibitor

Question 57

Must monitor renal function; Cr and BUN often increase mildly (and expectedly) with..

Answer 57

ACE inhibitor

Question 58

Beneficial for all classes of heart failure with up to 30% decrease in mortality.

Answer 58

Beta blockers

Question 59

What MUST you check in aldosterone antagonists

Answer 59

potassium levels!!! | these are K sparing, may have HYPERkalemia

Question 60

only oral inotropic agent available; improves cardiac contractility. Increases automaticity of cardiac electrical tissue - can induce arrhythmias.

Answer 60

Digoxin