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Flashcards in Non-Pharmacology Heart Failure Deck (21)
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Framingham Major Criteria of HF

Major criteria:
Paroxysmal nocturnal dyspnea
Neck vein distention
Radiographic cardiomegaly (increasing heart size on chest radiography)
Acute pulmonary edema
S3 gallop
Increased central venous pressure (>16 cm H2O at right atrium)
Hepatojugular reflux
Weight loss >4.5 kg in 5 days in response to treatment


Framingham Minor Criteria of HF

Minor criteria:
Bilateral ankle edema
Nocturnal cough
Dyspnea on ordinary exertion
Pleural effusion
Decrease in vital capacity by one third from maximum recorded
Tachycardia (heart rate>120 beats/min.)

Minor criteria are acceptable only if they can not be attributed to another medical condition (such as pulmonary hypertension, chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome).


Criteria Guidelines for HF

EF lower than 45% AND
2 major OR 1 major + 2 minor criteria met

People can be perfectly normal and functional with an EF of 20% because that is how their body works even though 55% and higher is normal


Most Important Vital Sign for HF

The biggest and most important vital sign in heart failure is the weight
1 liter of water = 1kg
Have patients monitor weight for fluid balance


Clinical Stages of CHF

Normal: no symptoms, normal exercise, normal LV function

Asymptomatic LV Dysfunction: no symptoms, normal exercise, abnormal LV function

Compensated CHF: no symptoms, slightly decreased exercise, abnormal LV dysfunction

Decompensated CHF: symptoms, greatly decreased exercise, abnormal LV function

Refractory CHF: symptoms not controlled with treatment


Medical Therapies for Systolic HF

Many therapies, but standards are:
ACE (preload and afterload reduction)
Beta blockers (decrease sympathetics and recover EF over time)
AICD automatic internal cardiac defibrillator
Aldosterone receptor blockers (decrease hospitalizations and improve mortality)



Ultrafiltration: catheters in veins (one in central and one in peripheral vein); taking water from peripheral vein and putting the leftovers into central vein; results in isotonic aquaresis
Class IIa indication: not enough scientific evidence that every hypervolumic patient


Sympathetic Acute and Chronic Activation

They are initially beneficial by releasing NE trying to increase CO, HR, and contractility, but over time this is not good; people die, ventricular arrhythmias, increased mortality, etc.
Parasympathetic goes down as well due to this; causes increased mortality
Want to oppose these when chronically activated


Experimental Ways of Increasing PNS vs. SNS

Vagal nerve stimulation

Spinal nerve stimulator: inhibits SNS activity to the cardiac region to decrease stimulation on the heart

Carotid Sinus Stimulator: activates parasympathetic NS; stimulate impulses on carotid body to induce vagal response


Single Chamber ICD and Subcutaneous ICD

Single Chamber ICD:
Defibrillator implant
Lead is sitting in R ventricle
Shocking coils to facilitate charge and vectors anywhere in the triangle by setting up polarities to cause shocks

ICD = internal cardiac defibrillator
Doesn’t have to be tunneled into the venous system and only below the skin and above the ribcage


SCD HeFT Study

SCD = sudden cardiac death
Landmark trial for heart failure
Ventricular tachycardia = SCD and people died
ICD implant to see if more people would better survive because need defibrillator within 2-3 minutes to live
Found: showed lowest mortality rate compared to the other two groups; now standard of care


Indications for ICD

Secondary Prevention:
Documented VF (resuscitation from a previous episode)
Hemodynamically unstable VT
Unexplained syncope with LVEF ≤ 35%

Primary Prevention:
LVEF ≤ 40%; with ischemic based etiology & spontaneous NSVT or inducible sustained monomorphic VT
LVEF ≤ 35% (Ischemic or Non-ischemic Cardiomyopathies)
Certain inherited disorders or conditions with structural heart disease: HCM, ARVD, Long QT, Brugada syndrome



As a heart fails, the heart is not pumping in synchrony
As a heart starts to dilate, the walls are not pumping together and get a delay so blood is going back and forth and not pushing it out properly

Heart enlarges and lengthens and remodels = papillary muscles and leaflets are being pulled apart and leads to dyssynchrony
There is a delay between septum and lateral wall beating so blood is not being pumped out effectively


Stages and Classes of HF

Stages = risk factors for heart failure
A: high risk but no structural disorders
B: structural disorder with no symptoms
C: past or current symptoms
D: end stage disease

Class I: no limits and no symptoms
Class II: slight limits, comfortable at rest, ordinary activity causes symptoms
Class III: marked limits, comfortable at rest, less than ordinary activity causes symptoms
Class IV: limits due to discomfort, symptoms at rest



CRT = Biventricular (BiV) Device
3 Lead device in RA, RV, Overlying LV

BBB occurs somehow: must go myocyte to myocyte, so try to restore contraction from this ; septum contracts first and then lateral wall causing widening of QRS

Coordinate contraction: lead in R atrium and find coronary sinus (drains veins into R atrium) and poked a wire into the sinus and go through the vein to pace the L ventricle; have the R ventricular lead fire to stimulate the septum and the lead overlying the L ventricle fire so they fire together; not putting lead in L ventricle because cannot but lead into aortic valve

These leads can cause some minor regurgitation, but no thrombi will form usually; although, infection risk can increase



Give the ICD with the BiV because you want to fix the dyssynchrony but also prevent
Only 70% of patients benefit from this with NYHA Class II-IV
Widely accepted


Aortic Stenosis: Transcatheter Aortic Valve Replacement (TAVR)

Can happen from calcifications and what not
Insert valve through groin and place it where it needs to be

Indications: High Risk Surgical Patient


Mitral Regurgitation:MitraClip

Percutaneous insertion to avoid open heart
Catheter is over wire and clip is introduced into the L atrium and then placed into leak or the valve where the clip is opened after going past the leaflets and then retrograde the clip to repair the valve so the clip is over the outside of the leaflets to prevent regurgitation


Options for Pump Failure

Stem cell therapy

Impella/Tandem Heart: wear on leg and have pump connected through femoral artery and vein; acts like second pump for the heart; acute care


Heart Transplant

Once all therapies have failed
Waiting list is high and many die because never get one

LVADs: Continuous pump without a pulse, but trying to make one with pulse; used in patients waiting for transplant, or do not qualify for one


Watchman Device

Intraatrial septum is cross by making incision
L atrial appendage and watchman device is released through a wire and left in place and seals off the appendage to prevent stroke; indicated for patients that cannot be on anticoagulation; endothelizes over time but until this happens they need to be on anticoagulants