CHF

Question 1

LV failure

Answer 1

Symptoms due to low cardiac output and congestion, including dyspnea

Question 2

Optimal management for LV failure includes

Answer 2

ACE-I/ARB, BB, aldosterone inhibitors

Question 3

RV failure

Answer 3

cor pulmonale or more likely due to LV failure

symtoms: peripheral congestion

Question 4

High-output heart failure is a heart condition that occurs when the cardiac output is higher than normal, examples are:

Answer 4

beri beri (nutritional deficit in vitamin B1 (thiamine), and hyperthyroidism

Question 5

Causes of systolic CHF

Answer 5

• Ischemic cardiomyopathy
• HTN
• hypo/hyperthyroid
• HIV
• ETOH
• viral
• dilated
• cardiotoxins
• infectious (Chagas)
• hemochromatosis
• sarcoid, amyloid
• valvular
• tachycardia-mediated
• peri-partum

Question 6

Causes of diastolic CHF

Answer 6

• HTN
• hypertrophic
• restrictive
• DM
• pericardial disease
• aging (causes diastolic heart failure)

Question 7

Neurohormonal activation is partially responsible for ________

Answer 7

mechanical changes in heart failure

Question 8

Vasopressin secretion-

Answer 8

promotes water absorption by kidney

Question 9

Renin-angiotensin-aldosterone axis (RAAS)

Answer 9

• maintains cardiac output (CO) and tissue perfusion
• stimulates arterial vasoconstriction with angiotensin II
• expands intravascular volume with Na+ and water retention

Question 10

Left ventricular end diastolic pressure (preload right before cardiac output) is important when patient may have heart failure and is presenting with

Answer 10

SOB

• Need to know if LVEDP is high or low
• LVEDP is the last pressure right before it pumps blood out to body

Question 11

If LVEDP is high, _______

Answer 11

will have congestion and backing up into lungs

LVEDP is about the same as central venous pressure and jugular venous pulsation
Need to know if they’re “wet” (congested, fluid overload) or “dry” (Euvolemic, fluid status is stable, SOB from lung problems)

Question 12

Decreased CO leads to increased HR, increased contractility, vasoconstriction (all raise bp, increase CO)
Low CO also causes increased renin angiotensin, increased ADH and blood volume
Problem with this, you’ll have __________

Answer 12

pulmonary edema

Question 13

Classification by

Answer 13

stages A-D

NYHA uses FC class 1-4

Question 14

general S/S and physical exam findings

Answer 14

Tachycardia, Palpations, S3/S4, S3 indicates systolic dysfunction, murmurs, HJR (hepatojugular reflex, press on liver, may see increase in jugular venous pressure), JVP, edema

Question 15

Labs

Answer 15

-BNP (BNP becomes physiologically elevated, increases in response to left vent wall stress increase, triggers atrium to release ANP)

Question 16

What do you use to assess LV function?

Answer 16

Echo (best way overall, no radiation, easy), MUGA (Multi Gated Acquisition Scan-BEST WAY to look at EF, intervention), angiogram

Question 17

Treatments

Answer 17

Target any potential reversible causes (CAD, tachycardia, ETOH, etc..)

Question 18

When do you biopsy?

Answer 18

• if pt has acute fulminant myocarditis (pt comes in with flu like illness and then crash, have arrhythmias, pt needs biopsy to rule out giant cell myocarditis, worst type but is treatable)
• Acute presentation (symptoms are new and just started), hemodynamic compromise at initial presentation, new AVB, VT

Question 19

S/S of CHF caused by venous congestion (right sided)

Answer 19

• hepatomegaly
• ascites
• pleural effusion–> edema, jugular venous distension

Question 20

S/S of CHF caused by low cardiac output

Answer 20

• fatigue/low energy
• pallor
• sweating
• cool extremities
• poor growth
• dizzy
• altered consciousness
• syncope
• tachypnea, nasal flaring/grunting (indicates left sided)
• retractions; pulmonary edema

Question 21

Other etiologies of CHF

Answer 21

• Infectious myocarditis
• Dilated cardiomyopathy
• Tako-Tsubo (apical ballooning)
• Hypertrophic
• Restrictive
• Drug induced (chemo/toxic)

Question 22

Dilated cardiomyopathy

Answer 22

ARVD (arrhythmiogenic RV dysplasia also called Uhl Cardiomyopathy; fattiness of R vent and can lead to death in young people), non-compaction (massive trabeculation;
tx: defibrillator)

Question 23

Tako-Tsubo (apical ballooning)

Answer 23

Stress cardiomyopathy; typically in females, older, emotional stress can trigger sympathetic surge, hypercontratility of base of left vent and base will dilate (balloon), must rule out coronary disease; usually reversible

Question 24

Hypertrophic heart

Answer 24

CHF and risk of sudden death (at risk for myopathy, put defibrillator on heart); hypertrophy of left vent, blood cant get out

Question 25

Diastolic heart

Answer 25

- “little old lady heart”; very small, has low volume - SOB; LVEDV is low; JV distension; edema (reflected with elevated central vein pressures) - BNP increases (EF is greater than 45) *NOTHING REDUCES MORTALITY- NO MEDS TO IMPROVE MORTALITY FOR DIASTOLIC; little bit of lasix, try and lower BP, but still wont decrease mortality*

Question 26

Systolic heart

Answer 26

- heart is dilated, it’s very big; has many liters of volume - SOB; LVEDP is low; JV distension; edema (reflected with elevated central vein pressures) - BNP increases because of stretch, wall tension, vol or P, whatever makes left V work harder; If you hear S3 its systolic (EF is less than 45) *LOWER MORTALITY FOR SYSTOLIC: ACE inhibitors, ARBs, beta blockers (metropalol or carbatolol only); aldosterone antagonists*

Question 27

If you hear an S3 the problem is

Answer 27

systolic (Not diastolic)

Question 28

EF, ejection fraction is less than _______ you GET A DEFRIBILATOR, ICD (implantable cardioverter defibrillator)

Answer 28

35

Question 29

What can be used in African Americans to reduce mortality?

Answer 29

hydrolazine nitrate combo reduces mortality

Question 30

Besides S3, only way you can tell the difference (systolic vs diastolic) is _______

Answer 30

from an Echo (can’t rely on S/S because they’re the same)

Question 31

1. Heart failure presentation (clinical)- Patient comes into ER presenting with

Answer 31

SOB, sitting upright, JVP is to mandible, cool, clammy, sweaty, respiratory distress and edema -Patient is probably in heart failure, appears that they aren’t profusing well

Question 32

2. Heart failure presentation (clinical)- First drug to give a patient like this?

Answer 32

Give Lasix (IV, not PO) immediately

Question 33

3. Heart failure presentation (clinical)- O2 sat is 91%, give O2 also In triage, patient with SOB should have EKG, it shows

Answer 33

No ST elevation indicating MI, so you know its not a stmi

Question 34

4. Heart failure presentation (clinical)- BP is 190/100, patient is not on any medications, patient probably has an S3 but they are very hard to hear. Do a Chest Xray and see

Answer 34

cardiomegaly and pulmonary vascular congestion

Question 35

Need to lower BP: Imodapine is a

Answer 35

CA blocker for long term BP management

Question 36

You CAN'T use Imodapine for 1st time acute decompensated heart failure if pt __________

Answer 36

isn't on a beta blocker (Metropalol) already -can give it to them once they are stabilized, so DON'T give when they 1st come into ER if they arent already on a B-blocker

Question 37

What can you give patient first to lower BP?

Answer 37

Nitroglycerine drip- can use this; it's a venodilator, some vasodilation, dilates pulmonary vessels, preload decreases, pulmonary congestion decreases, afterload decreases some, this clears up congestion and decrease BP

Question 38

Additional treatment

Answer 38

Noninvasive ventilation with BiPAP machine, measure output carefully so may use foley cath

Question 39

During CHF, EKG may show

Answer 39

QRS duration > 120 LBBB Abnormal QS pattern Broad R wave with deep S wave and inverted T wave

Question 40

Frank Starling Curve shows that

Answer 40

stroke volume of the heart increases in response to an increase in the volume of blood filling the heart (the end diastolic volume) when all other factors remain constant

Question 41

LVAD (Left Ventricular Assist Device) is a treatment method that

Answer 41

sucks blood out of left vent and dumps it back into aorta; takes the place of your left vent -Bridge in between transplantation, end of life care, etc.

Question 42

OMM treatments

Answer 42

1. Lymphatic Pump: fluid mobilization 2. Diaphragmatic Techniques: abdominal and thoracic 3. Effluerage: mobilize peripheral fluid 4. Clavicular releases: promote thoracic duct drainage 5. CV4: fluid homeostasis and decrease stress 6. OA, thoracics, lumbar, Chapman pts, fascia

Question 43

2 types of dilated cardiomyopathies are

Answer 43

1. Systolic Dysfunction | 2. Eccentric hypertrophy (sarcomeres added in series)

Question 44

Causes of dilated cardiomyopathies

Answer 44

- ETOH - chronic cocaine - beri-beri (lack of vitamin B1/thiamine) - coxsackie virus - chagas (tropical parasitic disease) - doxorubicin (chemo for cancer) - hemochromotosis (iron overload) - sarcoid - peripartum-(PPCM) is a form of dilated cardiomyopathy that is defined as a deterioration in cardiac function presenting typically between the last month of pregnancy and up to six months postpartum; heart muscle can't contract forcefully enough to pump adequate amounts of blood to the body

Question 45

Hypertrophic Cardiomyopathy

Answer 45

-60-70% inherited as auto dominant (Beta-myosin heavy-chain mutation) -Can be a/w friedrich ataxia -Syncope during exercise and sudden death in athletes due to VT -Tx: cessation of high-intensity athletics (BB, CCB, ICD if high risk)

Question 46

Examples of Restrictive/infiltrative cardiomyopathy

Answer 46

- Sarcoid - amyloid - postradiation fibrosis, - Loffler (endocardial fibroelastosis w/ eosinophilic infiltrate) - hemochromotosis (dilated can also occur)