Heart Failure

Question 1

heart failure definition:

Answer 1

-inability of the heart to pump sufficient blood to meet the metabolic needs of the body

Question 2

myocardial failure definition:

Answer 2

• defective myocardial contraction

- results in heart failure!

Question 3

circulatory failure definition:

Answer 3

• a condition in which an abnormality of some circulatory component (heart, vessels, blood volume, etc) is responsible for inadequate cardiac output
  ex) hemorrhage

Question 4

prevalence of heart failure:

Answer 4

• 23million worldwide

- 4.7 million in US (1.5-2%)

Question 5

incidence of heart failure:

Answer 5

-declining rates!!

Question 6

What is the neurohormonal mechanism of heart failure:

Answer 6

1) activation of sympathetic nervous system (with a concomitant suppression of parasympathetic NS)
- Inc adrenergic activation = more circulating NE = peripheral vasoconstriction
- dec myocardial NE =we dont know why
- Beta1 stim= inc HR and contractility
- alpha1 stim=mild inc in tropism and peripheral vasoconstriction
2) activation of the renin-angitensin system (happens later)
- decreased renal perfusion
- dec Na in distal renal tubule
- inc adrenergic stim = inc renin release
- more antiotensin I=more antiotensin II = organ fibrosis (heart and kidney) & enhanced NE release

Question 7

Result of neurohormonal model in HF:

Answer 7

• peripheral arterial constriction
• Na/Water retention
• activation of inflammatory mediators of cardiac remodelling

Question 8

LV remodelling:

Answer 8

1) dilation and shape change
- neurohormonal activation = changed function/shape
- pressure overload = parallel or concentric hypertrophy
- volume overload = SERIES or eccentric hypertrophy
- action potential prolongs in advanced HF (fetal gene activation)=contractile dysf
- contractile and reg proteins altered
- inc myocardial wall tension (LVEDV rises)
- MV regurg (papillary muscle separation)

Question 9

Backward HF:

Answer 9

• as the LV fails to completely eject its contents - blood accumulates in the LA
• pressure rises in pulmonary circulation
• trasudation of fluid into the pulmonary interstitium = pulmonary congestion/edema

Question 10

Forward HF:

Answer 10

• inadequate delivery of oxygen into arterial system (reduced cardiac output)
• results in dec perfusion of vital organs + mental clouding, weakness, and Na/water retention

Question 11

RV HF -

Answer 11

1) most often a consequence of LV failure with pulmonary congestion
2) results in SYSTEMIC CONGESTION
- hepatomegally, mesentery and bowel edema, leg edema, ascites
- fluid retention becomes generalized in RV failure

Question 12

LV heart failure is:

Answer 12

-true congestive heart failure due to central venous congestion

Question 13

Systolic failure (LV):

Answer 13

• abnormal systoic function
• high EDV in ventricles
• poor perfusion –> na and water retained

Question 14

Diastolic failure (LV)

Answer 14

• abnormal diastolic filing (heart cant fill-heart isnt stretching well)
• high LV filling pressure
• eventual pulmonary and systemic congestion

Question 15

Pure R side failure due to

Answer 15

corpulmonale!!

Question 16

Heart failure - precipitating causes:

Answer 16

• ischemia/infarction (MOST COMMON)
• hypertension
• arrhythmias (a fib)
• infectious/inflammatory
• pulmonary embolus
• physical, emotional, environmental stress
• cardiac toxins (chemo,alcohol)
• high output states
• reduction of therapy (LEAST COMMON)

Question 17

Symptoms of HF:

Answer 17

1) short of breath (progressive)
- exertional
- paroxysmal nocturnal dyspnea
- orthopnea
- resting dyspnea
2) diminished exercise capacity
3) fatigue/weakness
4) nocturia
5) CNS impairment (memory, insomnia)
6) symptoms of RV faiure

Question 18

Classification of HF:

Answer 18

-class1=no limitation
-class2=slight limitation
(orginary activity causes symtpoms)
-class3=marked limitation
(Less than normal activity precipitate symptoms)
-class4=symptoms at rest

Question 19

Physical exam of HF patient:

Answer 19

1) pallor, cool extremities
- sympathetic tone causes cutaneous vasoconstriction
2) Anxiety, dyspnea at rest
3) Pulses normal to rapid, weak
- fast pulse from sympathetic tone & low SV
4) blood pressure varies
5) Pulmonary rales as LV fails
6) elevated jugular pulsations in RV failure
7) kussmauls sign in RV failure
- venous return is enhanced with inhalation = jugular veins are distended (normally not)
8) hepatojugular REFLUX
- 60 sec of pressure on dome of liver=jugular venous pulses rise in the neck
9) congestive hepatomegaly
10) edema - symmetrical, pitting, dependent
11) pleural effusion
12) ascites

Question 20

cardiac exam of HF patient:

Answer 20

• cardiomegaly (apical impulse down and to the left)
• S3 universal
• S4 rare (not usually a poor compliance issue)
• pulsus alternans
• murmurs -systoc (MR, AS, TR) & diastolic (AI)
• cardiac cachexia (late) - so much edema that the abdomen is full of fluid = cant eat

Question 21

Lab of HF patients:

Answer 21

• electrolyte abn - water excess, renal dysf (hyponatremia-water/Na balance issue)
• liver enzyme elevations
• findings related to precipitating causes (thyroid studies)

Question 22

X-ray of HF patients:

Answer 22

• cardiomegaly
• pulmonary cogestion
• pleural effusion
• kerley B lines (engorged lymphatics)

Question 23

ECG and HF patient?

Answer 23

non-diagnostic - can help with ischemia or chamber elargement

Question 24

HF prognosis:

Answer 24

• pooor bc it just keeps gettig worse
• 1.7 year men and 3.2 years for women post diag
• 5 year for men = 25%
• 5 year for women=32%

Question 25

most HF patients die from:

Answer 25

pump failure | tachyarrhythmias

Question 26

worse HF prognosis factors:

Answer 26

- male - ischemic heart disease (CAD) - S3 - low pulse pressure - high functional class - reduced exercise capacity

Question 27

hgih output HF-

Answer 27

- high CO but metabolic needs no met | - so much shunting of blood that tissues that need blood dont get it

Question 28

etiologies of high output HF:

Answer 28

- anemia - AV fistula (hemo patients) - hyperthyroidism - beri-beri - pagets disease of bone

Question 29

Goals of HF therapy

Answer 29

- relieve symptoms - prolong survival - improve quality of life - delay or prevent progression of myocardial dysf

Question 30

common causes of HF:

Answer 30

- CAD (ischemic cardiomyopathy; MI) - HTN - valvular disease - cardiomyopathies - cor pulmonale - congenital heart disease

Question 31

General approach to HF Tx:

Answer 31

- base therapies on Functional class - reverse potentially treatable problems (CAD=reperfusion;repair structural abn ex valvular disease) - aggressive screening for DM - immunize for pneumonia and influenza - appropriate activity and rest

Question 32

Meds that make HF WORSE:

Answer 32

- verapamil, diltiazem (neg ionotropic) - NSAIDs - sotalol (anti-arrhythmic) - beta blockers

Question 33

Functional classes of HF:

Answer 33

- 1=asymptomatic-no activity limit- no Sx - 2=mild symptoms-slight activity limit-some Sx with ordinary activity - 3=marked limit of activity-much more Sx with less than ordinary activity - 4=decompensated - MANY Sx at rest

Question 34

Heart Failure stages:

Answer 34

- A= high risk for HF - no structural heart disease or Sx (yet) - B=structural dysf (LVH) but no Sx - C=structural Dysf (MI) with Sx (SOB) -- MOST PEOPLE HERE - D=refractory HF

Question 35

Non-drug Tx:

Answer 35

-HF risk factor reduction -education (smoking, EtOH, dietary Na, fluid intake, monitor WG) -activity (heavy physical labor is no-no) for compensated HF (func classes 1-3) regular moderate exercise helps -Diet- restrict Na -manage fluid status - make sure they dont drink to much fluid if kidneys and heart is bad

Question 36

prevent HF progresson by:

Answer 36

1) counteracting neurohormonal activation - ventricular remodeling due to adrenergic activation - renin angiotensin aldosterone system activation - -> relieved symptoms - -> tabilizes or reverses remodeling

Question 37

what drugs help with the neurohormonal activation of HF

Answer 37

- angiotensin converting enzyme inh (ACEI) (BEST CHOICE!!!!) - angiotensin receptor blocker (ARBs) - beta blocker

Question 38

How ACEI help:

Answer 38

``` -interfere with renin angiotensin loop =block effect of angio2 on AT-1 receptors =stabilize LV remodeling =improve symptoms (QOL improved) =reduce/prevent hospitalization =prolong life ```

Question 39

ACEI - the drugs:

Answer 39

- captopril - enalapril - fosinopril - lisinopril - quinapril - ramipril THE -PRILS

Question 40

beta blockers on HF

Answer 40

- not always BAD - anti-adrenergic agents for chronic HF - interfere with adverse effects of adrenergic activation on beta1 receptor - USED WITH ACEI!

Question 41

Which beta blockers tolerated by HF aptients:

Answer 41

- metoprolol (BETA1 BLOCKER) - carvedilol (beta1 block with alpha 1 aka vasodil properties) - bisoprolol )beta1 selective

Question 42

when do give beta blockers:

Answer 42

-patient is functional class 2 or 3 already on ACEI or diuretic with no contraindications (asthma, AV block)

Question 43

Spironolactone is used how?

Answer 43

-aldosterone antagonist - only when all other drugs used and not helping enough (lousy diuretic - K sparing/saving!)

Question 44

other HF tx:

Answer 44

1) Mechanical - intra aortic balloon pump - LV assist device 2) Transplant 3) artificial heart!?!