Term
| What % of the adult population has heart failure? How many? |
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Definition
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Term
| What % of individuals over 75 have heart failure? |
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Definition
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Term
| How many people over 40 are at risk for heart failure? |
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Definition
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Term
| What % of those diagnosed with heart failure die within a year of diagnosis? |
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Definition
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Term
| What % of those diagnosed with heart failure die within 5 years of diagnosis? |
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Definition
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Term
| What acute secondary cause accounts for 70% of heart failure seen in the ED? |
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Definition
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Term
| Name 2 acute secondary causes of heart failure. |
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Definition
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Term
T/F
Sudden death may occur at any time during the course of heart failure. |
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Definition
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Term
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Definition
| clinical syndrome in which the heart is unable to pump blood at a rate sufficient to meet the metabolic demands of the body |
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Term
| What ejection fraction indicates systolic dysfunction? |
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Definition
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Term
T/F
An ejection fraction greater than 40% indicates that there is not heart failure. |
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Definition
| False - can indicate diastolic dysfunction if seen with signs and symptoms of heart failure and impaired ventricular relaxation |
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Term
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Definition
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Term
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Definition
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Term
| What are some causes of heart failure? |
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Definition
| MI, HTN, degenerative valve disease (usually secondary to LVH), rheumatic valve disease, alcoholic cardiomyopathy, Chagas disease, endomyocardial fibrosis, and "idiopathic" dilated cardiomyopathy |
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Term
| What compensatory mechanisms come into play in heart failure? |
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Definition
| ventricular hypertrophy and remodeling, vasoconstriction, Frank-Starling mechanism, and tachycardia (sympathetic nervous system activation) |
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Term
T/F
Heart failure often occurs in isolation. |
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Definition
| False - it doesn't occur in isolation |
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Term
T/F
Heart failure is progressive. |
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Definition
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Term
| What drugs act on angiotensin II? |
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Definition
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Term
| What drugs act on Norepinephrine? |
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Definition
| ACE-Is, beta blockers, digoxin |
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Term
| What things are angiotensin II-acting drugs treating? |
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Definition
| hypertrophy, remodeling, and apoptosis |
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Term
| What things are norepinephrine-acting drugs acting on? |
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Definition
| tachycardia, vasoconstriction, and increased contractility |
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Term
| What does aldosterone do? |
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Definition
| sodium retention, interstitial cardiac fibrosis, target-organ fibrosis, and vascular remodeling |
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Term
T/F
Heart failure is an unlikely cause of dyspnea if BNP levels are normal. |
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Definition
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Term
T/F
Elevation of BNP levels in treated patients indicates a poor prognosis for heart failure. |
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Definition
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Term
| What are the symptoms and signs of heart failure? |
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Definition
symptoms: dyspnea, fatigue, exercise intolerance, cachexiia/anorexia
signs: peripheral edema, pulmonary rales, S3 gallup, tachycardia, cardiomegaly, raised JVP |
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Term
| What does the echocardiogram tell you about heart failure? |
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Definition
| ejection fraction, valve disease, cardiomegaly, cardiomyopathy |
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Term
T/F
New onset peripheral edema in an older adult requires evaluation for HF. |
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Definition
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Term
| What signs of heart failure are you looking for on a CXR? |
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Definition
| primary pulmonary disease, edema as Kerley B lines, cardiomegaly |
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Term
T/F
NYHA classification I correlates with AHA class B. |
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Definition
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Term
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Definition
Risk, no symptoms of HF
HTN, DM, obesity, atherosclerotic disease |
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Term
|
Definition
Structural heart disease, no signs and symptoms of HF
previous MI, LVH, low EF (< 40%), asymptomatic |
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Term
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Definition
| Structural heart disease, prior or current S & S of HF |
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Term
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Definition
Marked limitation of physical activity
no symptoms at rest
less than ordinary activity leads to symptoms |
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Term
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Definition
D = refractory (end-stage) HF
symptoms are present at rest
inability to carry on physical activity without discomfort
usually EF < 10% |
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Term
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Definition
EF < 40%
systemic venous congestion from reduced peripheral perfusion
pulmonary congestion may also arise |
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Term
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Definition
| heart failure with preserved EF |
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Term
| What medications are used to treat systolic HF? |
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Definition
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Term
| Name 2 ACE-I used to treat HF? |
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Definition
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Term
| Name 3 beta blockers used to treat HF |
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Definition
metoprolol succinate
carvedilol
bisoprolol |
|
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Term
| What receptors does carvedilol block? |
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Definition
| beta 1, beta 2, and alpha 1 adrenergic receptors |
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Term
| How do you titrate a HF patient's meds? |
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Definition
| Start on ACE-I and titrate to half the dose. Start on beta blocker and titrate to dose, then finish titrating the ACE-I. Up the dose every 2-3 weeks. |
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Term
| What is the first line of treatment for HF? |
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Definition
ACE-I/Beta blocker
Beta blocker/ARB only if ACE-I reaction
ACE-I/ARB only if beta blocker intolerant |
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Term
T/F
For severe cases of HF, using triple therapy of ACE-I/ARB/beta blocker may be in order. |
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Definition
| False - NEVER use triple therapy |
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Term
| What drug is used to treat HF in a patient with renal insufficiency? |
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Definition
| hydralazine and long acting nitrates |
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Term
| What kind of drug is hydralazine? |
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Definition
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|
Term
isosorbide dinitrate
isosorbide mononitrate
nitroglycerin transdermal pathes |
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Definition
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Term
| When is digoxin prescribed in HF? |
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Definition
| prescribed for uncontrolled symptoms |
|
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Term
| What serum levels of digoxin are beneficial in CHF? |
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Definition
|
|
Term
| At what serum level is digoxin toxic? |
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Definition
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Term
| What are the effects of digoxin? |
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Definition
mild inotropic effect
attenuate carotid baroreceptor reflex
decreases norepi levels
decreases renin levels |
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Term
|
Definition
loop diuretic used to treat peripheral edema
20, 40, 80 mg tabs
20-80 gm QAM/BID (max 160 mg) |
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|
Term
|
Definition
loop diuretic used to treat peripheral edema
5, 10, 20 mg tabs
5-20 mg QAM/BID (max 80 mg) |
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Term
|
Definition
loop diuretic used to treat peripheral edema
0.5, 1, 2 mg tabs
0.5-2.0 mg QAM/BID (max 4 mg) |
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Term
|
Definition
| K sparing diuretic used to treat peripheral edema |
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Term
|
Definition
| K sparing diuretic used to treat peripheral edema |
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Term
| What do elevated aldosterone levels lead to? |
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Definition
| sodium retention, electrolyte imbalances, endothelial dysfunction, and myocardial fibrosis |
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Term
| What is the mechanism for loop diuretics? |
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Definition
they inhibit the Na+/K+/2Cl- transport in the thick ascending limb of Henle
35% NaCl reabsorption is prevented
Enhanced secretion of K+ and H+ due to increased Na+ absorption |
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Term
T/F
Hypokalemic alkalosis is a potential side effect of loop diuretics. |
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Definition
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Term
| What are the possible direct side effects of loop diuretics? |
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Definition
| hypokalemia, hyponatremia, hypochloremia, hypomagnesemia, hypocalcemia |
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Term
| What supplement is required with a loop diuretic? |
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Definition
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Term
| What medications might you add to a loop diuretic to increase diuresis? |
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Definition
indapamide or metolazone
thiazide diuretics |
|
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Term
| What is the mechanism of action of thiazide diuretics? |
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Definition
| Block NaCl transport, which causes an increased delivery of Na to the collecting tubule, which then enhances the effects of the loop diuretics |
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Term
|
Definition
needed with loop diuretics
8, 10, 20 mEq
10 is needed with 20-40 mg of furosemide, 5-10 mg of torsemide, and 0.5-1.0 mg of bumetanide. 20 is needed with higher doses |
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Term
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Definition
K sparing diuretic
Not indicated for HF |
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|
Term
|
Definition
K-sparing diuretic and aldosterone antagonist
indicated for advanced HF (III-IV) |
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Term
|
Definition
K-sparing diuretic and aldosterone antagonist
indicated for advanced HF (class III-IV) |
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Term
T/F
Rate of K+, H+ excretion is proportional to aldosterone levels. |
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Definition
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Term
| K sparing diuretics can cause what metabolic issue? |
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Definition
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Term
| Which drug may cause gynecomastia? |
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Definition
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Term
| Which K sparing diuretic has no effect on aldosterone (and is therefore not indicated for HF)? |
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Definition
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Term
T/F
Aldosterone causes K secretion in the urine. |
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Definition
| True - this is why aldosterone antagonists help spare K |
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Term
| What is the mechanism of action of K sparing diuretics? |
|
Definition
They block the effects of aldosterone on principal cells
Slow the Na+ transport channel which causes less Cl in the blood and less K+ in the urine
intercalated cells: H+ excretion is driven by Cl, so with less Cl, there is less H+ excretion |
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Term
| What metabolic condition can K+ sparing diuretics cause? |
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Definition
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|
Term
| When is the aldosterone blockade taken advantage of? In which patients? |
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Definition
| class III or IV HF patients - severe symptoms of heart failure |
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Term
T/F
HF patients should get the flu vaccine every year and a pneumococcal vaccine every 5 years. |
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Definition
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|
Term
| Who should get a pneumococcal vaccine before age 65? |
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Definition
| Patients with diabetes, COPD/asthma, or heart disease |
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Term
| What lifestyle modifications should HF patients attempt to make? |
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Definition
1. restrict salt intake
2. alcohol moderation except alcoholic cardiomyopathy
3. stop smoking
4. weight control
5. regular exercise
6. Q10 supplements
7. organized care - adhere to treatment and be flexible with diuretic dosing |
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Term
| What are the symptoms of acute heart failure? |
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Definition
dyspnea on exertion (this is very sensitive for making the diagnosis)
paroxysmal nocturnal dyspnea (highly specific, but not always present) |
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Term
| What is the best indicator of acute HF on physical exam? |
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Definition
|
|
Term
| What would the BNP be in a patient with acute HF? |
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Definition
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Term
| What tests do you run on a patient in suspected acute HF? |
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Definition
Transthoracic ECHO
EKG
BMP
TSH
CBC |
|
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Term
| What is the pharmacological treatment of acute decompensated HF? Why each? |
|
Definition
oxygen
IV opiod
diuretic - reduce preload
nitrate - reduce preload, dilate coronary arteries
intubation as needed - acute respiratory distress, reduce preload
dobutamine - treat hypotension, increase cardiac output, increase HR, systemic vasodilator |
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Term
| What options are available for pacing the heart? |
|
Definition
1. implantable cardioverter defibrillator (ICD)
2. cardiac resynchronisiation-defib device (CRT-D)
3. Dual cardiac resynchonisiation therapy (CRT)
4. heart transplant
5. erythropoietic agents for anemia - secondary to renal failure
6. palliative care |
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Term
T/F
Diastolic HF is a diagnosis of exclusion. |
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Definition
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|
Term
| What is the gold standard for diagnosis of diastolic HF? |
|
Definition
| cardiac cathetization - not really done though |
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Term
| What would the BNP be on a diastolic HF patient? How sensitive is this measurement? How specific? |
|
Definition
> 100 pg/mL
95% sensitive
14% specific |
|
|
Term
| What is the main problem with trying to treat diastolic HF? |
|
Definition
| There are no clinical trials to direct therapy |
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Term
| What lifestyle modifications are appropriate for a diastolic HF patient? |
|
Definition
weight loss
sodium restriction
exercise
vaccinations |
|
|
Term
| What drugs do you use to treat diastolic HF once the patient is symptomatic? |
|
Definition
| ACE-I, Beta blockers, and ARBS |
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