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53 Cards in this Set

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  • Back
CHF Definition
Syndrome comprising left. ventricular fxn and neuronhormonal regulation...accompanied by effort intolerance, fluid retention, and decreased longevity.
CHF trends
500 K new pts. in US/year
100-300K deaths/yr.
4 Stages of treatment
Prevention
Treatment aimed at prolonging life
Treatment aimed at reducing symptoms
End-stage considerations
Two major consequences of CHF
decreased CO
decreased venous congestion
Decreased CO consequences
Decreased delivery of O2 blood leading to forward failure
Characteristics of forward failure
Decrease exercise tolerance, increased fatigue, decreased renal perfusion, azotemia, cachexia, hypotension
Venous congestion consequences
More blood left behind in atrium-- Backward failure
Characteristics of backward failure
Increase venous pressure leads to neurohormonal response causing Na/fluid retention
Manifestations of backward failure
6 things
Atrial enlargement (A-fib)
Thromboembolism (venous stasis)
Pulmonary edema (lft. HF)
Peripheral edema (rt. HF)
Hypoxia/Hypoxemia
Dyspnea
What causes venous congestion in most CHF pts? Define the cause.
Excess preload
Tension in the ventricle at end diastole
Kinds of treatment for xs preload
Diuretics
Nitrates
Morphine
Na restriction
H2O restriction
Mainstay for xs preload treatment
Furosemide (loop diuretic)
What did the Rales Study find?
27% decrease in total mortality w/addition of K+ sparing diuretics in pts. with severe HF
Also drugs that improve forward fxn indirectly help
Example of K+ sparing diuretic
Spironolactone
Example of drugs that improve forward fxn.
ACEi : digoxin
Why do you need to avoid xs diuretic use?
Causes dehydration--inadequate preload--forward failure
Afterload
Wall stress during systole
What can cause increase afterload.
Decrease CO and the ensuing neurohormonal response.
What drugs break the viscious cycle of increase afterload?
ACEi
Angiotensin receptor blockers
Contractility
Squeezing of the pump
Definition of systolic dysfunction
Ejection fraction <45%
Causes of systolic dysfxn.
MI, idiopathic dilated cardiomyopathy, HTN, ischemia, toxin (EtOH, adriamycin), infection (Chagas), viral myocarditis, tachycardia
Drugs that directly improve systolic fxn.
Digoxin, B-adrenergic agonists (DOPA, dobutamine, epi), phosphodiesterase inhibitors and vesnarinone
Which drug is routinely used to treat sys dysfxn? Why?
Digoxin, the others have increase risk of mortality
Why should we use caution with using B-blockers early on in the treatment of systolic dysfxn?
Reduce contractility in the short term, can make it worse.
The result of chronic B-blocker use in sys. dysfxn.
significant increase in ejection fraction
What did the CIBIS II and Carvedilol trials find?
Addition of B-1 or non-selective B-blockers to an ACEi reduces tot. mortality in HF over ACEi alone
Should you use Ca blockers to treat sys. dysfxn.
No they reduce contractility leading to increased mortality.
Diastolic dysfxn.
Abnormally increased contractility
Who gets diastolic dysfxn
Left ventricular hypertrophy
HOCM
HTN* most common

**LVH and HOCM may have supranormal dP/dT
Why would pts. w/LVH or HOCM get diastolic dysfxn
Impaired cardiac filling leads to need to increase diastolic pressure (preload) to achieve adequate CO
How many pts w/CHF have diastolic dysfxn?
1/3
What eventually happens to stroke volume in diastolic dysfxn (DD)? What is the consequence?
Decreased SV --- decreased CO with increased EF
Ideal therapy for DD?
We don't know
DD aka
"Little old lady's heart"
Why should we use caution when using diuretics to treat DD.
Hypotension and low preload can result
Why is excessive afterload dangerous?
Can result in cavity obliteration (the ventricle empties completely @ end-systole) which can lead to syncope or pulmonary edema (due to tachycardia)
What is the reflex bradicardia causing syncope in cavity obliteration called?
Bezold-Jarisch response
Just remeber....
CO = SV * HR
:)
Compare sys dysfxn and diastolic dysfxn with dP/dT
Sys: ↓↓
Dias: ↑
Compare sys vs. diastolic dysfxn for EF
Sys: ↓↓
Dias:↑↑
Compare sys vs. diastolic dysfxn for chamber volumes
Sys:↑↑
Dias:↓
Compare sys vs. diastolic dysfxn fo LV diastolic pressure
Sys: ↑
Dias: ↑
Name the associated use for the drug listed in sys dysfxn
ACEi...+++ (first line Rx)
Ca blockers..CONTRAINDICATED

B-blockers..++

Diuretics..+ (spironolactone)

Digoxin..++ (symptomatic use)
Name the associated use for the drug listed in diastolic dysfxn.
ACEi + (esp. in BP is increase)

Ca blockers ++ (verpamil)

B-blockers +++ (esp if angina)

Diuretics +/- (beware hypotension)

Digoxin CONTRAINDICATED
Treatment for acute bradycardia
Atropine
B stimulants (dobutamine, epi)
How does chronic tachycardia decreased CO
Limits diastolic filling and can lead to sys. dysfxn
How does chronic tachycardia decreased CO
Limits diastolic filling and can lead to sys. dysfxn
What is an unrecognized cause of CHF?
A-fib w/rapid ventricular response
What is the drug of choice for maintaining sinus rhythm in HF?
Amiodarone
What drug is most often used to control ventricular rate in HF pts?
Digoxin
Last line treatment for those w/uncontrollable tachycardia
AV ablation
Four factors of ventricular performance
Preload
Afterload
Contractility
Heart rate and rhythm