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68 Cards in this Set

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What is CHF?
CHF is a clinical syndrome including dyspnea, fatigue and fluid overload that occurs as a final pathway in various cardiac diseases.

Left and/or right ventricles (RV and LV) may be involved.
What are the common causes of CHF?
Hypertension and coronary artery disease account for 50%-75% of left ventricular failure.

Right ventricular failure is usually due to failure of the left ventricle.
What are the common causes of LV failure?
1. Ischemia
2. HTN
3. Valvular disease
4. Idiopathic dilated cardiomyopathy
What are the less common causes of LV failure?
1. Chronic alcohol use
2. Hypothyroidism
3. Toxins (chemotherapy)
What are the rare causes of LV failure?
1. Viral myocarditis (including HIV)
2. Chest irradiation
3. Hemochromatosis
4. Amyloidosis (commonly present with diastolic dysfunction)
What are the common causes of RV failure?
1. LV failure
2. RV ischemia
3. COPD
What are the less common causes of RV failure?
1. Sleep apnea
2. Recurrent pulmonary emboli
What are the rare causes of RV failure?
1. Interstitial pulmonary diseases
2. Primary pulmonary hypertension (PPH)
How do I classify a patient's heart failure?
CHF is classifed as right or left ventricular failure, with systolic or diastolic dysfunction.
In systolic dysfunction, ejection fraction is low due to what?
Due to poor ventricular contraction.
In diastolic dysfunction, ejection fraction is normal, but cardiac output is low. Why?
Due to poor filling of a stiff ventricle during diastole.
How is functional status classified?
Via the New York Heart Association (NYHA) Functional Classification.

Class I: No limiation with ordinary physical activity

Class II: Mild symptoms, slight limitation with ordinary activitiy.

Class III. Marked symptoms of fatigue, dyspnea, palpitations, or angina with minimal activity.

Class IV: Symptoms at rest; symptoms increase with any activity.
What are the classic findings in left ventricular failure?
LV failure increases pulmonary venous pressure and causes pulmonary manifestations:

1. decreased exercise tolerance (dyspnea on exertion)
2. shortness of breath while supine (orthopnea)
3. Awakening from sleep short of breath (paroxysmal nocturnal dyspnea).

You may hear on physical exam:

1. S3, an early diastolic filling sound over the left ventricular apex

2. crackles in lungs due to pulmonary edema.
What are the characteristic CXR findings in CHF?
1. enlarged heart
2. pulmonary edema
3. pleural effusion
4. Kerley B lines
5. redistribution of pulmonary blood flow against gravity to upper lung zones.
T or F: LV failure can overload the right ventricle and create signs of RV failure.
True.
What you should ask in a history to assess for LV failure?
1. Orthopnea
2. Dyspnea on exertion
3. Paroxysmal nocturnal dyspnea
4. Cough
5. Frothy hemoptysis
What you should look for on physical exam to assess for LV failure?
1. leg edema
2. Rales (crackles)
3. S3 over left ventricle
4. PMI greater than 3cm and displaced laterally
5. Cool, mottled lower extremities
6. Abnormal abdominojugular reflux
What you should ask in a history to assess for RV failure?
1. Exercise intolerance
2. Dyspnea
3. Increasing abdominal girth
4. RUQ pain
5. Anorexia
What you should look for on physical exam to assess for RV failure?
1. Leg edema
2. JVP greater than 8cm H20
3. Right ventricular parasternal heave
4. S3 over right ventricle
5. Abnormal abdominojuglar relux
6. Ascites
Are there lung symptoms in RVF?
RVF increases systemic venous pressure. Isolated RVF does not cause lung symptoms, but because most RVF is due to LVF, the presence of lung findings helps determine if LVF is the cause.
How do you evaluate JVP (jugular venous pressure)?
1. Elevate the head of the bed to 30-45 degrees
2. Observe for venous pulsations in the neck.
3. Measure the height of the pulsations vertically up from the angle of Louis (where the second rib meets the sternum)
4. Add 5 cm to your measurement to estimate the vertical height in cm of H20 above the right atrium
How do you evalute for abdominojuglar reflux?
1. Apply pressure to the abdomen for 10 seconds while you watch the JVP
2. If JVP rises more than 4 cm for the duration of pressure, this implies high right heart filling pressures.
What diagnostic tests should I order in patient with new left-sided systolic heart failure?
Standard work-up includes:
1. chemistry panel
2. cholesterol
3. EKG
4. CXR
5. echocardiogram
Echocardiogram estimates _______ and evaluates ventricular ______ ______ and valvular function.
Echocardiogram estimates EJECTION FRACTION and evaluates ventricular WALL MOTION and valvular function.
An EF less than ___ % is considered systolic dysfunction.
An EF less than 40% is considered systolic dysfunction.
An ejection fraction of greater than 40% (does or does not) rule out CHF.
An ejection fraction of greater than 40% DOES NOT rule out CHF because LV diastolic dysfunction, seen in up to one third of patients with clinical CHF presents with normal EF.
Focal wall motion abnormalities suggest _________ injury.
Focal wall motion abnormalities suggest ISCHEMIC injury.
If standard work-up does not reveal a diagnosis for left-sided systolic heart failure, review the history for alcohol use, then consider further testing for ischemia, ______ , _______ , ________ , ________ or _______.
If standard work-up does not reveal a diagnosis for left-sided systolic heart failure, review the history for alcohol use, then consider further testing for ischemia, THYROID DISEASE, HEMOCHROMATOSIS, AMYLOIDOSIS, or HIV.
What are the treat goals in CHF patients?
Management goals are to reduce symptoms, prevent complications, and improve survival.
If standard work-up does not reveal a diagnosis for left-sided systolic heart failure, review the history for alcohol use, then consider further testing for ischemia, ______ , _______ , ________ , ________ or _______.
If standard work-up does not reveal a diagnosis for left-sided systolic heart failure, review the history for alcohol use, then consider further testing for ischemia, THYROID DISEASE, HEMOCHROMATOSIS, AMYLOIDOSIS, or HIV.
What can patients do to improve symptoms of CHF?
Patients can restrict salt intake to 3-4 gm/day, stay as active as possible and avoid cigarettes and alochol.

They can follow home blood pressures and daily weights and notify their physician of major changes so medications can be adjusted.
What are the treat goals in CHF patients?
Management goals are to reduce symptoms, prevent complications, and improve survival.
What can patients do to improve symptoms of CHF?
Patients can restrict salt intake to 3-4 gm/day, stay as active as possible and avoid cigarettes and alochol.

They can follow home blood pressures and daily weights and notify their physician of major changes so medications can be adjusted.
Recognize that _____________ is common in CHF patients (20%-60%) so counsel patients to take medications as prescribed.
Recognize that NONADHERENCE WITH MEDICATIONS is common in CHF patients (20%-60%) so counsel patients to take medications as prescribed.
Recognize that _____________ is common in CHF patients (20%-60%) so counsel patients to take medications as prescribed.
Recognize that NONADHERENCE WITH MEDICATIONS is common in CHF patients (20%-60%) so counsel patients to take medications as prescribed.
When treating LV systolic failure:

_________ are the first line agents for LV systolic
dysfunction. They reduce LV
_______ and decrease morbitiy and mortality, particularly in patients with decreased ejection fraction from recent myocardial infarction.
Angiotensin-converting enzyme inhibitors (ACEIs) are the first line agents for LV systolic dysfunction. They reduce LV AFTERLOAD and decrease morbidiy and mortality, particularly in patients with decreased ejection fraction from recent myocardial infarction.
When treating LV systolic failure:

Increase the ACEi dose as tolerated to maximum dose or systolic BP _______ mmHg
Increase the ACEi dose as tolerated to maximum dose or systolic BP 90-100 mmHg.
When treating LV systolic failure:

Monitor the serum _______ and the ________ frequently as both may rise with initiation of ACEI.
Monitor the serum CREATININE and the POTASSIUM frequently as both may rise with initiation of ACEI.
When treating LV systolic failure:

Common side effects include:
1.
2.
3.
4.
5.
6.
Common side effects include:
1. hypotension
2. worsening renal function
3. hyperkalemia
4. cough
5. rash
6. taste disturbance
When treating LV systolic failure:

The side effect of __________ is an absolute contraindication to continuing ACEis.
The side effect of ANGIOEDEMA is an absolute contraindication to continuing ACEis.
When treating LV systolic dysfunction:

About 10% of patients develop intolerable ACEI cough. Cough is common from CHF itself, but if clearly due to ACEI, consider changing to _______________ .
About 10% of patients develop intolerable ACEI cough. Cough is common from CHF itself, but if clearly due to ACEI, consider changing to ANGIONTENSIN II RECEPTOR BLOCKERS (ARBs).
ARBs also decrease __________ and mortality and do not cause cough.
ARBs also decrease AFTERLOAD and mortality and do not cause cough.
The combination of __________ and ___________, also used to decrease afterload, is less effective in reducing mortality, but should be used when angiotensin-blocking agents are not tolerated.
The combination of HYDRALAZINE and ISOSORBIDE also used to decrease afterload, is less effective in reducing mortality, but should be used when angiotensin-blocking agents are not tolerated.
When do patients need diuretics?
Most patients with CHF have sodium and water overload. Start a diuretic if ACEI alone does not resolve volume overload.

Titrate diuretics to achieve a JVP less than 8 cm H20.
Dose diuretics ___________ unless higher doses are required (e.g., furosemide greater than 160 mg/day).
Dose diuretics ONCE A DAY unless higher doses are required (e.g., furosemide greater than 160 mg/day).
Hypokalemia requires replacement if the potassium level is below ________ .
Hypokalemia requires replacement if the potassium level is below 4.0 mEq/L.
Use potassium replacement cautiously in patients on ________ .
Use potassium replacement cautiously in patients on ACEIs.
Low dose spironolactone (25 mg/day) decreases mortality and the need for potassium supplementation. Close monitoring of potassium is necessary if spironolactone is used with an ______ , because both can raise serum K+ levels.
Low dose spironolactone (25 mg/day) decreases mortality and the need for potassium supplementation. Close monitoring of potassium is necessary if spironolactone is used with an ACEI, because both can raise serum K+ levels.
When should I use B-blockers for CHF?

Increased plasma __________ levels in patients with CHF are strongly associated with worsening CHF an increased mortality. B-blockers block this effect and improve LV function, decrease hospitalization, and delay need for heart transplant.
Increased plasma NOREPINEPHRINE levels in patients with CHF are strongly associated with worsening CHF and increased mortality.
B-blockers decrease CHF mortality significantly, especially in post-MI patients.

Use carvedilol (an alpha and beta blocker with antioxidant properties), metoprolol, or bisoprolol. Because of negative __________ with these agents, symptoms may initially worsen. Start with low doses and monitor for fluid overload that suggests the need for a temporary increase in _________ .
Use carvedilol (an alpha and beta blocker with antioxidant properties), metoprolol, or bisoprolol. Because of negative INOTROPY with these agents, symptoms may initially worsen. Start with low doses and monitor for fluid overload that suggests the need for a temporary increase in DIURETICS.
Add digoxin when patients remain symptomatic on full dose ACEI and diuretics, and when _______________ are not an option.
Add digoxin when patients remain symptomatic on full dose ACEI and diuretics, and when BETA-BLOCKERS are not an option.
Digoxin is a good choice for patients with ___________ and CHF.
Digoxin is a good choice for patients with ATRIAL FIBRILLATION and CHF.

Digoxin increases exercise tolerance and improves functional class. Withdrawal of digoxin results in worsening CHF and increased risk for hospitalization. Digoxin has not been shown to decrease mortality.
Digoxin toxicity causes what type of symptoms?
Digoxin toxicity causes:
1. Arrhythmias
2. Confusion
3. Visual disturbances
4. Anorexia
5. Nausea
6. Vomiting
Levels do not reflect clinical digoxin toxicity, so follow symptoms and ___________ .
Levels do not reflect clinical digoxin toxicity, so follow symptoms and EKG changes.
What are some situations that increase the risk of digoxin toxicity?
1. Renal insufficiency
2. Hypokalemia
3. Hypothyroidism
4. Drug interactions

These increase the risk of digoxin toxicity.
How is treatment for diastolic dysfunction different?
B-blockers and calcium channel blockers are first line therapy.

ACEIs are second line.

These agents increase cardiac output by increasing diastolic filling time for patients with diastolic dysfunction.
What are the major prognostic indicators in patients with CHF?
Poor prognostic indicators include:

1. symptoms at rest
2. poor ejection fraction
3. hyponatremia
4. ventricular arrhythmias

Major causes of death include progressive CHF (40%) and sudden death (40%).

One year mortality for patients with class IV CHF exceeds 50%.
How do I prevent complications in CHF?

Up to 90% of CHF patients demonstrate complex ventricular ectopy. __________ suppresses ventricular arrhythmias.
Up to 90% of CHF patients demonstrate complex ventricular ectopy. AMIODARONE suppresses ventricular arrhythmias.
Automatic implantable cardiac debrillating devices (AICDs) can help resuscitate patients with frequent ventricular _______________ .
Automatic implantable cardiac debrillating devices (AICDs) can help resuscitate patients with frequent ventricular FIBRILLATION.
Thromobembolism is more common when left ventricular ejection fraction is less than or equal to 25%, so ___________ is often used.
Thromobembolism is more common when left ventricular ejection fraction is less than or equal to 25%, so WARFARIN is often used.
Depression decreases medication adherence. Since _____________ antidepressants increase the risk of arrhythmias, use ____________ .
Depression decreases medication adherence. Since TRICYCLIC antidepressants increase the risk of arrhythmias, use a SSRI.
When should I hospitalize patients with CHF?
Hospitalize patients with newly diagnosed CHF of unclear etiology to rule-out ischemic disease and begin work-up and treatment.

Admit patients for clinical exacerbations with hypoxia or hypotension, or if the EKG suggests new ischemic injury.
Admit orders for CHF patients should include:
1.
2.
3.
Admit orders for CHF patients should include:
1. Daily weights
2. Fluid intake and output records
3. Low salt (2-4 gm) diet

4.
Monitor clinical volume status using:
1.
2.
3.
Monitor clinical volume status using:
1. daily exam
2. serum chemistries
3. renal function.
What should you look for on daily exam to assess volume status?
Daily exam should include:
1. vital signs (including orthostatics)
2. weight
3. JVP
4. cardiovascular exam for S3 sounds
5. lung exam for crackles or effusions
6. extremity exam for edema.
For significant volume overload, give:
1.
2.
3.
For significant volume overload, give:
1. oxygen
2. IV diuretics
3. furosemide drip if necessary
______________ catheters are used in refractory CHF for careful volume management or when __________ agents are used.
SWAN-GANZ catheters are used in refractory CHF for careful volume management or when INOTROPIC agents are used.
IV ____________ , an inotropic agent, may be given to increase cardiac output and lower afterload.
IV DOBUTAMINE, an inotropic agent, may be given to increase cardiac output and lower afterload.

Some patients require intermittent hospitalization for IV dobutamine therapy while they await cardiac transplant.