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27 Cards in this Set
- Front
- Back
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What labs and studies are recommended in the initial evaluation of a patient with CHF?
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The labs include Electrolytes, fasting blood glucose, CBC, A1C, lipid profile, LFTs, TFTs and a BNP. THe studies include a 12 lead ECG and CXR, an echocardiogram (for LVEF, LV size and wall thickness and valve function) and Coronary arteriography if signs of angina/ischemia.
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What are the leading causes of CHF?
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CAD, HTN and dialated cardiomyopathy.
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What is the difference between systolic and diastolic HF?
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systolic has EF less than 40%, diastolic has impaired vetricular relaxation (resulting in increased LV ejection diastolic pressure).
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How do patients with HF generally present?
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with fluid retention, fatiguability or cardiac enlargement found during unrelated exam
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What are some typical symptoms of a patient with HF?
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SOB, orthopnea, fatigue, PND, weight gain, edema, DOE
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What are some typical signs of a patient with HF?
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S3, JVD or hepatojugular reflex, rhonchi, tachycardia, hepatomegaly, ascites, dependent edema, increaseing weight.
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What is the AHA stage A for HF?
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High risk, but no structural heart disease
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What is the AHA stage B for HF?
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Structural damage, but no symptoms.
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What is the AHA stage C for HF?
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Past or current HF symptoms, and structural damage
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What is the AHA stage D for HF?
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End stage disease, requiring special interventions.
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What is class I of the NYHA functional assessment?
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No limitation of physical activity. Ordinary physical activity does not cause HF symptoms.
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What is class II of the NYHA functional assessment?
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Slight limitations of physical activity. Ordinary physical activity causes dyspnea, fatigue, angina or palpitations.
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What is class III of the NYHA functional assessment?
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Marked limitation of physical activity. Comfortable at rest, but even minor activity causes fatigue, palpitaions, dyspnea or angina.
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What is class IV of the NYHA functional assessment?
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Unable to perform any physical activity without discomfort. HF symptoms present at rest, and worsen with any physical activity.
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What specific risk factors should be controlled in HF patients?
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Control HTN, HLP and atherosclerotic valvular disease. Treat DM, thyroid disorders. Smoking cessation. Control rate/rhythm of SVTs. For those with a family history or are recieving cardiotoxic drugs, evaluate LV function.
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What is the recommended therapy for systolic HF patients with A. Fib?
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Rate control (Beta-blocker with Digoxin if necessary, and verapamil/diltiazem if refractory) and anti-coagulation (Warfarin)
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Why are the CCBs not recommended for first line therapy in HF? When are they recommended, and what drugs should be used?
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CCBs worsen LV function over time, and thus are recommended only after all other attempts at rate control (for A. fib, using verapamil or diltiazem) or BP (for HTN, using fenlodipine or amlodipine) have failed.
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Should HF patients be anticoagulated for their HF?
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No. A single cohort study demonstrated mortality benefit for patients with HF, but it is insufficient as of now.
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What cardiac drugs should not be used in patients with cardiac amyloidosis resulting in HF?
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CCBs (specifically verapamil, diltiazem and nifedipine) and Digoxin.
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What drugs should be avoided in HF?
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CCB (except felodipine and amlodipine), Anti-arrhythmics (except B-blockers, but especially class I anti-arrs), NSIADs, Anti-neoplastic agents, Thiazolidinediones (-glitazones, absolute contraindication in NYHA Class III and IV), Metformin (mostly in acute exacerbations) and Cilostazol (PDE inhibitor used in claudication).
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What is the main pharmacologic goal of treating heart failure? What is the primary way this is achieved?
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The main goal is to improve symptoms by reducing filling pressures of the left ventricle without significantly reducing CO. Reducing heart rate is the primary way of acheiving this goal.
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What are the specific class I recommendations for treating CHF?
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Control HTN, use a diuretic for symptoms of volume overload, and control the ventricular rate in patients with A. fib.
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What are specific class IIb recommendations for treating CHF?
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Use BB, ACEIs, non-DHP CCBs or ARBs for resistant HTN, use digoxin for symptom control, and restore sinus rhythm in A. fib.
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What two classes of drugs are recommended in patients with asymptomatic reduced LVEF? When are each specifically recommmended?
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BB and ACEI. BB may be used with just asymptomatic reduced LVEF, ACEI should be added with history of MI. Use an ARB if the patient is intolerant of ACEIs.
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What is recommended in HF patients with past or present symptoms of volume overload? What are some caveats wrt NYHA and ACA class ratings?
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Diuretics, especially in NYHA III and IV patients. Class C patients should also be given medications that reduce mortality (BB, ACEI and ARBs).
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What are the most common diuretics used in symptomatic overload? What are the advantages of these?
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Loop diuretics are the most common. They are useful in renal failure patients (CrCl less than 40), unlike Thiazide diuretics.
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What should be monitored when a patient is placed on diuretic therapy?
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Daily weight (1-2 lbs/day), Symptoms of dehydration or hypotension, Electrolytes (specifically K and BUN/Cr in 1-2 weeks).
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