Heart Failure

Front 1

What is commonly the primary insult to the myocytes?

Back 1

Either myocardial loss such can occur in MI or due to overload.

Front 2

What happens with the heart itself when its pumping ability is insufficient?

Back 2

It will hypertrophy and dilate due to cardiac remodelling.

Front 3

What endocrine changes will occur as a result of an inability of the heart to supply the body?

Back 3

Activation of the renin-angiotensin-aldosterone system with subsequent fluid retention and edema etc. Angiotensin II is the main cause of the cardiac remodelling.

Front 4

How is LV dysfunction graded?

Back 4

Based upon the EF.

Front 5

What is Grade I LV dysfunction?

Back 5

EF > 60%

Front 6

What is Grade II LV dysfunction?

Back 6

EF = 40-59%

Front 7

What is Grade III LV dysfunction?

Back 7

EF = 21-39%

Front 8

What is Grade IV LV dysfunction?

Back 8

EF = <20%

Front 9

What are the clinical findings of systolic dysfunction?

Back 9

Apex beat displaced, S3, increased cardithroacic index, decreased LVEF, LV dilation

Front 10

Into what two groups can the causes of LV systolic dysfunction be divided?

Back 10

Ischemic & nonischemic causes

Front 11

Which are the nonischemic causes of LV systolic dysfunction?

Back 11

hypertension
diabetes mellitus
alcohol
myocarditis
dilated cardiomyopathy

Front 12

What are findings in isolated diastolic dysfunction?

Back 12

hypertension,
apex beat sustained,
S4,
normal-sized heart on CXR,
LVH on ECG/echo
Normal LVEF

Front 13

How common is isolated diastolic dysfunction?

Back 13

Diastolic dysfunction without systemic dysfunction is present in about 1/3rd of heart failure patients.

Front 14

What are the causes of decreased compliance of the heart?

Back 14

Transiet: ischemia
Permanent: severe hypertrophy, due to HTN, AS, HCM
Restrictive cardiomyopathy
MI

Front 15

Describe the NYHA classes of heart failure.

Back 15

Class I: Dyspnea only on extended exertion.
Class II: Dyspnea on ordinary physical activity, comfortable at rest.
Class III: Marked limitation of ordinary activity, less than ordinary activity causes dyspnea.
Class IV: Inability to carry out any physical activty. Dyspnea may be present at rest.

Front 16

Name the five most common causes of heart failure in descending order.

Back 16

CAD 60-70%
HTN
Idiopathic dilated cardiomyopathy
Valvular disease
Alcohol

Front 17

What is a rather common cause of heart failure in south america?

Back 17

Chaga's disease

Front 18

What are the precipitants of heart failure? What is the mnemonic?

Back 18

HEART FAILED

Hypertension
Endocarditis/environment
Anemia
Rheumatic heart disease/valvular
Thyrotoxicosis
Failure to take meds
Arrhythmia (common)
Infection/Ischemia/Infarction
Lung problems
Endocrine (pheochromocytoma, hyperaldosteronism)
Dietary indiscretions

Front 19

What is the most common cause of right sided heart failure?

Back 19

Left sided heart failure.

Front 20

What are the signs and symptoms of left sided heart failure?

Back 20

FATIGUE
SYNCOPE
Systemic hypotension
Cool extremities
Slow capillary refill
Peripheral cyanosis
Pulsus alterans
Mitral regurgitation
S3

DYSPNEA, ORTHOPNEA, PND
COUGH
Crackles/Rales

Front 21

What are the signs and symptoms of right heart failure?

Back 21

Mimics many of the left sided heart failure.

Tricuspid regurgitation
S3
PERIPHERAL EDEMA
ELEVATED JVP with AJR and Kussmauls sign
Hepatomegaly
Pulsatile liver

Front 22

What is the first step in the treatment of newly diagnosed heart failure?

Back 22

Identification and treatment of precipitating factors, such as pneumonia.

Front 23

Which blood tests should be run in a patient with heart failure?

Back 23

CBC, electrolytes, BUN, creatinine, TSH, ferritin, BNP, uric acid

Front 24

What can be seen on ECG?

Back 24

Chamber enlargement, arrhythmia, ischemia/infarction

Front 25

What can be seen on echocardiography of heart failure?

Back 25

LVEF, cardiac dimensions, flow or wall motion abnormalities, valvular disease or pericardial effusion

Front 26

What can be seen on chest xray?

Back 26

cardiomegaly, pleural effusion, redistrobution, Kerley-B lines, bronchiolar-aleolar cuffing

Front 27

What can be seen on radionuclide angiography?

Back 27

LVEF

Front 28

What is often the manifestation of decompensated heart failure which needs acute treatment?

Back 28

Pulmonary edema

Front 29

How should acute pulmonary edema be treated?

Back 29

Sit up,
Oxygen,
Furosemide 40mg I.V
Morphine 2-4mg I.V
Nitroglycerin (if not right-sided!)

Front 30

When may sympathomimetics be needed in HF?

Back 30

If there is cardiogenic shock.

Front 31

Which sympathomimetics are given?

Back 31

Dopamine
Dobutamine
Milrinone
Epinephrine

Front 32

Why is dopamine so good to give?

Back 32

Because it selectively vasodilates the renal vascular bed.

Front 33

Which drugs should be given in the chronic treatment of heart failure?

Back 33

- ACEi has grade A evidence of slowing progression and improving survival.
- ARB's if ACEi intolerant or if ACEi not enough.
- Hydralazine and nitrates second line to ACEi.
- Beta-blockers. Not in acute decompensation.
-Diuretics, controls symptoms and manages fluid overload.
-Aldosterone antagonists, such as spironolactone and eplerenone.
- Digoxin previously used to improve symptoms.
- Antiarrhythmics
- Anticoagulants
- CCBs

Front 34

Which are the three groups of drugs which shows a benefit on mortaility in the treatment of heart failure?

Back 34

ACEi, Betablockers and Aldosterone antagonists.

Front 35

Which are the meds which are contraindicated in a patient with heart failure?

Back 35

NSAIDs (incr. BP)
Class I/III antiarrhythmics
Metformin in severe HF
Thiazolidinediones
cGMP phophodiesterase inhibitors such as sildenafil.

Front 36

What are the procedural interventions we can perform on a patient with heart failure?

Back 36

Resynchronization therapy.
Intracardiac defibrillator.
Ventricular assist devices.
Cardiac transplantation
Valve repair

Front 37

What does the resynchronization therapy do and why does it help?

Back 37

It synchronizes the ventricles to beat more symmetrically and thus it helps increase the EF and improves symptoms of heart failure.

Front 38

When should resynchronization therapy be considered?

Back 38

When QRS>130ms, LVEF <35% and severe symptoms despite optimal drugs.

Front 39

When should ICD be considered?

Back 39

Prior MI, optimal medical therapy, LVEF <30%, clinically stable.

Front 40

How many percent of patients with HF have sleep disturbances?

Back 40

45-55%

Front 41

What are the typical breathing disturbances during sleep of a patient with HF?

Back 41

Cheyne-stokes breathing and sleep apnea.

Front 42

What are the sleep disturbances of HF associated with?

Back 42

A poor LV function and a worse prognosis.

Front 43

What is a method of treating the sleep breathing problems due to HF?

Back 43

CPAP, nasal continuous positive airway pressure.