Cardiology 2 - Heart Failure

Heart failure results from ___ impairment of the ventricular filling

functional or structural

Which demographic groups are most highly affected by heart failure before 74 years old?

black men and women

Which demographic groups are most highly affected by heart failure after 75 years old?

white and black males

Mortality rates of HF within 5 years are around ___

50%

Incidence of HF is ___ but the prevalence is ___ due to improved survival

declining, increasing

3 multiple choice options

HFrEF is defined by a EF of ___

less than 40%

HFrEF is caused by decreased pumping function of the heart which leads to ___

fluid backup in the lungs

HFpEF is caused by a thickened and stiff heart muscle which causes the heart to ___

not fill properly causing fluid backup

Is HFrEF or HFpEF more common?

HFpEF

What are some examples of HFrecEF?

- pregnancy induced CMO

- drug related CMO

- viral myocarditis

Heart failure shares many of the same major risk factors as ___

diabetes mellitus

What are the treatment goals of heart failure tx?

- improve function

- improve symptoms

- improve survival

- reduce hospitalizations

- proactive clinical care

What are some patient-related factors relating to heart failure?

- aging

- non-adherence

- high salt/fluid intake

- alcohol use

What are some cardiac comorbidities relating to HF?

- ACS

- tachy/bradycardias

- HTN

- myocarditis

- acute PE

What are some non cardiac comorbidities?

- renal dysfunction

- respiratory diseases

- anemia

- arthritis

- cognitive disorders

- depression

- COPD

- thyroid disorders

What is the most common cause of heart failure?

Ischemic cardiomyopathy

What are some causes of non-ischemic heart failure?

- amyloidosis

- sarcoidosis

- hemachromatosis

- COVID

- metabolic/drugs/toxins

___ is a restrictive cardiomyopathy with myocardial protein deposition

Amyloidosis

Risk factors for ___ include LV thickening, aortic stenosis, HFpEF, carpal tunnel, spinal stenosis and autonomic sensory polyneuropathy

cardiac amyloidosis

T/F: no single test is diagnostic for heart failure

True

Stages of classification (A-D) for heart failure are based around ___

structural changes

Functional classification (I-IV) of heart failure is related to ___

limitations of physical activity and symptoms

What are prognosis outcomes relevant to an individual patient?

- survival

- quality of life

- costs/burden

What is the most high sensitivity symptom for heart failure?

dyspnea (95% sensitive)

What heart failure symptoms will occur with RV failure?

- RUQ pain

- nausea

- loss of appetite

- peripheral edema

- ascites

Alterations in therapy, Na+ load, arrhythmias, infection, excessive activity, PE and worsening disease can cause intermittent episodes of ___ in HF patients

ischemia

S/S of HF?

- dyspnea

- tachy

- hypotensive

- decreased pulse pressure

- diaphoresis

- cool extremities

What are some things you may find on PE in a heart failure patient?

- JVP elevation*

- PMI displacement*

- S3 heart sounds*

- LE edema

- hepatojugular reflex*

- dyspnea, cyanosis, cachexia

- Thyromegaly

- carotid pulse

- crackles, wheeze, rhonchi, PE

* = high specificity

Cardiovascular examination of HF patient may show:

- diminished first sound

- S3 gallop

- murmurs (exclude valvular disease)

- hepatomegaly

- LV lift

What labs should be used to evaluate HF?

- CBC (anemia)

- BMP (renal insufficiency/electrolytes/hyponatremia)

- thyroid studies

Normal ___ values will rule out heart failure

BNP

T/F: BNP level does not determine severity of HF

False

What are some non-cardiac causes of elevated BNP?

- anemia

- aging

- renal failure

- OSA/pneumonia/pulmonary HTN

- illness/sepsis/burns

- chemotherapy

EKG changes in heart failure

- biphasic P wave = atrial enlargement

- inverted deep QRS complex = ventricular enlargement

- non-specific ST changes

- atrial fibrillation

What can be seen on CXR for HF?

- cardiomegaly

- pleural effusion

- interstitial edema

Which test can be used to determine ischemic vs non-ischemic etiology of HF?

- Thallium stress test

- catheterization can also determine presence of CAD

___ relieve symptoms but do not help with ejection fraction or slowing remodeling

Diuretics

___ decrease mortality in HF by up to 20%, prevent hospitalizations, decrease hospitalizations and decrease symptoms.

ACE inhibitors

___ decrease symptoms long term, reduce remodeling, reduce hospitalizations, reduce sudden death and improve survival

Beta blockers

___ help reduce afterload in heart failure patients

vasodilators

___ are useful in acute events for severely decompensated failure/MI/ischemia

Nitrates

___ may accelerate progression of HErEF and worsen LV function - avoid if possible unless treating associated angina

CCB's (except amlodipine)

Tx of Stage B/Class I HF?

ACE or ARB

w/ BB

Tx of stage C/Class I-IV?

ACE and/or ARB

w/ BB

Diuretic

Aldosterone antagonist

Hydralazine

Digoxin

CRT, ICD

Tx of stage D/Class IV?

All stage C meds

w/ inotropic agents, vasodilators

Experimental drugs or surgery

Transplant

Palliative care

Which medication reduces mortality the MOST in HF?

Beta Blockers

What are the two 'new' medication options for HF?

- ivabradine: inhibits SA node to decrease HR

- Sacubitril/valsartan: Neprilysin inhibitor increased BNP to counter maladaptive mechanisms

Which DM medication can be effective for reduction of hospitalization in HF?

SGLT-2 inhibitors

Tx of acute pulmonary edema in HF exacerbation?

- airway control

- diuretics (IV)

- BP control

- check for rhythm disturbances, ischemia and renal fxn

Alternative tx for HF?

- diet/exercise

- Coronary revascularization in pts with CAD

- biventricular pacing for widened QRS complexes

- temporary defibrillator

- LVAD

- transplant

Which positive inotrope can be used in HF?

milrinone