Heart Failure Clinical Aspects-Weinstein

Question 1

What is the 5 year survival of heart failure

Answer 1

50%

Question 2

What is the most common mode of death of heart failure?

Answer 2

Sudden death

Question 3

What is the increase in prevalence of HF from 50 to 89?

Answer 3

10x

Question 4

What percentage of HF patients are over 65?

Answer 4

>75%

Question 5

What is the most common hospital diagnosis in patients over 65?

Answer 5

Heart failure

Question 6

What percentage of HF patients die suddenly?

Answer 6

40%

Question 7

Definition of sudden death

Answer 7

Death within an hour of onset of symptoms. Usually caused by arrhytmias

Question 8

What percentage of HF patients have ventricular arrhythmias?

Answer 8

90%, including PVCs (premature ventricular contractions), multiform PVCs and NSVT (nonsustained ventricular contractions)

Question 9

Prognostic factors of heart failure

Answer 9

LV Dysfunction Coronary Artery Disease Arrhythmias Exercise Tolerance  Plasma Noradrenaline ↓ Serum Sodium.

Question 10

New York Heart Association Classification of Heart Failure

Answer 10

I-Asymptomatic, II-Mild, III-Moderate, IV-Severe

Question 11

What is involved in class I NYHA?

Answer 11

Known to have dysfunction but asymptomatic during a reasonable amount of exercise.

Question 12

What is involved in class II NYHA classification?

Answer 12

Can perform everyday activities but LV dysfunction prevents exertion above regular activities (can walk but not run). 2/3 die of sudden death, otherwise CHF/fluid retention, pulmonary edema, etc.

Question 13

What is involved in class III NYHA classification?

Answer 13

Symptomatic in normal everyday activities. 1/2-2/3 sudden death, 1/4 CHF death.

Question 14

What is involved in class IV NYHA classification?

Answer 14

Symptomatic even at rest. Ex: short of breath while sitting in chair. Over half of deaths are from CHF, only 1/3 sudden death.

Question 15

Definition of heart failure?

Answer 15

Clinical syndrome with symptoms, signs AND objective evidence.

Question 16

What are the symptoms typical of HF

Answer 16

Dyspnoea, fatigue, ankle swelling

Question 17

What are the signs typical of HF

Answer 17

Tachycardia, tachypnoea, ↑JVP, oedema, hepatomegaly

Question 18

What objective evidence needs to be shown of a structural or functional heart abnormality

Answer 18

Cardiomegaly, S3, murmur, abnormal echo, ↑BNP-all at rest.

Question 19

Stages of LV dysfunction and HF classified by the AHA

Answer 19

Stage A: risk factors (normal healthy people, keep evaluating), Stage B: asymptomatic and structural heart disease (keep following up and treat risk factors, like NYHA class I), Stage C: symptomatic and structural heart disease (known to have HD but need aggressive treatment of risk factors, NYHA II), Stage D: severely symptomatic and structural heart disease (most patients either in HF and feeling good or potentially on their way to HF, tip of iceberg)

Question 20

What is the difference between NYHA and AHA classificiation?

Answer 20

NYHA is a clinical assessment (already ill) and AHA looks at overall picture and how aggressively to treat, risk factor modification, etc.

Question 21

Respiratory symptoms and signs of left heart failure

Answer 21

Exertional dyspnea, orthopnea (sit up to ease breathing), paroxysmal nocturnal dyspnea (PND), pulmonary congestiona nd edema (worst aspect, outpouring of fluid into lung tissue itself)

Question 22

Systemic igns and symptoms of heart failure

Answer 22

Respiratory, fatigue (LV not perfusing skeletal muscle), weakness, nocturia, cerebral symptoms (rare)

Question 23

Signs of physical exam in left heart failure

Answer 23

Rales (at lung bases like hair), pleural effusion, decreased pulse pressure, pulsus alternans, abnormal apical impulse (weak from LV dilation), muffled heart sounds, apical S3, mitral regurgitation (original insult or secondary)

Question 24

What is Pulsus alternans?

Answer 24

LV destroyed and so weak that between one beat to next, doesn’t sufficently recover to perform adequate systole. Monitor might show 100bpm but may only have 50 functional beats on BP monitor. Extremely uncommon-“end of the road” sign.

Question 25

Symptoms of extreme left heart failure

Answer 25

Pulmonary edema, unable to breathe, legs down to increase pooling (DIY preload reduction), steronomastoids and accessory muscles, tremendous sympathetic response, pouring with sweat, limbs cold and clammy.

Question 26

Symptoms of right heart failure

Answer 26

Fatigue, weakness, GI (anorexia, abdominal pain-upper quadrant and distension, asciites), weight gain (d/t fluid retention, edema of intestinal walls/gastric walls, drops appetite, congestion of liver), peripheral edema (legs)

Question 27

Signs of right heart failure on physical exam

Answer 27

Elevated jugular venous pressure, hepatojugular reflux, hepatomegaly, peripheral edema, pleural effusion, cyanosis, asciites, right sided S3, tricuspid regurgitation (from failing RV)

Question 28

What is hepatojugular Reflux?

Answer 28

If JVD is not palpable, press area of liver, compression forces fluid into RA from portal vein, increases pressure in RV and makes jugular venous pressure increase.

Question 29

Picture of signs of right heart failure

Answer 29

Cyanosis, engorgement of jugular veins, enlargement of liver, asciites, dependent edema in legs, elevated venous pressure (seen in monometer), not in distress.

Question 30

Precipitating factors in chronic heart failure

Answer 30

Lack of compliance (diet and drugs), uncontrolled HTN, arrhythmias (Afib most common), environmental factors, inadequate therapy, pulmonary infection, Fluid overload (causing pulmonary edema or HF, ex: steroids/NSAIDS, negative inotropes), MI, thyrotoxicosis and other endocrine disorders, worsening of renal function

Question 31

Aspects of HF management

Answer 31

1. History (confirm diagnosis, lifestyle, NYHA class, underlying diseases, etc.), 2. Physical examination, 3. baseline investigations (ECG, CXR)

Question 32

Baseline investigations/exams in HF

Answer 32

Blood chemistry (renal, thyroid, cardiac markers), ECG (sinus, old infarct, other underlying problems), Echocardiogram, IHD investigations (within clinical context: exercise test, thallium, catheterization), BNP, Holter

Question 33

What aspects need to be treated in heart failure?

Answer 33

1. Underlying condition, 2. Precipitating condition (ex: Afib from pulmonary infection give antibiotics) 3. Heart failure itself

Question 34

What points are important to convey in patient education?

Answer 34

Why they are in HF, signs of deterioration, physical activity (mild if can’t strenuous), rehab, sexual dysfunction

Question 35

What pharmacological therapy is used for heart failure (big list)?

Answer 35

ACE inhibitors, diuretics, Beta blockers, aldosterone antagonists, angiotensin antagonists, cardiac glycosides, vasodilator agents, positive inotropes, anticoagulation, antiarrhythmics, oxygen

Question 36

Compiled list of device and surgery interventions for heart failure

Answer 36

Revascularization, pacemakers, ICDs, heart transplantation, ventricular assist devices, artificial heart, ultrafiltration/hemodialysis

Question 37

When are ACE inhibitors used?

Answer 37

First line therapy in patients with reduced LVEF. Only drug to give to asymptomatic patients with LV dysfunction (use guidelines, not symptoms to treat).

Question 38

What are the outcomes with ACE inhibitors?

Answer 38

Decrease development of symptoms and hospitalizations, delay onset of problems. Best benefit in most severe cases.

Question 39

What are the restrictions of ACE inhibitors?

Answer 39

If side effects (cough) on ACE inhibitors, can give ARBs), moderate renal insufficiency but NOT contraindictations.

Question 40

What are the absolute contraindications for ACE inhibitors

Answer 40

Bilateral renal artery stenosis, angioedema,

Question 41

What are the pros and cons of ARBs?

Answer 41

Fewer side effects, efficacy may or may not be the same as ACE inhibitors. Given only when ACE inhibitor intolerance.

Question 42

When are beta blockers recommended?

Answer 42

For symptomatic patients NYHA Class II and above, in addition to ACE inhibitors and diuretic.

Question 43

What are the benefits of beta blockers?

Answer 43

Decreases symptoms of LV systolic dysfunction after MI, reduces: mortality when added to ACE inhibitors.  total mortality  cardiovascular mortality  sudden death  death due to progressive HF  hospitalizations (all, HF, CV) FC II-IV Improves functional class I, A Less worsening of HF Independent of age, sex, FC, EF, etiology

Question 44

What are the 4 currently recommended beta blockeres?

Answer 44

Carvedilol (blocks both alpha and beta), beta 1 selective: metoprolol succinate, bisoprolol, nebivolol

Question 45

When are ICDs recommended (Implanted Cardiac Defibrillator)

Answer 45

Prior resuscitated cardiac arrest, demonstrated underlying propensity for life-threatening arrhythmias or severe MI complications, ischemic etiology and >40 days post MI or nonischemic etiology.

Question 46

What does an ICD do?

Answer 46

Pacemaker type implanted under skin with electrode to RV gives internal shock when senses arrhythmia. Doesn’t pace patient, just waits for VF or VT to happen. During an atrial block will let pts own internal pacemaker system and when it doesn’t work gives its own pulse.

Question 47

When is a CRT (Cardiac resynchronization therapy used?

Answer 47

1. Significant HF: NYHA class III or IV and QRS extended over 120ms., 2. On max therapy, 3. Severe LV dysfunction

Question 48

What does a CRT do?

Answer 48

Pacemaker. Fully takes over conduction as it sits on the right ventricle. Improves symptoms and decreases hospitalization, reduces mortality.

Question 49

When is a CRTD (Cardiac resynchronization therapy defibrillator) used?

Answer 49

In patients candidates for CRT but underlying propensity to develop arrhythmias and need ICD. Paces by ICD electrode but also gives shocks.

Answer 50