Congestive Heart Failure (CHF)
What is hydralazine?
*Direct arterial vasodilator - reduces afterload* MOA - not fully understood Very important drug clinically - acute and chronic therapy For patients that can't tolerate ACE/ARB Lowers Systemic Vascular Resistance
What are the goals of therapy in heart failure patients?
*Treat Underlying Cause* Ischemic -Medication, PCI - stenting, CABG Valvular -Medication, repair or replace valve Hypertension
How does a cardiac muscle cell work in the contraction phase?
A large amount of calcium is released from the sarcoplasmic reticulum. *Calcium activates the contractile proteins* (actin, tropomyosin and troponin) and the cell contracts. Calcium disengages from the contractile proteins and most is pumped back into the sarcoplasmic reticulum.
What medications work on the renin-angiotensin-aldosterone system?
Ace - Inhibitors -Lisinopril, Ramipril, Altace... Angiotensin Receptor Blockers -Losartan, Valsartan
What is the treatment for systolic left heart failure?
Ace Inhibitor + β-blocker + Loop Diuretic
What is the treatment for diastolic heart failure?
Ace inhibitor + β-blocker or CCB (do not use diuretics in stable chronic diastolic failure)
What is the difference between loop diuretics and thiazide diuretics?
Act in Ascending Loop of Henle to Inhibit Sodium and Chloride reabsortion by the Kidney Act in Distal Convoluting Tubule to block Sodium and Chloride reabsortion by the Kidney
What are the types of heart failure and which is most common?
Acute systolic heart failure Chronic systolic heart failure Acute on chronic systolic heart failure Acute diastolic heart failure Chronic diastolic heart failure - aortic stenosis Acute systolic on chronic diastolic heart failure is the *most common.*
How should acute pulmonary edema be treated?
Admit to ICU Oxygen therapy CPAP, BiPAP, intubation IV diuretic therapy Positive inotrope -Dobutamine, milronone Pressors (if hypotensive) -Vasopressin, epinephrine Add ACE inhibitor and beta-blocker when hemodynamically stable, wean off meds. -Why not start here? These detract from contractility; only exacerbate.
What is the treatment of non-acute congestion heart failure?
Angiotensin - Converting Enzyme Inhibitors Angiotensin Receptor Blockers B-Blockers Minerlocorticoid Receptor Antagonists Sacubitrtil - Valsartan Hydralazine Ivabradine Digitalis
What is length-dependent activation?
As a myocyte stretches (as occurs with increased preload) the sarcomeres stretch and there is an increase in force of contraction. *Stretching the sarcomere increases TN-C affinity for calcium*, which leads to increased tension development. This is referred to as *length-dependent activation.*
What are the HF Core Measure Indicators?
Assessment of LVF (left ventricular function) (i.e. EF). Prescribed ACE inhibitor or ARB for LVSD. Smoking cessation information/education provided to a patient who has smoked within the year prior to arrival (even if they've "quit" 3 months ago). Written Discharge Instructions covering 6 areas: Diet, Activity, Follow-Up, Daily Weights, What do do if Symptoms Worsen, Complete list of Discharge Medications AND signed.
What is the difference between stenting and CABG?
Blockage greater than 50% Multivessel disease, location of blockage and diabetes, risk of surgery This will improve ejection fraction
What is the Heartmate III?
Bridge to transplant and destination therapy.
What are useful laboratory values for patients with heart failure?
Bun/Cr (metabolic panel) Serum sodium level (metabolic panel) Bicarbonate level (metabolic panel) -You become acidotic when your organs don't perfuse ABG CBC- anemia - high output state Urinalysis TSH LFTs and bilirubin BNP - reduced by heart failure therapies - not used as a guide
What are non-medical therapies for non-acute congestion heart failure?
Cardiac Resynchronization Therapy Cadioverter - Defibrilator ICD -If EF <40% after CABG or stent, have to put in ICD because of increased arrhythmia risk Life - Vest* Ventricular Assist Device Heart Transplant Exercise Training
What is cardiac output?
Cardiac output = heart rate X stroke volume
How does cardiomegaly appear on a chest x-ray?
Cardiomyopathy, probably LVH.
What are the diagnostic modalities for a patient with suspected heart failure?
Chest x-ray -Heart size, pulmonary congestion EKG -Rhythm, MI, LVH, BBBs Echocardiogram -EF <40%, valve dysfunction, wall thickness, dilation, wall motion abnormalities, right-sided failure Laboratory tests -BUN (remember vicious cycle) -Cr -Na++ -BNP -Troponin -Diabetics: blood vessels on endothelium don't do their job well --> subendocardial ischemia)
What are anticoagulants?
Coumadin -Reverse with FFP, vitamin K Eliquis Xarelto Pradaxa
What is dobutamine?
Dobutamine is a *synthetic catecholamine* that acts on *alpha-1, beta-1 and beta-2 adrenergic receptors*. In the heart, the stimulation of these receptors produces a relatively strong, additive inotropic effect and a relatively weak chronotropic effect. In the vasculature, alpha-1 agonist activity (vasoconstriction) balances the beta-2 agonist effect (vasodilatation) Dobutamine has a rapid onset of action and a short half-life. It increases myocardial contractility, while the reflex reduction in sympathetic tone, in response to augmentation of stroke volume, leads to a decrease in total peripheral resistance. The expected hemodynamic effects are an *increase in cardiac output and a decrease in systemic vascular resistance without significant change in arterial pressure or heart rate*.
What are the symptoms of heart failure?
Dyspnea -Is it at rest or with activity and how much activity? Orthopnea/PND -How many pillows and how many times a night? Edema -1-4+, generalized or pitting, ascites, hepatomegaly Fatigue Cognitive -Dysfunction or depression confusion Chest pain -Angina Palpitations -Irregular/regular Sleep apnea, night terrors, not feeling rested
What is the gold standard for heart failure diagnosis?
Echocardiogram.
Why is early stabilization of heart failure patients important?
Efforts to identify and treat immediate life-threatening conditions within the ER comprises approximately the first 12-18 hours of care. Effective intervention for treating HF are time-sensitive and require rapid assessment, diagnosis, and treatment. Evaluation of the initial response to therapy, followed by adjustment as indicated is required for efficient risk stratification and appropriate pt. disposition. Pt. treated and released from the ED and those placed in observation service are included in this component.
What history elements should you taken in a patient with suspected heart failure?
Family history Cardiovascular disease -Hypertension, valvular disease Co-morbidities -Diabetes, hypertension, obesity, viral infection Relevant expsures -Drugs, chemotherapy -Common in breast CA: echo before and after chemo High output states -Cycling, running, tri-athletes (most common groups will see in)
What is the impella?
For refractory heart failure, placed with fluoroscopy. Catheter sucks blood and pushes it to rest of body.
What physical examination should you perform on a patient with suspected heart failure?
General apperance -Gray, short of breath answering questions, tachypneic, anxious, pale, clammy, confused, diaphoretic, cyanotic Vital signs -Low oxygen saturation, hypotensive, hypertensive, tachycardic, bradycardic, a-fib, afebrile, febrile JVD -Seen mostly in acute CHF Cardiac exam -Heart rate, rhythm, palpitations, murmurs or rubs, S3, gallop, displaced PMI Pulmonary exam -Presence of rales or diminished basilar breath sounds--pleural effusion Abdominal exam -Presence of ascites or hepatomegaly Extremities/pulses -Pitting edema, diminished pulses, cold feet -- low cardiac output
What is the therapy for stage B heart failure?
Heart disease is present but there are no symptoms (structural changes in heart before symptoms occur) ICD - < 35% Stent/CABG
What is stage B heart failure?
Heart disease is present but there are no symptoms (structural changes in heart before symptoms occur).
Why is heart failure important?
Heart failure results in more than 1 million annual hospital admissions and is growing rapidly. Most common reason for admission for patients 65 and older. All hospitals are being evaluated on the quality of heart failure care as *documented in the patient medical record.* NJ hospitals are required to submit HF data to the Joint Commission, NJ Department of Health, and the Centers for Medicare and Medicaid. Results are published and reported to the public. Mortality rate for heart failure is 50% within 5 years. 10,000 people a day are turning 65 years of age. 400,000 new cases a year. More than 10% of the popular older than 80 years has heart failure.
What are end stage congestion heart failure therapies?
Impella Heartmate III Heart transplant
What are the goals of therapy after assessing and treating the underlying cause?
Improve blood supply to heart Reduce work on the heart -Reduce preload -Reduce afterload Reduce hypertrophy and remodeling
What is heart failure?
Inability of the heart to pump enough blood to meet the metabolic needs of the body.
What are compensatory mechanisms to CHF?
Increased heart rate - sympathetic = norepinephrine Dilation - Frank Starling + contractility Neurohormonal - redistribution of blood to the brain (by kidneys)
What are pathophysiologic causes of CHF?
Increased workload Myocardial dysfunction Increased ventricular filling
What are the chronic etiologies of heart failure?
Ischemic heart disease Idiopathic cardiomyopathy Hypertension Valvular heart disease -Aortic stenosis -Mitral regurgitation -Aortic regurgitation -Mitral stenosis -Tricuspid regurgitation -Pulmonic stenosis
What is the relationship of blood flow to pathology?
Left heart failure, untreated, leads to biventricular failure. Right heart failure doesn't always lead to LHF.
What are the signs and symptoms of left ventricular failure and right ventricular failure?
Left ventricular -Dyspnea on exertion -Pulmonary edema Right ventricular -Peripheral edema -Ascites -Hepatomegaly -Cor pulmonale - pulmonary hypertension (COPD, interstitial lung disease, sleep apnea, chronic PE, cystic fibrosis, pulmonary stenosis) Bi-ventricular -Both, usually caused by left-sided failure though
What is diuretic therapy?
Loop Diuretic -Furosemide - Lasix, Bumex Thiazide Diuretics - avoid in some patients -Hydrochlorathiazide
What is atrial fibrillation?
Many patients with CHF develop atrial fibrillation or it may be their presenting symptom. -Must know how to treat atrial fibrillation -Must know how to dose coumadin -Must know how to use all anticoagulants
What does the Swan-Ganz catheter measure?
Measures: -Cardiac output/cardiac index -Pulmonary artery pressures -Right atrial/central venous pressure (pre-load) -Systemic vascular resistance (afterload) -Venous saturation Cardiac index is CO/BSA -Normally 2.1 to 5.0
What are the effects of beta blockers?
Metoprolol Toprol Carvedilol Bisoprolol Decrease contractility, decrease HR
What is class II heart failure?
Mild. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
What is milronone?
Milronone *increases cytoplasmic cyclic adenosine monophosphate (cAMP)* resulting from phosphodiesterase III inhibition in cardiac and smooth muscle. *cAMP is essentially the fuel of the myocardial cell* Milronone increases cardiac contractility which results in an increase in cardiac output {01}. Milrinone also relaxes both arterial and venous smooth muscle, thereby reducing both preload and afterload.
What is class III heart failure?
Moderate. Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity causes fatigue, palpitation or dyspnea.
What are the acute etiologies of heart failure?
Myocardial infarction Ruptured chordae tendinae -Severe mitral valve regurgitation Acute ventricular septal defect (left to right shunt) Acute vegetative endocarditis -Tricuspid, mitral and aortic Acute viral cardiomyopathy Acute constrictive or restrictive pericarditis Pericardial effusion
What are alarm signs for a patient with heart failure (cont.)?
New onset AHF where a rapid outpatient etiologic workup is not available. Those on IV infusions being actively titrated. Significant comorbidities requiring acute interventino. Significantly elevated respiratory rate (>32 breaths/min) or requiring noninvasive ventilation at the time - CPAP. Signs of poor perfusion at the time of entry. Patients with poor response to initial therapy, indicated by a lack of urinary output or lack of improvement in vital signs. -More than 30 mLs/hr
What medications can be used to treat ischemic heart failure?
Nitrates: arterial and venous dilators - smooth muscle Beta-blockers: block B1 and B2 receptors -Negative chronotrope, help heart remodel Calcium channel blockers: block calcium channels -Negative chronotropes, dilate blood vessels Diuretics: reduce sodium levels and increase urine output ACE inhibitors: improve remodeling of heart muscle, lower BP
What is class I heart failure?
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation (feeling heart beats), or dyspnea (shortness of breath).
What are antiplatelets?
Plavix Effient Brilinta Aspirin
What is the prognosis of CHF?
Poor prognosis factors: chronic kidney disease, diabetes, lower LVEF, severe symptoms, old age 5-y mortality: 50%
What are the elements of cardiac performance?
Pre-load: Amount of blood/volume that returns to the heart or end-diastolic volume at the beginning of systole. -Primarily a *venous and diastolic function* After-load: Amount of pressure that the heart has to pump against *or* the ventricular pressure at the end of systole -Primarily an arterial and systolic function Contractility/inotropy: how well or hard the heart contracts Heart rate/chronotropy: how fast or slow the heart beats
What is the therapy for stage D heart failure?
Presence of advanced heart disease with continued heart failure symptoms requiring aggressive medical therapy
What is stage D heart failure?
Presence of advanced heart disease with continued heart failure symptoms requiring aggressive medical therapy.
What is the therapy for stage A heart failure?
Presence of heart failure risk factors but no heart disease and no symptoms - Treat Risk Factors
What is stage A heart failure?
Presence of heart failure risk factors but no heart disease and no symptoms.
What are alarm signs for a patient with heart failure?
Renal dysfunction (BUN >40 mg/dL or creatinine >3 mg/dL) Low serum sodium (<135 mEq/L) Low SBP (<100 mmHg) New ischemic changes of ECG Positive cardiac troponin
What are the average, normal intracardiac and vascular pressures?
Right atrium: 0-4 (varies with respiration) Right ventricle: 25 sys/4 dias Pulmonary artery: 25 sys/10 dias Left atrium: 8-10 Left ventricle: 120 sys/10 dias Aorta: 120 sys/80 dias
What is class IV heart failure?
Severe. Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
How does a cardiac muscle cell work in the relaxed phase?
Sodium channels open in cell membranes causing change in electrical charge. This causes surface membrane calcium channels to open, causing small calcium influx. Calcium binds to calcium-releasing channel proteins on the sarcoplasmic reticulum.
What are aldosterone antagonists?
Spironolactone -Blocks second effector hormone in the Renin- Angiotensin- Aldosterone cascade - for advanced CHF Why? Excessive Aldosterone promotes sodium retention and hypokelemia and contributes to myocardial fibrosis which can lead to arrhythmias. Good for remodeling.
What is the therapy for stage C heart failure?
Structural heart disease is present AND symptoms have occurred Surgery and medication
What is stage C heart failure?
Structural heart diseases is present AND symptoms have occurred.
What are invasive diagnostic and hemodynamic monitoring modalities for patients with suspected heart failure?
Swan-Ganz catheter Cardiac MRI - cardiomyopathies Myocardial biopsy - cardiomyopathies Exercise capacity - 5 meter and 6 minute walk
What is the difference between systolic heart failure and diastolic heart failure?
Systolic failure: decrease in *contractility*--ventricle doesn't squeeze -EF <55% Diastolic failure: decrease in *compliance*--ventricle is stiff -Normal EF
What is the Frank-Starling Law?
The energy delivered with each cardiac contraction is a function of the length of the muscle fibers in the ventricular wall.
