Hf

WOF have a survival benefit in systolic heart failure

(HABAN)

Frusemide

Digoxin

Carvedilol

ACE-I

Atorvastatin

71. Treatments known to prolong survival in heart failure includeMetoprololEplerononeAICDCardiac resynchronization therapyCardiac transplant

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Heart failure develops when the heart, via an abnormality of cardiac function (detectable or not), fails to pump blood at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure.

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tachycardia

manifestations of

venous congestion (eg, edema)

low cardiac output (eg, fatigue). Breathlessness is a cardinal symptom of left ventricular (LV) failure that may manifest with progressively increasing severity.

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In HFrEF (also called systolic HF), global LV systolic dysfunction predominates

The LV contracts poorly and empties inadequately, leading to increased diastolic volume and pressure and decreased ejection fraction.

Many defects in energy utilization, energy supply, electrophysiologic functions, and contractile element interaction occur, with abnormalities in intracellular calcium modulation and cAMP production.

Predominant systolic dysfunction is common in heat failure due to

myocardial infarction, myocarditis,

dilated cardiomyopathy.

Systolic dysfunction may affect primarily the LV or the right ventricle (RV); LV failure often leads to RV failure.

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•Complete blood count (CBC)

•Iron studies

•Urinalysis

•Electrolyte levels

•Renal and liver function studies

•Fasting blood glucose levels

•Lipid profile

•Thyroid stimulating hormone (TSH) levels

•B-type natriuretic peptide levels

•N-terminal pro-B-type natriuretic peptide levels

•Electrocardiography

•Chest radiography

•Two-dimensional (2-D) echocardiography

•Nuclear imaging

•Maximal exercise testing

•Pulse oximetry or arterial blood gas

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Symptomatic treatment

Increasing survival

Preventing complications

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Major criteria comprise the following:

•Paroxysmal nocturnal dyspnea

•Weight loss of 4.5 kg in 5 days in response to treatment

•Neck vein distention

•Rales•Acute pulmonary edema

•Hepatojugular reflux

•S 3 gallop

•Central venous pressure greater than 16 cm water

•Circulation time of 25 seconds or longer

•Radiographic cardiomegaly

•Pulmonary edema, visceral congestion, or cardiomegaly at autopsy

accepted only if they cannot be attributed to another medical condition) are as follows:

•Nocturnal cough

•Dyspnea on ordinary exertion

•A decrease in vital capacity by one third the maximal value recorded

•Pleural effusion

•Tachycardia (rate of 120 bpm)

•Hepatomegaly

•Bilateral ankle edema

Non pharmacologic

Pharmacologic

Surgical

Oxygen

noninvasive positive pressure ventilation,

dietary sodium and fluid restriction

physical activity as appropriate, and attention to weight gain

(BANADIHA)

Beta-adrenergic blockers

ACEI /ARB

(Vasodilators)

Nitrates /Hydralazine

Aldosterone antagonists

Diuretics

Inotropic agents

Hydralazine

Anticoagulants

•Electrophysiologic intervention

•Revascularization procedures

•Valve replacement/repair

•Ventricular restoration

•Extracorporeal membrane oxygenation

•Ventricular assist devices

•Heart transplantation

•Total artificial heart

may be caused by myocardial failure

but may also occur in the presence of near-normal cardiac function under conditions of high demand.

Heart failure always causes circulatory failure, but the converse is not necessarily the case, because various noncardiac conditions

(eg, hypovolemic shock, septic shock) can produce circulatory failure in the presence of normal, modestly impaired, or even supranormal cardiac function.

To maintain the pumping function of the heart, compensatory mechanisms increase

blood volume,

cardiac filling pressure,

heart rate

cardiac muscle mass.

However, despite these mechanisms, there is a progressive decline in the ability of the heart to contract and relax, resulting in worsening heart failure.

Breathlessnes is a CARDINAL feature of HF that may manifest with progressively increasing severity.Heart failure can be classified according to a variety of factors The New York Heart Association (NYHA) classification for heart failure comprises four classes, based on the relationship between symptoms and the amount of effort required to provoke them, as follows •Class I patients have no limitation of physical activity•Class II patients have slight limitation of physical activity•Class III patients have marked limitation of physical activity•Class IV patients have symptoms even at rest and are unable to carry on any physical activity without discomfortThe American College of Cardiology/American Heart Association (ACC/AHA) heart failure guidelines complement the NYHA classification to reflect the progression of disease and are divided into four stages, as follows [3]:•Stage A patients are at high risk for heart failure but have no structural heart disease or symptoms of heart failure•Stage B patients have structural heart disease but have no symptoms of heart failure•Stage C patients have structural heart disease and have symptoms of heart failure•Stage D patients have refractory heart failure requiring specialized interventions

NYHA

American College of physicians criteria

The New York Heart Association (NYHA) classification for heart failure comprises four classes, based on the relationship between symptoms and the amount of effort required to provoke them, as follows .

•Class I patients have no limitation of physical activity

•Class II patients have slight limitation of physical activity

•Class III patients have marked limitation of physical activity

•Class IV patients have symptoms even at rest and are unable to carry on any physical activity without discomfort.

The American College of Cardiology/American Heart Association (ACC/AHA) heart failure guidelines complement the NYHA classification to reflect the progression of disease and are divided into four stages, as follows •Stage A patients are at high risk for heart failure but have no structural heart disease or symptoms of heart failure•Stage B patients have structural heart disease but have no symptoms of heart failure•Stage C patients have structural heart disease and have symptoms of heart failure•Stage D patients have refractory heart failure requiring specialized interventions

BNP

Anti pro B BNP

In acute heart failure, patient care consists of

stabilizing the patient's clinical condition

establishing the diagnosis, etiology,

precipitating factors;

and initiating therapies to provide rapid symptom relief and survival benefit.

Along with oxygen

medications assisting with symptom relief include diuretics, digoxin, inotropes, morphine.

Drugs that can exacerbate heart failure should be avoided

nonsteroidal anti-inflammatory drugs [NSAIDs]

calcium channel blockers [CCBs] most antiarrhythmic drugs

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•Diuretics (to reduce edema by reduction of blood volume and venous pressures) and salt restriction (to reduce fluid retention) in patients with current or previous heart failure symptoms and reduced left ventricular (LV) ejection fraction (EF) for symptomatic treatment

•Angiotensin-converting enzyme inhibitors (ACEIs) for neurohormonal modification, vasodilatation, improvement in LVEF, and survival benefit•Angiotensin receptor blockers (ARBs) for neurohormonal modification, vasodilatation, improvement in LVEF, and survival benefit•Hydralazine and nitrates to improve symptoms, ventricular function, exercise capacity, and survival in patients who cannot tolerate an ACEI/ARB or as an add-on therapy to ACEI/ARB and beta-blockers in the black population for survival

•Hydralazine and nitrates to improve symptoms, ventricular function, exercise capacity, and survival in patients who cannot tolerate an ACEI/ARB or as an add-on therapy to ACEI/ARB and beta-blockers .

•Beta-adrenergic blockers for neurohormonal modification, improvement in symptoms and LVEF, survival benefit, arrhythmia prevention, and control ventricular rate.

•Aldosterone antagonists, as an adjunct to other drugs for additive diuresis, heart failure symptom control, improved heart rate variability, decreased ventricular arrhythmias, reduction in cardiac workload, improved LVEF, and increase in survival

•Digoxin, which can lead to a small increase in cardiac output, improvement in heart failure symptoms, and decreased rate of heart failure hospitalizations

•Anticoagulants to decrease the risk of thromboembolism

•Inotropic agents to restore organ perfusion and reduce congestion

Teaching PointsAll choices provided can present with air-space disease, though pleural effusion (PE) is not common with sarcoidosis. The bilateral symmetry is unlikely for lobar pneumonia and pulmonary embolism. The cardiomegaly favors congestive heart failure (CHF).In CHF, the pleural effusion, if unilateral, tends to be right sided

. On upright CXR, as pulmonary venous hypertension develops, blood vessel diameter will be greater in the upper lungs, the reverse of normal.With PE, the air-space process represents a parenchymal infarct. It is typically not large, perihilar, symmetric, or bilateral.Sarcoidosis has multiple presentations on chest radiography, including not only air-space disease but more commonly, interstitial fibrosis, nodules and lymphadenopathy. It is also a multi-organ disorder, affecting the central nervous system, osseous, renal, and other organ systems as well.

Well done! You answered successfullyTeaching PointsIn a post-operative patient who has rales, dyspnea, and weight gain, one should always think about heart failure.The immediate treatment of congestive heart failure is to establish perfusion and oxygen delivery.If there is fluid overload, one should administer intravenous furosemide, which usually works within minutes.To prevent the development of heart failure, the first line therapy is to place the patient on an angiotensin converting enzyme inhibitor and a beta-blocker.

Well done! You answered successfullyTeaching PointsAn angiotensin-converting enzyme inhibitor (ACEI) can rapidly improve symptoms in patients with congestive heart failure.ACEIs are recommended for all patients with recurrent or other symptoms of congestive heart failure or reduced left ventricular function. ACEIs decrease afterload and permit lower ventricular remodeling. The drugs have been shown to increase survival and decrease rate of hospitalization.Side effects of ACEI include hyperkalemia, hypotension, cough, rash, changes in mental state, angioedema, and dry cough.If a cough develops, the patient can be switched to an angiotensin-receptor blocker.

Well done! You answered successfullyTeaching PointsCongestive heart failure is a restrictive type of lung disorder.The lungs get stiffer in congestive heart failure and functional residual volume is decreased.Approximately 5.1 million people in the United States have clinically manifest heart failure. The prevalence continues to increase, especially for individuals greater than 65 years of age.The most common causes of systolic and diastolic dysfunction are idiopathic dilated cardiomyopathy, ischemic coronary heart disease, hypertension, and valvular disease. Hypertrophic obstructive cardiomyopathy and restrictive cardiomyopathy also are common causes of diastolic dysfunction.

Teaching PointsCongestive heart failure (CHF) is treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and sometimes digoxin.The most common diuretics used to treat CHF are loop diuretics.ACE inhibitors not only reduce symptoms but also prolong life. These drugs reduce levels of angiotensin 2 and aldosterone.Diuretics and digoxin are the oldest treatments for congestive heart failure.

Well done! You answered successfullyTeaching PointsThis patient has newly diagnosed, acute heart failure.Acute heart failure can be precipitated or exacerbated by beta-blockers, non-dihydropyridine calcium channel blockers, NSAIDs, and alcohol.Increasing cardiac output is the main goal of therapy for a patient with congestive heart failure (CHF).In the long-term management of CHF, diuretics, beta-blockers, ACE inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitor, hydralazine plus nitrate, digoxin, and aldosterone antagonists can improve CHF symptoms depending on the severity of the heart failure.

Peribronchial cuffing represents fluid around bronchi when seen end on due to lymphatic congestion.Viewed end on, the walls of the bronchus appear thicker than normal.Peribronchial cuffing is seen in many medical disorders. The first thought should be early pulmonary edema, but airway diseases such as asthma and bronchiolitis in children must also be considered. Postoperatively, fluid overload must be evaluated.Chest x-ray findings in pulmonary embolus are often absent, especially early. Lobar pneumonia classically presents with localized air-space disease which would obscure peribronchial cuffing.

Well done! You answered successfullyTeaching PointsInsulin has no inotropic activity.Common inotropes used in the intensive care unit include bipyridine derivative-like milrinone, calcium, digoxin, and catecholamines.Sometimes glucagon and thyroid hormone are used to stimulate the heart's pumping activity.Negative inotropes include beta-blockers, calcium channel blockers, and class 1 anti-arrhythmic agents.

Pulsus alternans is a waveform with alternating strong and weak beats.Pulsus alternans is always an indication of a failing heart.Patients with congestive heart failure and weak left ventricle usually develop pulsus alternans.Pulsus alternans is associated with a poor prognosis.

Angiotensin-converting enzyme (ACE) inhibitors are now recommended for the treatment of hypertension and congestive heart failure.Decreased afterload is considered to be the most beneficial effect of ACE inhibitors.ACE inhibitors block the conversion of angiotensin I to angiotensin II. This helps lower afterload and increases venous capacitance.Ultimately, ACE inhibition causes natriuresis and allows for ventricular remodeling.

Well done! You answered successfullyTeaching PointsCongestive heart failure (CHF) has symptoms of orthopnea, dependent edema, paroxysmal dyspnea, wheezing, and fatigue.Wheezing is a feature of CHF, but stridor is not.StatPearls Topic: Heart Failure, Congestive (CHF)PubMed References: Heart Failure, Congestive (CHF)

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Well done! You answered successfullyTeaching PointsCongestive heart failure can be caused by medications that are negatively inotropic such as calcium channel blockers and beta blockers.Despite this, beta blockers have been shown to be beneficial in these patients but not calcium channel blockers.Beta-blockers reduce mortality and prevent deleterious remodeling.It can also be triggered by medications that cause fluid retention such as NSAIDS.

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Well done! You answered successfullyTeaching PointsCongestive heart failure was traditionally treated with a positive inotrope, digoxin, and diuretics.ACE inhibitors have been found to reduce afterload and preload. They can be used as monotherapy in some patients.They also are used for patients with recent myocardial infarction.Patients with the lowest ejection fraction have the best response.

ACE inhibitors reduce aldosterone secretion,

Cause naturesis and reduce salt and water retention,

Decrease afterload and afterload.

ACE inhibitors are now considered first-line drugs for congestive heart failure.

Congestive heart failure (CHF) is often associated with fluid overload and thus diuretics are the mainstay of treatment.To prevent decompensation, other first line drugs include angiotensin-converting enzyme inhibitors such as lisinopril.ACE inhibitors have been shown to improve survival and quality of life in patients with CHF.Other drugs for CHF include beta blockers and spironolactone.

Dobutamine is an inotropic agent with beta-1 receptor agonist activity.

Besides increasing the force of contraction of the heart, it also can be a vasodilator for the pulmonary arteries.

Dobutamine acts by direct stimulation of beta-1 receptors in the myocardial fibrils.

At high doses, dobutamine can increase the risk of arrhythmia.

In CHF, there is build up of fluid in the alveoli.The red blood cells are engulfed by the macrophages and can be stained for iron.Pleural effusions in CHF are transudative.Other causes of hemosiderin-laden macrophages include pulmonary bleeding, coagulopathies, and trauma.

The pulmonary artery catheter is essential for differentiating ARDS from CHF.

In CHF, the pulmonary wedge pressure usually is elevated.

In ARDS, the pulmonary wedge pressure usually is normal.

Most clinicians make a diagnosis of ARDS based on clinical features rather than a pulmonary artery catheter.

ACE inhibitors have been shown to reduce mortality and morbidity in congestive heart failure.

ACE inhibitors reduce aldosterone secretion, salt and water retention, and afterload.

ACE inhibitors are now considered first-line drugs for congestive heart failure.

Beta-blockers also decrease mortality but are not used during acute exacerbations.

Well done! You answered successfullyTeaching PointsRight heart failure does not cause pulmonary edema.

There is no "backup" of fluid in the lungs from right-sided failure, as the right heart structures are proximal to the lungs when viewed in series.

Left-sided heart failure can cause pulmonary edema.

However, the most common cause of right-sided heart failure is left-sided heart failure. So it is possible to see simultaneous right-sided heart failure and pulmonary edema.

Well done! You answered successfullyTeaching PointsAn S3 heart sound is heard during mid-diastole.A left side S3 is heard best during expiration at the left ventricular border.A right side S3 is heard best during inspiration at the left sternal border.Other characteristic physical exam findings are pulsus alternans and apical impulse.

Well done! You answered successfullyTeaching PointsPulmonary rales can be heard in left heart failure and also may be associated with wheezing.In general, patients with right heart failure do not develop dyspnea or rales until there is a severe reduction in cardiac output.Other features of right heart failure include ascites, hepatomegaly, and anasarca.Additional features may include bloating, constipation, bloody stools, and nausea.

Well done! You answered successfullyTeaching PointsThe hepatojugular reflex represents distension of the jugular vein by applying manual pressure over the liver.The hepatojugular reflex is increased in patients with right-sided heart failure.An elevated hepatojugular reflex is found in patients with left-sided pressure and elevated capillary wedge pressure.Other characteristic physical exam findings in heart failure are pulsus alternans, apical impulse, and an S3 gallop.

ACE inhibitors reduce aldosterone secretion, salt and water retention, and afterload.They also lower arterial resistance, increase venous capacitance, increase cardiac output, and lower renovascular resistance.First-line therapy for those with congestive heart failure secondary to reduced systolic function should include ACE inhibitors or angiotensin receptor blockers.

Well done! You answered successfullyTeaching PointsThe most common symptom of left heart failure is dyspnea. The disorder is characterized by congestion of the pulmonary vessels.Other symptoms of left heart failure include fatigue, chest pain, orthopnea, and paroxysmal nocturnal dyspnea.With time, the left heart failure progresses to confusion, dizziness, and profuse sweating.Most people develop cool extremities and cool, clammy skin.

Well done! You answered successfullyTeaching PointsOligemia is by definition hypovolemia or reduced circulating intravascular volume.In patients with congestive heart failure (CHF), there is florid congestion of the lungs.Common chest-x-ray findings in a patient with CHF are a cardiac-to-thoracic width ratio above 50 percent, cephalization of the pulmonary vessels, Kerley B lines, and pleural effusions.Oligemia is more likely to be seen in patients with a pulmonary embolism.

Well done! You answered successfullyTeaching PointsSpironolactone is beneficial for patients with Class III (limitation in normal activities) or class IV CHF (dyspnea at rest) and an ejection fraction < 35%.Beta-blockers have been shown to decrease mortality and are indicated for all stable CHF patients but are not indicated in acute congestive heart failure.Warfarin is indicated in patients with atrial fibrillation that are at a high risk of developing a stroke.Nitrates can help in an acute congestive heart failure exacerbation by decreasing afterload and allowing the heart to pump against less resistanc

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Hypertension is the most common cause of heart failure in the elderly.Hypertensive heart disease leads to systolic dysfunction.Ischemic heart disease is also a common cause of heart failure.Cardiomyopathy is the leading cause of heart failure in the adult population.

Well done! You answered successfullyTeaching PointsA transudative effusion is seen in CHF.This pleural effusion has low LDH and protein levels.It also has a high serum to pleural fluid LDH ratio.Red blood cell counts are high in exudative effusions.

Well done! You answered successfullyTeaching PointsVentricular hypertrophy, shortness of breath, and an elevated BNP are most indicative of CHF.CHF involves the inability of the heart to function as a pump, resulting in deficient filling and pumping of blood to the body.

Well done! You answered successfullyTeaching PointsThe diagnosis of CHF is based on a combination of symptoms, physical exam, imaging and laboratory testing.Imaging should include a chest x-ray and a transthoracic echocardiogram.Laboratory tests include a complete blood count, urinalysis, complete metabolic panel, brain natriuretic peptide, and TSH.Cardiac catheterization is not routinely required unless the CHF is a result of a myocardial infarction.

Well done! You answered successfullyTeaching PointsClass I heart failure is considered mild. The patient is asymptomatic at rest and with activity.Class II patients have slight limitation of physical activity.Class III patients have marked limitation of physical activity.Class IV patients have severe limitations. Experience symptoms even while at rest. Mostly bedbound patients

Well done! You answered successfullyTeaching PointsAll of the above diseases should be treated, however, alcohol cessation is most likely to result in functional improvement in her CHF.

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