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Touro University (NV)
Physician Assistant Cardio
Physician Assistant Cardio
Touro University (NV)
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What is heart failure?
The inability of the cardiac muscles to pump sufficient blood to meet the metabolic demand of the body.
What may be the cause of heart failure?
May be caused by the impaired ability of cardiac muscle to contract or by an increased workload imposed on cardiac tissue.
What are the types of heart failure?
Systolic dysfunction, diastolic dysfunction, left and right heart failure, high demand, and low output.
What are the two major causes of impaired ventricular function?
Coronary artery disease and hypertension.
What is the effect of age on heart failure risk?
It increases exponentially with age
What is the most common hospital admission diagnosis?
What is the most common cause of heart failure in both men and women?
Coronary artery disease and hypertension
What are NYHA class I patients?
Those with risk factors for heart failure but suffer no symptoms and have no limitations on physical activity.
What are NYHA class IV patients?
Patients who should be confined to bed and feel discomfort/symptoms at rest.
What is refractory CHF?
Heart failure where the symptoms are not controlled with treatment.
What are some symptoms of heart failure?
Decreased exercise tolerance, SOB, tachycardia, peripheral edema, and fatigue.
What is cor pulmonale?
Failure of the right side of the heart brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart.
What is cardiomyopathy?
A disease process that has direct dysfunction of the heart muscle.
What is the result of left ventricle dysfunction?
A lower ejection fraction meaning less blood is pumped systemically.
What is the effect of left ventricle dysfunction of the kidneys?
Higher renin-angiotensin and aldosterone leading to sodium and fluid retention.
What is the effect of left ventricular dysfunction on vasculature?
Increased sympathetic tone due to baroreceptor simulation which leads to vasoconstriction and tachycardia.
What do treatment modalities for heart failure tend to manipulate?
Preload, afterload, or contractility.
What is afterload?
The peripheral vascular resistance that the left ventricle must pump against.
What causes the ventricles to hypertrophy?
Constant stress from high bp or end diastolic pressure resulting the walls of the heart dilating to relieve stress.
What is the result of the compensatory mechanisms in the long term?
They end up being more harmful than helpful.
What are the compensatory mechanisms in heart failure?
Increased preload, sympathetic tone, catecholamines, renin-angiotensin, aldosterone, vasopressin, and ANP.
What is diastolic heart failure?
When the heart fails due to hypertrophy or growing too muscular.
What is systolic heart failure?
When the heart fails due to dilating or increasing the chamber size while decreasing muscle mass.
What are the characteristics of systolic heart failure?
Inability of the ventricle to contract normally resulting in inadequate cardiac output and hypoperfusion.
How can you remember that systolic heart failure is the result of thinning muscle and larger chamber?
Systolic heart failure is when the heart can't pump adequately enough. If there is a decrease in muscle mass, there cannot be the same amount of blood ejected.
How can you remember that diastolic heart failure is the result of hypertrophy?
Diastolic heart failure is when the heart can't pump enough blood because it's unable to fill with enough blood for the body. If the muscle is too thick the chamber size decreases.
What are the characteristics of diastolic heart failure?
The inability of the heart to relax or fill normally leading to reduced preload.
What are high output heart failure etiologies?
Hyperthytoidism, anemia, pregnancy, av fistulas, beriberi, Paget's disease.
What are low cardiac output etiologies?
Ischemia, hypertension, dilated cardiomyopathy, valvular disease
What are the predominant symptoms of left-sided heart failure?
Dyspnea, orthopnea, and pulmonary congestion.
What are the predominant symptoms of right-sided heart failure?
Edema, ascites, JVD, hepatic congestion.
What is the cardinal symptom of left heart failure?
What is orthopnea?
Positional dyspnea due to redistribution of collected fluid in the lungs.
What is paroxysmal nocturnal dyspnea?
Attack of severe SOB that generally occur at night due to nocturnal respiration depression, low adrenergic stimulation on the myocardium, and redistribution of pulmonary edema.
What causes dyspnea in CHF?
Interstitial pulmonary edema reduces compliance in the lungs increasing the work of the respiratory muscles. Plus decrease oxygen diffusion and blood flow to respiratory muscles.
What is B-type natriuretic peptide level useful for?
What are some physical exam possible findings for left-sided heart failure?
Tachycardia, S3 or S4, weak pulses, murmurs, displaced apical pulses, crackles/rales, cyanosis, and hypotension
What are some physical exam possible findings for right-sided heart failure?
Elevated jugular vein pressure, hepatomegaly, peripheral edema, and ascites.
What will labs should be run for a potential CHF patient?
Test electrolytes, renal function, anemia, TSH level, iron to r/o hemochromatosis, r/o multiple myeloma, and test B-type natriuretic peptide
What is the BNP level for acute CHF?
BNP > 400 pg/mL
What are poor prognostic signs for CHF?
Hyponatremia, increase BUN/creatinine, hypokalemia, elevated liver function test, and non-specific ECG.
If BNP is 100-400 pg/mL, what must be ruled out to diagnose CHF?
Cor pulmonale and acute PE.
What do Kerley B lines indicate?
What should acute CHF patients be treated with?
O2, loop diuretics, vasodilators, ionotropes
What should chronic CHF patients be treated with?
ACE inhibitors, beta blockers, aldosterone antagonists, loop diuretics, digoxin, implanted defibrillators, heart transplant
What is the primary goal of treating mild-moderate heart failure?
To reduce mortality
What is the primary goal in treating moderate-severe heart failure?
To reduce symptoms and improve quality of life
What is the purpose of diuretics in treating heart failure?
To decrease preload
What is the goal of diuretics in heart failure?
To reduce symptoms, there is no survival benefit.
What are non-pharmacologic treatments for heart failure?
Salt restriction, fluid restriction, smoking cessation, avoiding exercise, weight loss
What is the goal of ACE inhibitors in heart failure?
To increase ejection fraction and reduce risk of MI
When are thiazide diuretics useful in CHF patients?
In mild cases with normal renal function.
What are the most commonly used diuretics in treating CHF?
What is aldactone?
A potassium sparing diuretic that blocks the effects of aldosterone.
What is spironolactone?
An aldosterone antagonist that should be considered for every NYHA class III or IV patinet
What are ACE inhibitors?
Drugs that block the conversion of angiotensin I to II to cause vasodilation, reduce afterload, and increase cardiac output.
What are the cautions of ACE inhibitors?
Hyperkalemia, hypotension, renal insufficiency, and contraindicated in severe bilat renal artery stenosis
What is an angiotensin receptor blocker?
Works much the same as an ACE inhibitor by blocking AT2 receptor.
What is the effect of digoxin?
Increases contractility, decreases heart rate to increase preload
What is digoxin's effect on mortality?
Has no effect on mortality
What is the effect of beta blockers?
Block activation of sympathetic nervous system and decreases the effects of norepinephrine
What should be used cautiously with NYHA class IV patients?
What are the benefits of beta blockers?
Improves symptoms, decreases incidence of sudden death, improves survival by 30%
What is nesiritide?
Recombinant human BNP that acts as a vasodilator and is more effective than IV nitroglycerine.
What is refractory heart failure?
Severe decompensation of CHF or CHF with low intravascular volume.
What are the treatments for refractory heart failure?
Dopamine, dobutamine, and amrinone
What is the effect of dopamine?
In low doses is a renal and mesenchymal vasodilator, in high doses it stimulates cardiac beta receptors and increases stroke volume.
What is the effect of dobutamine?
Lowers vascular resistance
What is the effect of amrinone?
Lowers vascular resistance
What is characteristic of patients who have been in a prolonged state of cardiac low CO?
The pulmonary vasulature adapts and hypertrophies causing a slow development of edema. These patients require slow prolonged diuresis.
What are the treatment goals of refractory heart failure?
To optimize therapy and lifestyle modifications such that the condition is not exacerbated, monitor for degeneration of condition to acute cases requiring hospitalization.
What are the indications for surgical intervention of refractory heart failure patients (implanted defibrillators, bivalve, and transplant)?
Those with refractory symptoms with an ejection fraction down to 20%.
What are the contraindications for major heart surgery in refractory heart failure?
Patient over 70, hepatic failure, lung or kidney disease, severe PVD, insulin dependent diabetes, etc.
What drugs are used in CHF regardless of stage?
ACE inhibitors and Beta Blockers.
What drugs are used in midstage CHF?
Dig and diuretics (and of course ACEI with Beta blockers in all cases)
What drugs are saved for use in late stage CHF?
Spiro and Inotropes. (With ACI, B-blockers, Dig, and diuretics indicated for earlier stages)
What is hematochromatosis?
A disorder of too much iron being absorbed from the GI tract. Can be toxic systemically (to all organs)
What are the mentioned factors that can cause heart failure?
CAD, hypertension, cardiomyopathy, valvular disease, CHD, mitral stenosis, and pericardial disease.
What are some physiological effects of angiotensin II?
Vasoconstriction, thirst, sodium retentions, and aldosterone release.
What does increase left ventricular end diastolic pressure indicate?
A heart failure state
What respiratory symptom do early heart failure patients experience?
Dyspnea on exertion only.
What are some examples of edema in heart failure?
Peripheral edema, sacral edema, abdominal distention, anasarca
What is anasarca?
Diffuse and generalized edema.
What are signs of right heart failure?
Peripheral edema, rales, JVD, hepatomegaly, and pleural effusion.
What are the most likely causes of left ventricular heart failure?
Ischemic heart disease and hypertension
How can changing hormone concentrations contribute to heart failure?
Increasing epi, NE, aldosterone, or Ang II can contribute to myocardial dysfunction if kept at a sustained level.
Other than heart dysfunction, what are Beta blockers used for?
Toprol XL improves heart failure survival by how much?
What is furosemide?
A loop diuretic that reduces water retention.
What is the most common furosemide?
What is furosemide's mechanism of action?
Inhibits sodium-potassium symporter such that sodium and potassium is lost or remains in the filtered fluid and pulls more water out for excretion.
What are the side-effects of furosemide?
Renal dysfunction, hypotension, hyponatriemia and kalemia, and a rash
What increases renin production?
Decreased renal profusion (BP), decreased Na delivery to kidneys, and increased sympathetic stimulation.
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