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1.02) CARDIOVASCULAR SYSTEM > 5. MTB Step 3 - Congestive Heart Failure (CHF) > Flashcards

5. MTB Step 3 - Congestive Heart Failure (CHF) Flashcards

1
Q

CONGESTIVE HEART FAILURE (CHF)

The Mechanism that matters for CHF has to do with the Difference in Treatment between which (2) Types of CHF?

A
  1. Systolic Dysfunction w/ a Low EF
  2. Diastolic Dysfunction w/ a Normal EF
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2
Q

CONGESTIVE HEART FAILURE (CHF)

What is the Typical Clinical Manifestation for a patient with CHF?

A

Shortness of Breath, particularly on exertion, in a person with ANY of the following:

  • Edema
  • Rales on lung exam
  • Ascites
  • JVD
  • S3 Gallop
  • Orthopnea
  • Paroxysmal Nocturnal Dyspnea
  • Fatigue
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3
Q

CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Rales on Lung Exam in a patient with CHF?

A

Increased Hydrostatic Pressure develops in the Pulmonary Capillaries from Left Heart Pressure overload.

This causes Transudation of Liquid into the Alveoli.

During Inhalation, the Alveoli open with a “Popping” sound referred to as RALES.

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4
Q

CONGESTIVE HEART FAILURE (CHF)

Which of the Clinical Manifestations of CHF is considered the Worst?

A

PULMONARY EDEMA

Pulmonary Edema is a Clinical Diagnosis

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5
Q

CONGESTIVE HEART FAILURE (CHF)

What (4) Therapeutic Treatments are considered the Mainstay of Therapy for Acute Pulmonary Edema?

A
  1. Morphine
  2. Oxygen
  3. Nitrates
  4. Furosemide
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6
Q

CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Action for Carvedilol?

A

Carvedilol - a Beta-1 and Beta-2 receptor Antagonist, as well as an Alpha-1 receptor Antagonist.

  • Beta-1 = Anti-ARRHYTHMIC*
  • Beta-2 = Anti-ISCHEMIC*
  • Alpha-1 = Anti-HYPERTENSIVE*
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7
Q

CONGESTIVE HEART FAILURE (CHF)

What (5) Diagnostic Tests should be ordered on First-Screen on CCS, and at the Same Time as the Initial Therapy (eg, Morphine, Oxygen, Nitrates, Furosemide)?

A
  1. ECG
  2. Echocardiogram
  3. Continuous Oximeter
  4. Chest X-Ray (CXR)
  5. Arterial Blood Gas (ABG)
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8
Q

CONGESTIVE HEART FAILURE (CHF)

What are (2) Findings on ECG in a patient with CHF?

A
  1. Sinus Tachycardia
  2. Atrial & Ventricular arrhythmia
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9
Q

CONGESTIVE HEART FAILURE (CHF)

Which Diagnostic Test allows for distinguishing Systolic from Diastolic dysfunction in a patient with CHF?

A

Echocardiogram

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10
Q

CONGESTIVE HEART FAILURE (CHF)

What are (4) Findings on CXR in a patient with CHF?

A
  1. Cardiomegaly
  2. Pulmonary Vascular Congestion
  3. Effusion
  4. Cephalization of Flow
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11
Q

CONGESTIVE HEART FAILURE (CHF)

What is (1) Finding on Oximetry in a patient with CHF?

A

Hypoxia

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12
Q

CONGESTIVE HEART FAILURE (CHF)

What is (1) Finding on ABG in a patient with CHF?

A

Respiratory ALKALOSIS

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13
Q

CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of “Cephalization” of Flow in a patient with CHF, as seen on CXR?

A

The bottoms of the lungs are generally more “Full” of Blood because of gravity.

As fluid builds up in the lungs, it fills the vessels from the bottom to the top.

This moves the fluid toward the Head (Cephalization)

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14
Q

CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Action (MOA) of Dopamine?

A

Increases Cardiac Contractility and causes VASOCONSTRICTION (alpha-1-agonist)

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15
Q

CONGESTIVE HEART FAILURE (CHF)

  1. What is the Mechanism of Action (MOA) of Dobutamine, Inamrinone, and Milrinone?
  2. When would you use these Medications in a patient with Pulmonary Edema?
A
  1. Increase Cardiac Contractility and cause VASODILATION
    • ​​Inamrinone & Milrinone = PDE Inhibitors
    • Dobutamine = Positive Inotrope​​​
  2. Used as Further Management of Acute Pulmonary Edema cases AFTER the clock is moved forward 30 - 60 minutes AND there is no response to Preload Reduction
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16
Q

CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Respiratory Alkalosis in a patient with CHF, as seen on ABG?

A

Fluid Overload ⇒ Hypoxia

  • Hypoxia ⇒ Hyperventilation*
  • Hyperventilation ⇒ Decreased pCO2*
  • Decreased pCO2 ⇒* Alkalosis
17
Q

CONGESTIVE HEART FAILURE (CHF)

Where should you Place patients with Pulmonary Edema and Myocardial Infarction (MI)?

A

Intensive Care Unit (ICU)

18
Q

CONGESTIVE HEART FAILURE (CHF)

“An 80-yo woman is admitted to the ICU for Acute Pulmonary Edema. She has Rales to the Apices and JVD. Her ECG shows V-Tach. What is the Best Therapy for this patient?”

A

Synchronized Cardioversion - used when V-Tach is associated with Acute Pulmonary Edema

19
Q

CONGESTIVE HEART FAILURE (CHF)

What is the medication Nesiritide and what is it used for?

A

Nesiritide is a synthetic version of Atrial Natriuretic Peptide that is used for Acute Pulmonary Edema as part of Preload Reduction.

  • It decreases symptoms of Shortness of Breath.*
  • NO mortality benefit*
  • NO clear indication for answering Nesiritide*
20
Q

CONGESTIVE HEART FAILURE (CHF)

What is Brain Natriuretic Peptide (BNP) Level and what is it used for?

A
  • BNP level is a Blood Test that can be used to establish a diagnosis of CHF in a patient who is Short of Breath.
  • If the presentation is not clear, a BNP level can be used to help distinguish between PE, Pneumonia, Asthma, and CHF.
  • BNP level goes UP in CHF but is Nonspecific (Low Specificity)
  • A Normal BNP level excludes CHF (High Sensitivity)
21
Q

CONGESTIVE HEART FAILURE (CHF)

“A patient comes with Pulmonary Edema. A Right Heart Catheter is placed.” What is most likely to be found on the following measurements?:

  1. Cardiac Output (CO)
  2. Systemic Vascular Resistance (SVR)
  3. Left Atrial Pressure (LAP) / Wedge Pressure
  4. Right Atrial Pressure (RAP)
A
  1. CO = Decreased
  2. SVR = Increased
  3. LAP = Increased
  4. RAP = Increased
22
Q

CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism for Decreased CO in a patient with Pulmonary Edema from CHF?

A

Pump Failure ⇒ Backup of Blood into LA ⇒ Increased LAP

  • Left Atrial Pressure (LAP)** is a.k.a. **Wedge Pressure
  • LV Failure** = **Increased LAP** = **Increased Wedge Pressure
  • Right Heart Catheterization - inflated balloon blocks pressure from behind catheter, making catheter tip pick up flow from “in front,” or downstream.
23
Q

CONGESTIVE HEART FAILURE (CHF)

In a patient with Cardiogenic Shock, what is most likely to be found on the following measurements?:

  1. Cardiac Output (CO)
  2. Systemic Vascular Resistance (SVR)
  3. Left Atrial Pressure (LAP) / Wedge Pressure
  4. Right Atrial Pressure (RAP)
A
  1. CO = Decreased
  2. SVR = Increased
  3. LAP = Decreased
  4. RAP = Decreased
24
Q

CONGESTIVE HEART FAILURE (CHF)

In a patient with Septic Shock, what is most likely to be found on the following measurements?:

  1. Cardiac Output (CO)
  2. Systemic Vascular Resistance (SVR)
  3. Left Atrial Pressure (LAP) / Wedge Pressure
  4. Right Atrial Pressure (RAP)
A
  1. CO = Increased
  2. SVR = Decreased
  3. LAP = Decreased
  4. RAP = Decreased
25
Q

CONGESTIVE HEART FAILURE (CHF)

What is the Mechanism of Measuring Increased Left Atrial Pressure (LAP) / “Wedge” Pressure in a patient with CHF?

A

The inflated Balloon blocks pressure from behind the catheter, making the catheter tip pick up flow from “in front,” or downstream.

“Downstream” for the pulmonary capillaries means the Left Atrium.

LV Failure = Increased LA Pressure = Increased “Wedge” Pressure

26
Q

CONGESTIVE HEART FAILURE (CHF)

What Test should ALL patients, having been stabilized from Acute Pulmonary Edema, have, and why?

A

Echocardiogram - establish whether there is Systolic Dysfunction with Low EF or Diastolic Dysfunction with a Normal EF

27
Q

CONGESTIVE HEART FAILURE (CHF)

The Long-Term Management (Chronic CHF) of Dilated Cardiomyopathy or Systolic Dysfunction is based on the use of Which (3) Medications that also have a Mortality Benefit?

A
  1. ACEIs / ARBs
  2. Beta-Blockers - only Metoprolol, Carvedilol, Bisoprolol
  3. Spironolactone - an anti-androgenic that lowers mortality but has only been proven to do so for more advanced, symptomatic disease.
    • AE = Gynecomastia and ED in men: switch to Eplerenone (lowers mortality in CHF without the anti-androgenic side effects of spironolactone).
28
Q

CONGESTIVE HEART FAILURE (CHF)

What are (2) Medications given in the Long-Term Management of Chronic CHF that do NOT have a mortality benefit?

A
  1. Diuretics
  2. Digoxin - used to decrease symptoms and decrease the frequency of hospitalization.
29
Q

CONGESTIVE HEART FAILURE (CHF)

Which 2-Drug Combination is given for the Long-Term Management of CHF in patients where ACEIs / ARBs cannot be used?

A

Hydralazine + Nitrates

Hydralazine reduces Afterload

30
Q

CONGESTIVE HEART FAILURE (CHF)

What CHF Medication has an Adverse Effect of Transient Excess Brightness of Vision?

A

Ivabradine

31
Q

CONGESTIVE HEART FAILURE (CHF)

  1. What is the Mechanism of Action (MOA) of Ivabradine?
  2. Under what Condition would you Add Ivabradine?
A
  1. SA Nodal Inhibitor of “Funny Channels” that Slows the HR.
  2. Add it to Systolic Dysfunction if the HR is > 70 bpm or Beta-Blockers CAN’T be used.

There is NO mortality benefit with Ivabradine

32
Q

CONGESTIVE HEART FAILURE (CHF)

What 2-Drug Combination can be used instead of an ACEI in Chronic Management of CHF and gives the same Mortality Benefit for Systolic Dysfunction?

A

Sacubitril/Valsartan

Sacubitril is a Neprilysin Inhibitor and is added ONLY to an ARB.

33
Q

CONGESTIVE HEART FAILURE (CHF)

What (2) Drug Classes are used in the Chronic Management of CHF due to Diastolic Dysfunction (Normal EF)?

A
  1. Beta-Blockers - Metoprolol, Carvedilol, Bisoprolol
  2. Diuretic - you have to be careful NOT to overuse diuretics
34
Q

CONGESTIVE HEART FAILURE (CHF)

What (7) Medications or Drug Classes are used in the Chronic Management of CHF due to Systolic Dysfunction (Low EF)?

A
  1. ACEI or ARB
  2. Sacubitril/Valsartan (Combination Drug if can’t give ACEI only)
  3. Hydralazine + Nitrates (2-drug combo if can’t give ACEI or ARB)
  4. Beta-Blockers - Metoprolol, Carvedilol, Bisoprolol
  5. Spronolactone or Eplerenone
  6. Diuretics
  7. Digoxin
35
Q

CONGESTIVE HEART FAILURE (CHF)

CHRONIC MANAGEMENT OF CHF

“A 69 yo man is seen in the office for further management of CHF. He currently has no symptoms and good exercise tolerance. He has been on Lisinopril, Metoprolol, Spironolactone, and Furosemide for the last 6 months. His EF is 23%.” What Treatment is most likely to benefit this patient?

A

Implantable Cardioverter/Defibrillator

Patients with an EF < 35% that PERSISTS are candidates for this treatment

36
Q

CONGESTIVE HEART FAILURE (CHF)

CHRONIC MANAGEMENT OF CHF

When is a Biventricular Pacemaker (a.k.a. Cardiac Resynchronization Therapy) the answer for CHF?

A

SEVERE Congestive Heart Failure (CHF) = an EF < 35% + QRS duration > 120 msec.

Wide QRS = Left & Right Ventricles NOT beating in sync

Biventricular PM Decreases Mortality for these patients

37
Q

CONGESTIVE HEART FAILURE (CHF)

CHRONIC MANAGEMENT OF CHF

What is the Mechanism of Biventricular Pacemaker?

A
  • Wide QRS means Ventricles are not beating together.
  • This means Inefficient Forward Flow.
  • Biventricular Pacemaker brings both Ventricles back to beating at the same time.
  • The effect is instant.
38
Q

CONGESTIVE HEART FAILURE (CHF)

CHRONIC MANAGEMENT OF CHF

What Condition is an Absolute Contraindication to the use of Beta-Blockers?

A

Symptomatic Bradycardia

1.02) CARDIOVASCULAR SYSTEM (22 decks)

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