Medicine Marrow Pg 321-330 (Cardiology)
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What is the most common cause of right heart failure?

  • Left heart failure (correct)
  • Dilated cardiomyopathy
  • Valvular heart disease
  • Congenital heart disease

    • Increased right atrial pressure does not affect venous pressure.

    False

    Name one sign or symptom of right heart failure.

    Hepatomegaly

    The site of palpation for the abdominojugular reflex is the __________ area.

    <p>periumbilical</p> Signup and view all the answers

    Match the following conditions with their respective criteria:

    <p>Acute pulmonary edema = Major Criteria Nocturnal cough = Minor Criteria Dyspnea on exertion = Minor Criteria S3 (Gallop) = Major Criteria</p> Signup and view all the answers

    What is the primary action of Aldosterone in the RAAS system?

    <p>Increase salt and water retention</p> Signup and view all the answers

    Natriuretic peptides inhibit the RAAS and promote water retention.

    <p>False</p> Signup and view all the answers

    What is the most preferred beta blocker commonly used for heart failure?

    <p>Bisoprolol</p> Signup and view all the answers

    The interaction of ADH leads to increased ______ retention, which can result in hyponatremia.

    <p>water</p> Signup and view all the answers

    Match the medication with their respective classes:

    <p>Metoprolol = Beta blocker Ramipril = ACE inhibitor Carvedilol = Beta blocker Losartan = ARB</p> Signup and view all the answers

    What is a symptom of advanced heart failure indicated by bending for 30 seconds?

    <p>Bendopnea</p> Signup and view all the answers

    In heart failure, pulmonary interstitial alveolar edema is characterized by warm peripheries.

    <p>False</p> Signup and view all the answers

    What condition is characterized by increased left atrial pressure and prones to atrial fibrillation?

    <p>Heart failure with preserved ejection fraction (HFpEF)</p> Signup and view all the answers

    The symptom characterized by breathlessness when lying down on one side is called ________.

    <p>Trepopnea</p> Signup and view all the answers

    Match the following clinical features with their associated conditions:

    <p>Fine crepitations that change with position = Heart Failure Warm peripheries and CO2 retention = COPD Dyspnea greater than cough = Heart Failure Cough greater than dyspnea = COPD</p> Signup and view all the answers

    Which risk factor is most important for acute decompensated heart failure?

    <p>Non-compliance to treatment</p> Signup and view all the answers

    Women are more commonly affected by HFNEF than men.

    <p>True</p> Signup and view all the answers

    Name one comorbidity commonly associated with heart failure with preserved ejection fraction (HFNEF).

    <p>Hypertension</p> Signup and view all the answers

    Anemia can lead to heart failure decompensation through a sequence of events involving _________.

    <p>gastrointestinal bleed</p> Signup and view all the answers

    Match the following compensatory mechanisms with their effects in heart failure:

    <p>Increased sympathetic activity = Increased heart rate Increased contractility = Prone for arrhythmias Increased heart rate = Maintains cardiac output</p> Signup and view all the answers

    Which medication is used as an inotropic support for HFrEF?

    <p>Dobutamine</p> Signup and view all the answers

    IV diuretics are not part of the management for acute decompensated heart failure.

    <p>False</p> Signup and view all the answers

    What is the purpose of administering morphine in acute decompensated heart failure?

    <p>To facilitate extravascular fluid shift</p> Signup and view all the answers

    In cardiogenic shock, a narrow pulse pressure is defined as SBP < __________ mm of Hg.

    <p>90</p> Signup and view all the answers

    Match the following management strategies with the condition they are used for:

    <p>IV Diuretics = Acute Decompensated Heart Failure Vasopressors = HFPEF Intra-aortic balloon pump = HFrEF Investigations for lactic acid = Cardiogenic Shock</p> Signup and view all the answers

    What is the main purpose of using ARNI in heart failure management?

    <p>Prevent degradation of Angiotensin II</p> Signup and view all the answers

    ARNI should be administered first in patients who are not euvolemic.

    <p>False</p> Signup and view all the answers

    Name one component of the Fantastic 4 in heart failure management.

    <p>ARNI, β blocker, Aldosterone antagonist, or SGLT2 inhibitors</p> Signup and view all the answers

    In treating refractory heart failure, if the patient has a wide QRS, the preferred treatment is __________ therapy.

    <p>cardiac resynchronization</p> Signup and view all the answers

    Match the following medications to their classifications or usages in heart failure treatment:

    <p>Valsartan = Angiotensin Receptor Blocker Sacubitril = Neprilysin Inhibitor Finerenone = Aldosterone Antagonist Empagliflozin = SGLT2 Inhibitor</p> Signup and view all the answers

    What is the primary diagnostic value of BNP and NT ProBNP in patients with renal failure?

    <p>To diagnose heart failure</p> Signup and view all the answers

    Early vasodilator therapy in Acute Aortic Regurgitation (AR) is primarily associated with the use of Nitroglycerin (NTG).

    <p>False</p> Signup and view all the answers

    What is the effect of Nitroprusside in the management of Acute Aortic Regurgitation?

    <p>Decreases aortic pressure and transvalvular gradient</p> Signup and view all the answers

    In patients with a probability of heart failure, BNP levels are greater than ______ pg/mL.

    <p>900</p> Signup and view all the answers

    Match the terms with their descriptions:

    <p>BNP = A peptide that indicates heart failure Dialysis = A treatment that removes waste from blood SCUF = A method for fluid management Vasodilator therapy = Treatment to decrease systemic vascular resistance</p> Signup and view all the answers

    What percentage of acute decompensated heart failure (ADHF) cases are caused by prior heart failure?

    <p>80%</p> Signup and view all the answers

    Cardiogenic shock is one of the classifications of acute decompensated heart failure.

    <p>True</p> Signup and view all the answers

    Name two risk factors associated with acute decompensated heart failure.

    <p>Infections and uncontrolled hypertension</p> Signup and view all the answers

    The most common presentation of mild to moderate ADHF is __________.

    <p>underlying HFrEF</p> Signup and view all the answers

    Match the following clinical features with their associated descriptions:

    <p>S3 heart sound = A common sign in heart failure Progressive dyspnea = Increasing shortness of breath Tender enlarged liver = Sign of right-sided heart failure Edema = Swelling due to fluid retention</p> Signup and view all the answers

    What is the starting dose for Torsemide, the most commonly used oral diuretic in acute decompensated heart failure?

    <p>5-10 mg</p> Signup and view all the answers

    Hypertensive acute decompensated heart failure (ADHF) is more common in males than females.

    <p>False</p> Signup and view all the answers

    What is a common symptom of acute pulmonary edema?

    <p>Acute onset of breathlessness</p> Signup and view all the answers

    In hypertensive acute decompensated heart failure, patients usually exhibit symptoms of __________ failure.

    <p>diastolic</p> Signup and view all the answers

    Match the following clinical features of acute pulmonary edema with their descriptions:

    <p>Tachypnea = Increased respiratory rate (&gt;130 bpm) Diaphoresis = Excessive sweating Frothy sputum = Fluid mixed with air, potentially with blood Air hunger = Gasping for breath or feeling of suffocation</p> Signup and view all the answers

    Which of the following conditions is associated with acute pulmonary edema?

    <p>Acute Aortic Regurgitation</p> Signup and view all the answers

    The cephalisation of pulmonary vessels is the earliest finding in acute pulmonary edema.

    <p>True</p> Signup and view all the answers

    What investigative technique is not typically done in an emergency setting for cardiac conditions?

    <p>Chest x-ray</p> Signup and view all the answers

    The pulmonary capillary wedge pressure (PCWP) is elevated in a warm and _______ acute pulmonary edema scenario.

    <p>wet</p> Signup and view all the answers

    Which type of Kerley lines is associated with fluid in the interlobular septa?

    <p>Kerley B lines</p> Signup and view all the answers

    Match the following medications with their respective usage:

    <p>Dobutamine = Inotropic support in cardiogenic shock Nesiritide = Treats heart failure with congestion Nitroglycerin = Vasodilator for acute pulmonary edema Milrinone = Improves cardiac output in heart failure</p> Signup and view all the answers

    Acute Mitral Regurgitation can lead to acute pulmonary edema.

    <p>True</p> Signup and view all the answers

    Name a common symptom associated with Takotsubo Cardiomyopathy.

    <p>Chest pain</p> Signup and view all the answers

    The LAP (Left Atrial Pressure) that indicates acute pulmonary edema is greater than ______ mm of Hg.

    <p>25</p> Signup and view all the answers

    Which of the following investigations would show a bat wing appearance?

    <p>Chest x-ray</p> Signup and view all the answers

    Study Notes

    RAAS System

    • Angiotensin II causes vasoconstriction, increasing afterload and aldosterone release.
    • Aldosterone promotes salt and water retention, increasing preload.

    ADH

    • ADH leads to free water retention, potentially causing hyponatremia.

    Natriuretic Peptides

    • Natriuretic peptides inhibit the RAAS and sympathetic nervous system, leading to the excretion of salt and water.

    Compensatory Mechanisms in Heart Failure

    • Sustained activation of compensatory mechanisms (RAAS, sympathetic nervous system, and natriuretic peptides) can lead to secondary end-organ damage within the ventricle, worsening left ventricular remodeling and subsequently causing cardiac decompensation.

    Treatment of Heart Failure

    • Recombinant natriuretic peptides, like Nesiritide, are no longer used.
    • Medications blocking the sympathetic pathway, RAAS, and degradation of natriuretic peptides are used for treatment.

    Pharmacotherapy

    Beta Blockers

    • Beta blockers block the sympathetic nervous system.
    • Common examples include metoprolol, bisoprolol (preferred starting dose of 1.25 mg), and carvedilol (preferred starting dose of 3.125 mg twice daily).

    ACE Inhibitors/ARB

    • Any drug from these groups is effective.
    • Common examples include Ramipril and Perindopril.
    • ACE inhibitors increase bradykinin levels compared to ARBs.

    Right Heart Failure

    • Most often caused by left heart failure.
    • Increased Right Ventricular End Diastolic Pressure (RVEDP) is the primary cause.
    • Increased right atrial pressure leads to elevated venous pressure.
    • Signs and symptoms:
      • Abdominojugular reflex
      • Ascites
      • Edema
      • Hepatomegaly
      • Increased jugular venous pressure
    • The abdominojugular reflex is elicited by palpating the periumbilical area.

    Causes of Right Heart Failure

    • Dilated cardiomyopathy (most often genetic)
    • Ischemic cardiomyopathy (post-MI/CAD)
    • Valvular heart disease (severe aortic regurgitation, very severe aortic stenosis, severe mitral regurgitation)
    • Congenital heart disease

    Framingham Diagnostic Criteria for Right Heart Failure

    • Major criteria: Acute pulmonary edema, cardiomegaly, abdominojugular reflex, increased jugular venous pressure, paroxysmal nocturnal dyspnea/orthopnea, crackles/rales, S3 (Gallop)
    • Minor criteria: Ankle edema, dyspnea on exertion, hepatomegaly, nocturnal cough, pleural effusion, tachycardia (>120 bpm)

    HFpEF/HFNEF

    Pathophysiology

    • Comorbidity-driven microvascular inflammation

      • Leads to left ventricular dysfunction
        • Longitudinal fibers (untwisting motion) are affected
        • Left ventricular diastolic dysfunction
          • Compensatory left ventricular hypertrophy (LVH) decreases cavity size
          • Increased left ventricular end diastolic pressure (LVEDP)
            • Increased left atrial pressure (LAP)
              • Left atrial stretching and dilation
                • Increased atrial contribution to cardiac output (> 40%) - Increased risk of atrial fibrillation
        • Increased pulmonary capillary wedge pressure (PCWP)
          • Pulmonary interstitial alveolar edema (crepitations)
            • Dyspnea

    • Results in pulmonary edema with bilateral pleural effusion

    • Bendopnea: A sign of advanced heart failure where bending for 30 seconds increases venous return and causes symptoms.
    • Trepopnea: Breathlessness on lying down on one side.
    • Platypnea: Breathlessness when sitting upright.

    Definition of HFNEF (European Society of Cardiology)

    • Symptoms of congestive heart failure.
    • Normal or mildly abnormal left ventricular systolic function.
    • Abnormal left ventricular relaxation.

    Presentation of HFNEF

    • More common in older age groups.
    • More common in women.
    • Common comorbidities include hypertension, obesity, chronic kidney disease, anemia, diabetes, and coronary artery disease.
    • Atrial fibrillation is more common in HFNEF than in HFrEF.

    Acute Decompensated Heart Failure (ADHF)

    Risk Factors

    1. Patient-related factors: Non-compliance with treatment, anemia, infective endocarditis, renal failure, pregnancy, uncontrolled hypertension, myocardial ischemia, drug-related decompensation (NSAIDs, calcium channel blockers)
    2. Infections: Lower respiratory tract infections
    3. Anemia: Especially in patients with CAD on aspirin due to potential GI bleeding
    4. Drug-related decompensation:
      • NSAIDs: Naproxen is the safest for patients with heart failure
      • Calcium Channel Blockers: Verapamil and Diltiazem can depress left ventricular function
    5. Arrhythmias: Atrial fibrillation is the most important to consider

    Pathogenesis of HFrEF

    • Index event (such as dilated cardiomyopathy or ischemia) leads to HFrEF.
    • This triggers compensatory mechanisms.
    • These mechanisms result in cardiac remodeling in an attempt to maintain cardiac output.

    Compensatory Mechanisms in HFrEF

    1. Sympathetic Activity: Increased sympathetic activity leads to increased contractility, increased heart rate, and increased risk of arrhythmias.

    Treatment of Heart Failure

    3. ARNI (Angiotensin Receptor Blocker + Neprilysin Inhibitor)

    • Valsartan (ARB) + Sacubitril (NI)
    • Prevents degradation of Angiotensin II
    • Degrades natriuretic peptides

    Primary Management

    • For all patients with HF: ARNI + β blocker

    Notes

    • Natriuretic peptides: ANP, BNP, substance P, adrenomedulline, bradykinin
    • ARNI > β blocker > ACE inhibitor > ARB (in terms of efficacy)
    • If the patient is not euvolemic:
    • Diuretics should be started first (to relieve congestion)
    • β blocker should be started only after congestion is addressed (otherwise it may lead to pulmonary edema).
    • Heart failure with renal failure: Hydralazine + Nitrate
    • "Fantastic 4" drugs with mortality benefits:
    • ARNI
    • β blocker
    • Aldosterone antagonist: Finerenone (non-steroidal)
    • SGLT2 inhibitors: Empagliflozin, Dapagliflozin

    Refractory Heart Failure

    • Maximum tolerated dose of β blocker + "Fantastic 4" drugs
    • If HR > 70/min: Ivabradine (funny current inhibitor)
    • Side effects: Visual disturbances
    • If the patient remains symptomatic despite treatment:
    • Refractory heart failure

    Treatment of Refractory Heart Failure

    • With wide QRS: Cardiac resynchronization therapy --> Cardiac transplant
    • With normal QRS: Left ventricular assisted devices or implantable cardioverter defibrillator (ICD)

    Acute Decompensated Heart Failure (ADHF)

    Management

    1. IV Diuretics (IV Bolus): 360 mg of Furosemide
    2. Semi-recumbent position (45°)
    3. High-flow oxygen via non-rebreather mask/non-invasive ventilation (NIV)
    4. Morphine: 4 mg IV (for extravascular fluid shift)
    5. Blood pressure control: Nitroglycerine at 5 µg/min

    Cardiogenic Shock

    Features

    1. Narrow pulse pressure (Systolic BP < 90 mm Hg)
    2. Fatigue
    3. Altered mentation
    4. Cyanosis
    5. Cold extremities
    • Note: Poor prognosis

    Management

    Investigations
    • Lactic acid levels: To rule out occult shock
    • Rule out acute coronary syndrome, do an early echocardiogram to rule out acute aortic regurgitation and acute mitral regurgitation.
    Treatment
    HFrEF
    1. Inotropic support/inodilator:
    • Inotrope: Dobutamine (most common)
    • Inodilator: Milrinone (most common)
    1. Intra-aortic balloon pump/ECMO support
    HFPEF
    • Vasopressors: Vasopressin/Desmopressin
    • Note:*
    • Patients with pulmonary edema and maintained BP who are not recovering may require dialysis or slow continuous ultrafiltration (SCUF) via central or femoral catheter.
    • BNP and NT-proBNP:

    • 900 pg/mL in patients with probability of heart failure

    • Lower in obese patients (as it is metabolized by adipocytes)
    • Diagnostic value is reduced in renal failure
    • Early vasodilator therapy in acute aortic regurgitation/mitral regurgitation:
    • Nitroprusside > NTG (Nitroglycerine)
    • Decreases aortic pressure
    • Decreases transvalvular gradient in AR/MR

    Differential Diagnosis

    1. Acute Coronary Syndrome
    2. Acute Aortic Regurgitation/Mitral Regurgitation:
    • Acute Aortic Regurgitation (due to aortic dissection, ruptured sinus of Valsalva, infective endocarditis)
    • Acute Mitral Regurgitation
    1. Myocarditis
    2. Bilateral Renal Artery Stenosis -> Splash pulmonary edema
    3. Takotsubo Cardiomyopathy

    Investigations

    Chest X-ray

    • Not done in an emergency
    • Bat wing appearance: Indicates cardiopulmonary edema
    • Cephalization of pulmonary vessels: Earliest finding associated with Kerley A/B/C lines

    Kerley Lines on Chest X-ray

    LAP Description
    Kerley A lines 12-19 mm of Hg Dilated anastomotic channels between peripheral and central lymphatics
    Kerley B lines 20-24 mm of Hg Fluid in the interlobular septa. Short, sharp lines horizontal and perpendicular to the pleura and parallel to the lung base.
    Kerley C lines 20-24 mm of Hg Reticular opacities. En face Kerley B lines
    LAP > 25 mm of Hg: Acute Pulmonary Edema

    Acute Pulmonary Edema

    Stable No Yes
    No Warm & Dry. Pulmonary Capillary Wedge Pressure (PCWP) normal. Cardiac Index (CI) normal Warm & Wet. PCWP elevated. CI normal
    Low Perfusion at Rest (compensated) CI normal
    Yes Cold & Dry. PCWP low/normal. CI decreased Cold & Wet. PCWP elevated. CI decreased
    Hypovolemia Natriuretic peptides, Nesiritide, Vasodilators, Nitroprusside, Nitroglycerine

    Pulmonary Edema + Cardiogenic Shock

    • Inotropic drugs: Dobutamine, Milrinone, Calcium sensitizers

    Congestion at rest

    Acute Decompensated Heart Failure (ADHF)

    Risk Factors & Classification

    • ADHF
      • 80%: Prior heart failure (HFrEF/HFPEF; NYHA 1/2)
      • 20%: De-novo heart failure

    Risk Factors

    1. Patient-related factors
    2. Infections (LRTI, IE)
    3. Anemia
    4. Drugs (NSAIDs)
    5. MI
    6. Atrial fibrillation
    7. Uncontrolled HTN
    8. Pregnancy

    Classification of ADHF

    1. Mild to moderate ADHF
    2. Hypertensive ADHF
    3. ADHF with acute pulmonary edema
    4. Cardiogenic shock

    Mild to Moderate ADHF

    • Most common (70% of ADHF)
    • Presents with underlying HFrEF
    • Often precipitated by lower respiratory tract infection (LRTI).

    Clinical Features:

    • Progressive dyspnea
    • Right-sided congestive symptoms
      • Tender, enlarged liver
      • Edema
    • No evidence of pulmonary edema/cardiogenic shock
    • Physical exam findings:
      • S3 heart sound
      • Cardiomegaly
      • Mitral regurgitation (possible due to annular dilatation)

    Management

    • Oral diuretics: Torsemide (most common), starting dose 5-10 mg

    Hypertensive ADHF

    • Most common in females
    • Presents with underlying HFPEF

    Clinical Features:

    • Progressive dyspnea
    • Uncontrolled hypertension
    • No evidence of pulmonary edema/cardiogenic shock
    • Presence of diastolic failure symptoms

    Management

    • IV diuretics
    • Oral antihypertensives

    ADHF with Acute Pulmonary Edema

    Clinical Features

    • Symptoms:
      • Acute onset of breathlessness, worsening over 60-90 minutes
      • Patient is sitting up, unable to lie down
      • Gasping (air hunger)
      • Diaphoresis
    • Signs:
      • Tachypnea (>130 bpm)
      • Hypertensive crisis
      • Crackles over all lung fields
      • Frothy sputum, +/- hemoptysis

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    Description

    This quiz focuses on the roles of the RAAS system, ADH, and natriuretic peptides in heart failure. It highlights how these mechanisms can lead to cardiac decompensation and discusses pharmacotherapy options available for treatment. Test your knowledge on the complexities of heart function and treatment strategies.

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