118 Questions
What is the recommended primary prevention of sudden cardiac death in patients with ischemic or nonischemic HFrEF?
Implantable cardioverter defibrillator in patients with LVEF of 35% or less and NYHA class II or III symptoms
What is the class III recommendation in patients with a low EF?
Use of nondihydropyridine calcium channel blockers with negative inotropic effects
What is the benefit of using DHP CCBs in HF patients?
They have neutral effects on morbidity and mortality in HF
What is the recommended therapy for those with an LVEF of 35% or less, in SR, and a left bundle branch block with a QRS of 150 milliseconds or greater?
Chronic resynchronization therapy
What is the life expectancy requirement for implantable cardioverter defibrillator recommendation?
Greater than 1 year
What is the preferred antiarrhythmic in patients with HFrEF for AF/atrial flutter?
Dofetilide
What is the New York Heart Association (NYHA) classification of the patient's heart failure?
NYHA II
What is the patient's left ventricular ejection fraction (LVEF)?
25%
What is the patient's American College of Cardiology (ACC) and American Heart Association (AHA) heart failure classification?
ACC/AHA C
Which medication is recommended for the patient's heart failure with reduced ejection fraction?
Carvedilol
What is the goal of the Guideline-Directed Treatment (GDT) algorithm for patients with heart failure with reduced ejection fraction?
To maximize the management of heart failure
What is the patient's heart failure caused by?
All of the above
What is the recommended anticoagulation therapy for the patient's heart failure?
Either warfarin or a direct oral anticoagulant (DOAC)
What is the role of statins in the patient's heart failure management?
Not recommended solely on the basis of heart failure diagnosis
What is the primary symptom of heart failure, leading to exercise intolerance?
Dyspnea
Which of the following is a cause of systolic dysfunction?
All of the above
What is the typical ejection fraction in heart failure with reduced ejection fraction (HFrEF)?
Less than 50%
What is the best approach to maximize the management of heart failure in a patient with NYHA class III?
Add Ivabradine 5 mg BID
What is the NYHA classification of a patient with marked limitation to physical activity and less than ordinary activity resulting in fatigue and palpitation?
NYHA class III
What is the primary goal of heart failure management?
Control BP and volume overload
What is the formula for cardiac output?
CO = HR × SV
What is the assessment of fluid status important for in heart failure diagnosis?
Evaluating volume overload
The patient's heart failure is classified as NYHA III and ACC/AHA C.
False
The patient's left ventricular ejection fraction (LVEF) is 40%.
False
Heart failure is primarily caused by hypertension in this patient.
False
The patient's symptoms are consistent with NYHA class I.
False
The patient's heart failure is classified as ACC/AHA stage A.
False
The patient's heart failure is caused by hypothyroidism.
False
The patient's ejection fraction is typical of heart failure with preserved ejection fraction (HFpEF).
False
The patient's symptoms are consistent with NYHA class IV.
False
The formula for cardiac output is CO = HR × SV.
True
Cocaine is a known cardiotoxin that can cause heart failure.
True
Chemotherapeutic agents are a cause of systolic dysfunction.
True
The clinical presentation of heart failure with reduced ejection fraction (HFrEF) always includes severe symptoms.
False
Ejection fraction is typically less than 50% in heart failure with reduced ejection fraction (HFrEF).
True
Assessment of fluid status is important for diagnosing heart failure.
True
Orthopnea is a common symptom of heart failure.
True
Alcohol is a known cause of systolic dysfunction.
True
The term 'heart failure' is preferred over 'congestive heart failure' because all patients present with volume overload.
False
An LV ejection fraction of 40% or lower is considered normal.
False
Heart failure with reduced ejection fraction is also known as diastolic heart failure.
False
Hypertension is the leading cause of heart failure.
False
One third of heart failure cases are attributable to nonischemic cardiomyopathy.
True
Heart failure is a complex clinical syndrome caused by any structural or functional cardiac disorder that impairs the ability of the atria to fill or eject blood.
False
Ejection fraction is usually measured only in the right ventricle.
False
Heart failure with preserved ejection fraction is characterized by an EF of 40% or lower.
False
What is the term preferred over 'congestive heart failure' and why?
The term 'heart failure' is preferred over 'congestive heart failure' because not all patients present with volume overload.
What is the normal range of ejection fraction in the left ventricle?
An LV ejection fraction of 55% or higher is considered normal.
What is the primary cause of heart failure with reduced ejection fraction?
Coronary artery disease and hypertension are the leading causes of heart failure.
What is the characteristic of heart failure with preserved ejection fraction?
Heart failure with preserved ejection fraction (HFpEF) is characterized by an EF ≥ 50%.
What is the pathophysiological definition of heart failure?
Heart failure is a complex clinical syndrome caused by any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.
What is the significance of assessing fluid status in heart failure diagnosis?
Assessment of fluid status is important for diagnosing heart failure.
What is the common symptom associated with heart failure?
Orthopnea is a common symptom of heart failure.
What is the proportion of heart failure cases attributable to nonischemic cardiomyopathy?
One third of heart failure cases are attributable to nonischemic cardiomyopathy.
What is the formula for cardiac output, and what do the variables represent?
CO = HR × SV, where CO is cardiac output, HR is heart rate, and SV is stroke volume.
What are the primary symptoms of heart failure with reduced ejection fraction (HFrEF)?
Dyspnea (especially on exertion) and fatigue, which lead to exercise intolerance.
What is the typical ejection fraction in heart failure with reduced ejection fraction (HFrEF)?
Less than 50%.
What is the importance of assessing fluid status in heart failure diagnosis?
It helps diagnose heart failure and guides management.
What are some common causes of systolic dysfunction?
Cardiotoxins, such as alcohol and cocaine, and chemotherapeutic agents.
What is the pathophysiological explanation for the symptoms of heart failure?
Decreased contractility, leading to decreased cardiac output, and fluid overload, resulting in symptoms such as dyspnea and fatigue.
What is the significance of orthopnea in heart failure?
It is a common symptom of heart failure, often resulting in difficulty sleeping.
What is the goal of management in heart failure with reduced ejection fraction?
To control BP and volume overload, and to improve symptoms.
What is the typical ejection fraction in heart failure with reduced ejection fraction (HFrEF)?
Less than 50%
What is the primary cause of heart failure in this patient?
CHD (MI 3 years ago)
What is the primary symptom of heart failure, leading to exercise intolerance?
Fatigue
What is the importance of assessing fluid status in heart failure diagnosis?
To diagnose heart failure
What is the pathophysiological mechanism underlying heart failure?
Impaired ability of the atria to fill or eject blood
What is the clinical presentation of heart failure with reduced ejection fraction (HFrEF)?
Marked limitation to physical activity, fatigue, and palpitation
What is the role of hypertension in heart failure?
Leading cause of heart failure
What is the New York Heart Association (NYHA) classification of the patient's heart failure?
NYHA II
The formula for cardiac output is CO = ______ × SV.
HR
Chemotherapeutic agents are a known cause of ______ dysfunction.
systolic
Ejection fraction is typically less than ______ % in heart failure with reduced ejection fraction.
50
The patient's heart failure classification is NYHA II and ACC/AHA ______.
B
Assessment of fluid status is important for ______ heart failure.
diagnosing
The patient's left ventricular ejection fraction (LVEF) is ______%.
25
Primary symptoms of heart failure include ______ and fatigue.
dyspnea
The patient's heart failure is caused by ______ and others.
CHD
Cocaine is a known ______ that can cause heart failure.
cardiotoxin
The symptoms of heart failure leading to exercise intolerance are primarily due to ______.
systolic dysfunction
Alcohol is a known cause of ______ dysfunction.
systolic
The patient's heart failure is classified as NYHA ______ and has symptoms of orthopnea and fatigue.
III
The assessment of ______ status is important for diagnosing heart failure.
fluid
Hypertension is a known ______ that can cause heart failure.
cardiotoxin
The patient's heart failure is classified as heart failure with ______ ejection fraction.
reduced
The term 'heart failure' is preferred over 'congestive heart failure' because not all patients present with ______ overload.
volume
Heart failure is a complex clinical syndrome caused by any structural or functional cardiac disorder that impairs the ability of the ___________ to fill or eject blood.
ventricle
The term 'heart failure' is preferred over 'congestive heart failure' because not all the patients are presented with ___________ overload.
volume
An LV ejection fraction of ___________ percent or higher is considered normal.
55
The leading causes of heart failure are ___________ artery disease and hypertension.
coronary
One third of heart failure cases are attributable to ___________ cardiomyopathy.
nonischemic
Ejection fraction is usually measured only in the ___________ ventricle.
left
Heart failure with reduced ejection fraction is characterized by an EF of ___________ percent or lower.
40
Any condition that places a great demand on the heart will result in heart failure, such as ___________ and obesity.
hypertension
Match the following cardiotoxins with their corresponding effects on the heart:
Alcohol = Causes systolic dysfunction Cocaine = Causes systolic dysfunction Chemotherapeutic agents = Causes systolic dysfunction CSS = Not a cardiotoxin
Match the following heart failure clinical presentations with their corresponding symptoms:
Dyspnea = Shortness of breath, especially on exertion Fatigue = Lack of energy, leading to exercise intolerance Orthopnea = Shortness of breath when lying down Nocturia = Urinating frequently at night
Match the following heart failure diagnosis assessments with their corresponding purposes:
Assessment of fluid status = Determine volume overload Assessment of ejection fraction = Determine systolic dysfunction BP control = Control hypertension Volume overload control = Reduce fluid buildup
Match the following heart failure pathophysiology concepts with their corresponding formulas:
Cardiac output = CO = HR × SV Stroke volume = The volume of blood ejected with each systole Heart rate = The number of heartbeats per minute Ejection fraction = The percentage of blood ejected from the ventricle
Match the following heart failure causes with their corresponding effects on the heart:
Hypertension = Increases blood pressure, leading to heart failure Hypothyroidism = Decreases thyroid hormone, affecting heart function Ischemic cardiomyopathy = Restricts blood flow to the heart, leading to failure Nonischemic cardiomyopathy = Damages the heart muscle, leading to failure
Match the following heart failure classification systems with their corresponding descriptions:
NYHA = Classifies heart failure based on symptoms and physical activity limitations ACC/AHA = Classifies heart failure based on stages of disease progression LVEF = Measures the percentage of blood ejected from the ventricle HFrEF = Classifies heart failure based on reduced ejection fraction
Match the following heart failure management approaches with their corresponding goals:
Control BP and volume overload = Reduce fluid buildup and hypertension Medication adjustment = Optimize medication dosages for heart failure management Lifestyle changes = Improve patient's ability to exercise and manage symptoms Device therapy = Use devices such as ICDs to manage heart failure
Match the following heart failure symptoms with their corresponding descriptions:
Paroxysmal nocturnal dyspnea = Waking up with shortness of breath Tachypnea = Rapid breathing rate Cough = Persistent coughing, possibly due to fluid buildup Fatigue = Lack of energy, leading to exercise intolerance
Match the following heart failure classification systems with their corresponding descriptions:
NYHA = Classifies heart failure based on physical activity limitations ACC/AHA = Classifies heart failure based on disease progression and treatment EF = Measures the percentage of blood pumped out of the heart's ventricles PAD = Classifies heart failure based on peripheral artery disease
Match the following heart failure causes with their corresponding pathophysiologies:
Hypertension = Increases afterload, leading to left ventricular hypertrophy Chronic kidney disease = Impairs kidney function, leading to fluid retention Hypothyroidism = Decreases cardiac contractility, leading to decreased cardiac output Myocardial infarction = Damages heart muscle, leading to systolic dysfunction
Match the following heart failure symptoms with their corresponding clinical presentations:
Fatigue = Marked limitation to physical activity Palpitation = Less than ordinary activity resulting in fatigue Orthopnea = Shortness of breath when lying down Edema = Swelling of the legs and feet due to fluid retention
Match the following heart failure diagnosis and assessment tools with their corresponding purposes:
Ejection fraction = Assesses the percentage of blood pumped out of the heart's ventricles Vital signs = Monitors heart rate and blood pressure Laboratory results = Assesses kidney function and electrolyte levels Thyroid-stimulating hormone = Assesses thyroid function
Match the following heart failure treatments with their corresponding indications:
Enalapril = Treats hypertension and heart failure Metoprolol = Treats heart failure and reduces mortality Furosemide = Treats fluid retention and edema Cilostazol = Treats peripheral artery disease
Match the following heart failure classification systems with their corresponding NYHA classes:
NYHA I = No symptoms with ordinary activity NYHA II = Mild symptoms with ordinary activity NYHA III = Marked symptoms with less than ordinary activity NYHA IV = Severe symptoms at rest
Match the following heart failure pathophysiologies with their corresponding ejection fractions:
Systolic dysfunction = Ejection fraction less than 40% Diastolic dysfunction = Ejection fraction greater than 40% Heart failure with preserved ejection fraction = Ejection fraction greater than 50% Heart failure with reduced ejection fraction = Ejection fraction less than 50%
Match the following heart failure causes with their corresponding prevalence:
Hypertension = Leading cause of heart failure Ischemic cardiomyopathy = One-third of heart failure cases Nonischemic cardiomyopathy = One-third of heart failure cases Chronic kidney disease = Common comorbidity in heart failure patients
Match the following terms with their corresponding descriptions related to Heart Failure:
Ejection Fraction (EF) = a measurement of the percentage of blood leaving the heart each time it contracts Heart Failure with Reduced Ejection Fraction (HFrEF) = a type of heart failure characterized by an EF of 40% or lower Heart Failure with Preserved Ejection Fraction (HFpEF) = a type of heart failure characterized by an EF of 50% or higher Left Ventricular Ejection Fraction (LVEF) = a measurement of the EF only in the left ventricle
Match the following conditions with their effects on the heart, leading to Heart Failure:
Hypertension = increases the demand on the heart Coronary Heart Disease = damages the heart muscle Aortic Stenosis = increases the pressure on the heart Hyperthyroidism = increases the heart rate
Match the following terms with their corresponding definitions related to Heart Failure pathophysiology:
Structural cardiac disorder = a condition that affects the heart's structure Functional cardiac disorder = a condition that affects the heart's function Ventricular dysfunction = a condition where the ventricle cannot fill or eject blood properly Cardiac syndrome = a complex condition characterized by ventricular dysfunction
Match the following symptoms with their corresponding effects on patients with Heart Failure:
Fatigue = reduces exercise tolerance Palpitation = increases heart rate Orthopnea = causes shortness of breath when lying down Dyspnea = causes shortness of breath on exertion
Match the following diagnostic tools with their corresponding uses in Heart Failure diagnosis:
Ejection Fraction (EF) = assesses the heart's pumping ability Left Ventricular Ejection Fraction (LVEF) = assesses the left ventricle's pumping ability Fluid status assessment = evaluates the body's fluid volume Cardiac output formula = calculates the heart's output
Match the following terms with their corresponding characteristics related to Heart Failure:
Heart Failure = a complex clinical syndrome caused by any structural or functional cardiac disorder Heart Failure with Reduced Ejection Fraction (HFrEF) = a type of heart failure characterized by an EF of 40% or lower Heart Failure with Preserved Ejection Fraction (HFpEF) = a type of heart failure characterized by an EF of 50% or higher Congestive Heart Failure = a term that is not preferred because it implies volume overload
Match the following causes with their corresponding effects on the heart, leading to Heart Failure:
Coronary Artery Disease = damages the heart muscle Hypertension = increases the demand on the heart Myocarditis = inflammation of the heart muscle Idiopathic cardiomyopathy = a condition of unknown cause
Match the following terms with their corresponding definitions related to Heart Failure diagnosis:
Ejection Fraction (EF) = a measurement of the heart's pumping ability Left Ventricular Ejection Fraction (LVEF) = a measurement of the left ventricle's pumping ability Heart Failure classification = a system to categorize heart failure severity Fluid status assessment = evaluates the body's fluid volume
Study Notes
HF Case 2: Patient Presentation and Management
- 62-year-old man with a history of CHD, HTN, depression, CKD, PAD, osteoarthritis, hypothyroidism, and HF (LVEF of 25%).
- Medications include aspirin, simvastatin, enalapril, metoprolol, furosemide, cilostazol, acetaminophen, sertraline, and levothyroxine.
- Vital signs: BP 120/70 mm Hg, HR 72 beats/minute.
- Laboratory results: K 4.1 mEq/L, SCr 2.8 mg/dL, and thyroid-stimulating hormone of 2.6 mIU/L.
- HF is stable and considered NYHA class II.
HFrEF Algorithm and Management
- Algorithm for pharmacologic management of heart failure with reduced ejection fraction.
- Guideline-directed treatment algorithm for patients with ACC/AHA stage C heart failure with reduced ejection fraction.
- Anticoagulation recommended for HF with permanent, persistent, or paroxysmal AF with an additional risk factor for stroke.
- Statins not recommended solely on the basis of HF diagnosis.
- Antiarrhythmics: dofetilide and amiodarone are preferred in patients with HFrEF.
- Nondihydropyridine calcium channel blockers (CCBs) with negative inotropic effects can be harmful in patients with low EF and should be avoided.
- DHP CCBs have no proven benefit on morbidity or mortality in HF.
Device Therapy
- Implantable cardioverter defibrillator recommended for primary prevention of sudden cardiac death in patients with ischemic or nonischemic HFrEF.
- Chronic resynchronization therapy recommended for those with an LVEF of 35% or less, in SR, and a left bundle branch block with a QRS of 150 milliseconds or greater.
HFrEF Pathophysiology
- CO = HR × SV (cardiac output equals heart rate times stroke volume).
- Causes of systolic dysfunction (decreased contractility) include various cardiotoxins.
HFrEF Clinical Presentation
- Patient presentation may range from asymptomatic to cardiogenic shock.
- Primary symptoms include dyspnea (especially on exertion) and fatigue, leading to exercise intolerance.
- Other symptoms include orthopnea, paroxysmal nocturnal dyspnea, tachypnea, cough, fluid overload, pulmonary congestion, and peripheral edema.
- Nonspecific symptoms may include fatigue, nocturia, hemoptysis, abdominal pain, anorexia, nausea, bloating, ascites, poor appetite, and weight gain or loss.
HFrEF Diagnosis
- Assessment of fluid status and ejection fraction (usually < 50%).
Heart Failure Definition
- Heart failure is a complex clinical syndrome caused by any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.
- The term "heart failure" is preferred over "congestive heart failure" because not all patients present with volume overload.
Heart Failure Classification
- NYHA (New York Heart Association) classification system:
- Class I: Patients with no symptoms or limitation in ordinary physical activity.
- Class II: Patients with slight limitation in ordinary physical activity.
- Class III: Patients with marked limitation in ordinary physical activity.
- Class IV: Patients who are unable to carry out any physical activity without discomfort.
- ACC/AHA (American College of Cardiology/American Heart Association) classification system:
- Stage A: High risk for heart failure, but no symptoms or structural heart disease.
- Stage B: Structural heart disease, but no symptoms.
- Stage C: Structural heart disease with symptoms.
- Stage D: Advanced heart failure requiring hospitalization.
Heart Failure with Reduced Ejection Fraction (HFrEF)
- Definition: Ejection fraction (EF) ≤ 40%.
- Previously known as systolic heart failure.
- Leading causes: coronary artery disease and hypertension.
- One third of cases are attributable to nonischemic cardiomyopathy.
- Other causes: myocarditis, idiopathic, tachycardia, peripartum.
Heart Failure with Preserved Ejection Fraction (HFpEF)
- Definition: Ejection fraction (EF) ≥ 50%.
- Pathophysiology: primarily diastolic dysfunction.
Pathophysiology
- Cardiac output (CO) = heart rate (HR) x stroke volume (SV).
- Causes of systolic dysfunction (decreased contractility): cardiotoxins (alcohol, cocaine, chemotherapeutic agents).
Clinical Presentation
- Primary symptoms: dyspnea (especially on exertion) and fatigue, leading to exercise intolerance.
- Other pulmonary symptoms: orthopnea, paroxysmal nocturnal dyspnea (PND), tachypnea, cough.
- Fluid overload can result in pulmonary congestion and peripheral edema.
- Nonspecific symptoms: fatigue, nocturia, hemoptysis, abdominal pain, anorexia, nausea, bloating, ascites, poor appetite or early satiety, and weight gain or loss.
Diagnosis
- Assessment of fluid status.
- Assessment of ejection fraction (usually < 50%).
- Same medications – none have shown mortality benefit.
- Control BP and volume overload.
Management
- Pharmacologic therapy:
- Beta blockers (e.g., metoprolol, carvedilol).
- ACE inhibitors (e.g., enalapril).
- Diuretics (e.g., furosemide).
- Spironolactone.
- Digoxin.
- Anticoagulation: recommended for HF with permanent, persistent, or paroxysmal AF with an additional risk factor for stroke.
- Statins: not recommended solely on the basis of HF diagnosis.
Heart Failure Definition
- Heart failure is a complex clinical syndrome caused by any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.
- The term "heart failure" is preferred over "congestive heart failure" because not all patients present with volume overload.
Heart Failure Classification
- NYHA (New York Heart Association) classification system:
- Class I: Patients with no symptoms or limitation in ordinary physical activity.
- Class II: Patients with slight limitation in ordinary physical activity.
- Class III: Patients with marked limitation in ordinary physical activity.
- Class IV: Patients who are unable to carry out any physical activity without discomfort.
- ACC/AHA (American College of Cardiology/American Heart Association) classification system:
- Stage A: High risk for heart failure, but no symptoms or structural heart disease.
- Stage B: Structural heart disease, but no symptoms.
- Stage C: Structural heart disease with symptoms.
- Stage D: Advanced heart failure requiring hospitalization.
Heart Failure with Reduced Ejection Fraction (HFrEF)
- Definition: Ejection fraction (EF) ≤ 40%.
- Previously known as systolic heart failure.
- Leading causes: coronary artery disease and hypertension.
- One third of cases are attributable to nonischemic cardiomyopathy.
- Other causes: myocarditis, idiopathic, tachycardia, peripartum.
Heart Failure with Preserved Ejection Fraction (HFpEF)
- Definition: Ejection fraction (EF) ≥ 50%.
- Pathophysiology: primarily diastolic dysfunction.
Pathophysiology
- Cardiac output (CO) = heart rate (HR) x stroke volume (SV).
- Causes of systolic dysfunction (decreased contractility): cardiotoxins (alcohol, cocaine, chemotherapeutic agents).
Clinical Presentation
- Primary symptoms: dyspnea (especially on exertion) and fatigue, leading to exercise intolerance.
- Other pulmonary symptoms: orthopnea, paroxysmal nocturnal dyspnea (PND), tachypnea, cough.
- Fluid overload can result in pulmonary congestion and peripheral edema.
- Nonspecific symptoms: fatigue, nocturia, hemoptysis, abdominal pain, anorexia, nausea, bloating, ascites, poor appetite or early satiety, and weight gain or loss.
Diagnosis
- Assessment of fluid status.
- Assessment of ejection fraction (usually < 50%).
- Same medications – none have shown mortality benefit.
- Control BP and volume overload.
Management
- Pharmacologic therapy:
- Beta blockers (e.g., metoprolol, carvedilol).
- ACE inhibitors (e.g., enalapril).
- Diuretics (e.g., furosemide).
- Spironolactone.
- Digoxin.
- Anticoagulation: recommended for HF with permanent, persistent, or paroxysmal AF with an additional risk factor for stroke.
- Statins: not recommended solely on the basis of HF diagnosis.
Heart Failure Definition
- Heart failure is a complex clinical syndrome caused by any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.
- The term "heart failure" is preferred over "congestive heart failure" because not all patients present with volume overload.
Heart Failure Classification
- NYHA (New York Heart Association) classification system:
- Class I: Patients with no symptoms or limitation in ordinary physical activity.
- Class II: Patients with slight limitation in ordinary physical activity.
- Class III: Patients with marked limitation in ordinary physical activity.
- Class IV: Patients who are unable to carry out any physical activity without discomfort.
- ACC/AHA (American College of Cardiology/American Heart Association) classification system:
- Stage A: High risk for heart failure, but no symptoms or structural heart disease.
- Stage B: Structural heart disease, but no symptoms.
- Stage C: Structural heart disease with symptoms.
- Stage D: Advanced heart failure requiring hospitalization.
Heart Failure with Reduced Ejection Fraction (HFrEF)
- Definition: Ejection fraction (EF) ≤ 40%.
- Previously known as systolic heart failure.
- Leading causes: coronary artery disease and hypertension.
- One third of cases are attributable to nonischemic cardiomyopathy.
- Other causes: myocarditis, idiopathic, tachycardia, peripartum.
Heart Failure with Preserved Ejection Fraction (HFpEF)
- Definition: Ejection fraction (EF) ≥ 50%.
- Pathophysiology: primarily diastolic dysfunction.
Pathophysiology
- Cardiac output (CO) = heart rate (HR) x stroke volume (SV).
- Causes of systolic dysfunction (decreased contractility): cardiotoxins (alcohol, cocaine, chemotherapeutic agents).
Clinical Presentation
- Primary symptoms: dyspnea (especially on exertion) and fatigue, leading to exercise intolerance.
- Other pulmonary symptoms: orthopnea, paroxysmal nocturnal dyspnea (PND), tachypnea, cough.
- Fluid overload can result in pulmonary congestion and peripheral edema.
- Nonspecific symptoms: fatigue, nocturia, hemoptysis, abdominal pain, anorexia, nausea, bloating, ascites, poor appetite or early satiety, and weight gain or loss.
Diagnosis
- Assessment of fluid status.
- Assessment of ejection fraction (usually < 50%).
- Same medications – none have shown mortality benefit.
- Control BP and volume overload.
Management
- Pharmacologic therapy:
- Beta blockers (e.g., metoprolol, carvedilol).
- ACE inhibitors (e.g., enalapril).
- Diuretics (e.g., furosemide).
- Spironolactone.
- Digoxin.
- Anticoagulation: recommended for HF with permanent, persistent, or paroxysmal AF with an additional risk factor for stroke.
- Statins: not recommended solely on the basis of HF diagnosis.
Heart Failure Definition
- Heart failure is a complex clinical syndrome caused by any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.
- The term "heart failure" is preferred over "congestive heart failure" because not all patients present with volume overload.
Heart Failure Classification
- NYHA (New York Heart Association) classification system:
- Class I: Patients with no symptoms or limitation in ordinary physical activity.
- Class II: Patients with slight limitation in ordinary physical activity.
- Class III: Patients with marked limitation in ordinary physical activity.
- Class IV: Patients who are unable to carry out any physical activity without discomfort.
- ACC/AHA (American College of Cardiology/American Heart Association) classification system:
- Stage A: High risk for heart failure, but no symptoms or structural heart disease.
- Stage B: Structural heart disease, but no symptoms.
- Stage C: Structural heart disease with symptoms.
- Stage D: Advanced heart failure requiring hospitalization.
Heart Failure with Reduced Ejection Fraction (HFrEF)
- Definition: Ejection fraction (EF) ≤ 40%.
- Previously known as systolic heart failure.
- Leading causes: coronary artery disease and hypertension.
- One third of cases are attributable to nonischemic cardiomyopathy.
- Other causes: myocarditis, idiopathic, tachycardia, peripartum.
Heart Failure with Preserved Ejection Fraction (HFpEF)
- Definition: Ejection fraction (EF) ≥ 50%.
- Pathophysiology: primarily diastolic dysfunction.
Pathophysiology
- Cardiac output (CO) = heart rate (HR) x stroke volume (SV).
- Causes of systolic dysfunction (decreased contractility): cardiotoxins (alcohol, cocaine, chemotherapeutic agents).
Clinical Presentation
- Primary symptoms: dyspnea (especially on exertion) and fatigue, leading to exercise intolerance.
- Other pulmonary symptoms: orthopnea, paroxysmal nocturnal dyspnea (PND), tachypnea, cough.
- Fluid overload can result in pulmonary congestion and peripheral edema.
- Nonspecific symptoms: fatigue, nocturia, hemoptysis, abdominal pain, anorexia, nausea, bloating, ascites, poor appetite or early satiety, and weight gain or loss.
Diagnosis
- Assessment of fluid status.
- Assessment of ejection fraction (usually < 50%).
- Same medications – none have shown mortality benefit.
- Control BP and volume overload.
Management
- Pharmacologic therapy:
- Beta blockers (e.g., metoprolol, carvedilol).
- ACE inhibitors (e.g., enalapril).
- Diuretics (e.g., furosemide).
- Spironolactone.
- Digoxin.
- Anticoagulation: recommended for HF with permanent, persistent, or paroxysmal AF with an additional risk factor for stroke.
- Statins: not recommended solely on the basis of HF diagnosis.
Determine the heart failure classification of a patient with a history of CHD, HTN, and other health conditions. Based on NYHA and ACC/AHA guidelines.
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