questions 10

Congestive Heart Failure

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Topic updated on 08/25/17 12:40pm

Snap Shot
  • Dilated cardiomyopathyA 68-year-old male presents to his primary care physician with dyspnea on exertion and swollen ankles. He has a long history of CAD and alcohol abuse. His chest x-ray is shown at right.
Introduction
  • CHF is defined as the inability of the heart to meet the demands of the body
  • Types
    • left-sided (MC)
      • heart cannot pump blood into systemic circulation
      • volume backs up behind the left heart into the pulmonary circulation
    • right-sided
      • heart cannot pump blood into pulmonary circulation
      • volume backs up behind the right heart into the systemic circulation
    • bilateral
    • high-output
      • cardiac output increased compared to resting
  • Cause (left, right, bilateral)
    • systolic dysfunction
      • weakened pumping function of the heart via
        • ischemic heart disease
        • chronic hypertension
        • cardiomyopathy (viral or idiopathic) in younger patients
    • diastolic dysfunction 
      • inability of the heart to relax/fill via
        • hypertension with LVH (most common cause)
        • hypertrophic cardiomyopathy
        • amyloidosis
        • sarcoidosis
        • hemochromatosis
        • scleroderma
        • post-operative/radiation fibrosis
    • valvular dysfunction
    • arrhythmias
  • Cause (high-output)
    • changes in blood flow factors
      • ↓ blood viscosity as seen in severe anemia
      • peripheral resistance as seen in endotoxic shock
      • ↑ blood return to heart as seen in AV fistula 
      • ↑ cardiac output as seen in hyperthyroidism
  • Precipitating factors
    • acute MI
    • long-standing HTN
    • chronic anemia
    • acute and/or recurrent pulmonary embolism
    • chronic endocarditis
    • post-partum females
    • thyrotoxicosis
  • Risk factors
    • CAD
    • family history of hypertrophic cardiomyopathy
    • HTN
    • valvular heart disease
    • ETOH abuse 
    • myocarditis
    • drug side effects (i.e. doxorubicin)
Presentation
  • Symptoms
    • patients suffering from CHF can present with a wide range of symptoms that help identify the affected side of the heart as follows 
      • left-sided failure (forward failure)
        • exertional dyspnea
        • orthopnea
        • paroxysmal noctural dyspnea
          • choking sensation when supine
          • relieved by sitting up/standing
          • caused by an increase in blood return to left heart when not pumping against gravity
        • persistent coughing due to pulmonary edema
          • pink/frothy sputum
          • alveoli contain hemosiderin-filled macrophages
            • "heart-failure cells" 
        • may progress to concomitant right-sided failure
      • right-sided failure (backwards failure)
        • abdominal fullness
        • exertional dyspnea
        • ankle-swelling
        • increased levels of atrial natriuretic peptide (ANP)
  • Physical exam
    • left-sided failure
      • bibasilar crackles
      • diffuse, left-displaced PMI
      • Cheyne-Stokes respiration
      • S3 heart sound (early diastolic)
        • first sign of left or right failure  
        • intensity increases with expiration
        • in left heart failure, S3 is best heard with bell of stethoscope with patient in left lateral decubitus position
      • may hear mitral regurgitation murmur
        • a result of ventricle dilation stretching the valve ring
    • right-sided failure
      • atrial fibrillation
      • JVD
      • S3 heart sound (early diastolic)
        • intensity increases with inspiration
      • may hear tricuspid regurgitation murmur
        • a result of ventricle dilation stretching the valve ring
      • hepatomegaly
        • result of blood flow backing up into liver
      • lower-extremity pitting edema + ascites
Evaluation
  • Mainly a clinical diagnosis
  • Serological
    • brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP)
      • released by the ventricles and the atria in response to increased stretch
      • both elevated in patients with heart failure and can be used to determine if acute dyspnea is caused by heart failure or another etiology
      • nesiritide is a recombinant form that has been used in the treatment of CHF
  • Imaging
    • chest x-ray
      • an important test to assess for severity of left heart failure
Treatment
  • Acute cases
    • if the patient has worsening dyspnea and other symptoms then
      • diurese aggressively
      • use ACE inhibitors in all patients who can tolerate them
      • dobutamine for inotropy
      • nitroprusside for afterload reduction.
  • Chronic cases
    • lifestyle modifications
      • limit dietary sodium intake
    • medications
      • ACE inhibitors are first-line have been shown to improve survival
      • digitalis and diuretics improve symptoms but not proven to improve survival
      • warfarin indicated with
        • severe dilated cardiomyopathy
        • atrial fibrillation
        • previous embolic episode
      • maintenance medications include
        • B-blockers 
        • afterload reduction via ACEi/ARB
        • spironolactone if K level is not high
        • hydralazine and long-acting nitrates (eg. isosorbide dinitrate) in African-Americans
      • arrhythmia medications
        • treat arrhythmias as they arise
  • Exacerbations (in Chronic Patients)
    • treat with loop diuretics such as furosemide when patient is volume-overloaded
  • Treat/control underlying etiologies if identified and possible
    • such as thyrotoxicosis, anemia, CAD, HTN, etc.
    • *avoid overdiuresis


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Qbank (8 Questions)

TAG
(M1.CV.23) A 50-year-old man with congestive heart failure (CHF) was started on an experimental analog of atrial natriuretic peptide. Which of the following would he expect to experience? Topic Review Topic

1. Increased water reabsorption by the renal collecting ducts
2. Vasoconstriction, increased blood pressure, aldosterone release
3. Increased glomerular filtration rate, restricted aldosterone release, vascular smooth muscle dilation
4. Increased renal absorption of sodium and water
5. Increased plasma calcium and decreased renal reabsorption of phosphate

PREFERRED RESPONSE ▶
TAG
(M1.CV.32) A 45-year-old African American woman presents to her family physician for a routine examination. Past medical history is positive for amyloidosis and non-rhythm-based cardiac abnormalities secondary to the amyloidosis. Which of the following cardiac parameters would be expected in this patient? Topic Review Topic

1. Preserved ejection fraction and increased compliance
2. Preserved ejection fraction and decreased compliance
3. Decreased ejection fraction and increased compliance
4. Decreased ejection fraction and decreased compliance
5. Increased ejection fraction and decreased compliance

PREFERRED RESPONSE ▶
TAG
(M1.CV.40) Under what physiologic state is the endogenous human analog of nesiritide produced? Topic Review Topic

1. Increased external stress
2. Increased ventricular stretch
3. Increased intracranial pressure
4. Increased circulatory volume presenting to the kidneys
5. Decreased circulatory volume presenting to the kidneys

PREFERRED RESPONSE ▶
TAG
(M1.CV.128) A 75-year-old man presents to his primary care physician with worsening breathlessness after walking up the stairs and the need to sleep propped up by an increasing number of pillows. On physical exam, the physician finds an early diastolic decrescendo murmur heard best at the left sternal border and crackles over both lower lung fields. The patient is sent for an echocardiogram with the attached result. Which of the following is the most likely etiology for this patient's symptoms? Topic Review Topic
FIGURES: A          

1. Aortic valve regurgitation
2. Aortic valve stenosis
3. Chronic hypertension
4. Mitral Regurgitation
5. Acute myocardial Infarction

PREFERRED RESPONSE ▶
TAG
(M1.CV.135) A 65-year-old male with multiple comorbidities presents to your office complaining of difficulty falling asleep. Specifically, he says he has been having trouble breathing while lying flat very shortly after going to bed. He notes it only gets better when he adds several pillows, but that sitting up straight is an uncomfortable position for him in which to fall asleep. What is the most likely etiology of this man's sleeping troubles? Topic Review Topic

1. Obstructive sleep apnea
2. Amyotrophic lateral sclerosis (ALS)
3. Myasthenia gravis
4. Right-sided heart failure
5. Left-sided heart failure

PREFERRED RESPONSE ▶
TAG
(M1.CV.144) A 36-year-old man with a history of a stab wound to the right upper thigh one year previously presents to the emergency department with complaints of difficulty breathing while lying flat. Physical examination reveals an S3 gallop, hepatomegaly, warm skin and a continuous bruit over the right upper thigh. Which of the following is most likely responsible for his symptoms? Topic Review Topic

1. Decreased sympathetic output
2. Increased peripheral resistance
3. Increased venous return
4. Decreased contractility
5. Increased pulmonary resistance

PREFERRED RESPONSE ▶
TAG
(M1.CV.205) A 70-year-old male presents for an annual exam. His past medical history is notable for shortness of breath when he sleeps, and upon exertion. Recently he has experienced dyspnea and lower extremity edema that seems to be worsening. Both of these symptoms have resolved since he was started on several medications and instructed to weigh himself daily. Which of the following is most likely a component of his medical management? Topic Review Topic

1. Ibutilide
2. Lidocaine
3. Aspirin
4. Carvedilol
5. Verapamil

PREFERRED RESPONSE ▶
TAG
(M1.CV.4754) A 71-year-old male presents to his primary care physician complaining of shortness of breath with exertion. He was previously able to walk one mile without stopping but has recently started to feel short of breath after walking a few blocks. He also complains of a choking sensation when supine that is relieved by sitting up. His medical history is notable for coronary artery disease, diabetes mellitus, and alcohol abuse. Physical examination reveals a diffuse, left-displaced point of maximal impact (PMI). Auscultation demonstrates an early diastolic gallop best heard over the apex with the patient in the left lateral decubitus position. A chest radiograph of the patient is shown (Figure A). Which of the following sets of cardiac parameters would be expected in this patient? Topic Review Topic
FIGURES: A          

1. Increased ejection fraction and decreased left ventricular end-diastolic volume
2. Preserved ejection fraction and normal compliance
3. Preserved ejection fraction and decreased compliance
4. Decreased ejection fraction and increased left ventricular end-diastolic volume
5. Decreased ejection fraction and decreased left ventricular end-diastolic volume

PREFERRED RESPONSE ▶
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