心衰问答专业知识宣贯

Question1

Tenyearsurvivalaftertheonsetofheartfailure:80-90%60-79%40-59%20-39%Under20%PrognosisinHeartFailure

Menover45yearsofAgeSurviving(%)YearsfromDiagnosisPrognosisinHeartFailure

Womenover45yearsofAgeSurviving(%)YearsfromDiagnosisQuestion2

Potentialunderlyingcausesofheartfailureinclude:CoronaryarterydiseaseHemochromatosisMitralregurgitationVentricularseptaldefectalloftheaboveHeartFailure

TheFinalCommonPathwayischemicdiseasevalvulardiseasecardiomyopathypericardialdiseasehypertensioncongenital

HeartFailureQuestion3

Thepathophysiologyofheartfailurecanbestbedescribedas:afailureofprotectivemechanismsactivationofharmfulpathwaysintroductionofpathogenicinfluencesinappropriateactivationofnormalmechanismsalloftheabovePhysiologicResponsetoHeartFailureLVDysfunction

Renal-AdrenalCarotidandLABaroreceptors

Renin-AngiotensinAldosteroneSympatheticOutputSodiumandfluidretentiontachycardiavasoconstrictionQuestion4

PhysiologiceffectsofAngiotensinIIinclude:vasoconstrictionactivationofthirstsodiumretentionaldosteronereleasealloftheaboveRenin-AngiotensinSystemReninAngiotensinIAngiotensinII

decreasedrenalperfusion

decreasedNadeliverysympatheticactivityAVPReleasevasoconstrictionaldosteroneIncreasedthirstNEreleasesodiumretentiondecreasedGFRQuestion5

Thefollowingisafeatureoftheheartfailurestate:reducedcirculatingcatecholaminesincreasedleftventricularenddiastolicpressurereducedplasmavolumeincreasedrenalsodiumexcretionreducedpulmonarycapillarywedgepressureCompensatoryMechanismsinHeartFailureincreasedpreloadincreasedsympathetictoneincreasedcirculatingcatecholaminesincreasedRenin-angiotensin-aldosteroneincreasedvasopressinincreasedatrialnatriureticfactorQuestion6

Patientswithearlyheartfailuretypicallypresentwith:NosymptomsDyspneaonexertiononlyDyspneawithminimalactivityDyspneaatrestAcuterespiratorydistressHeartFailure

ClinicalManifestations

Symptomsdyspneafatigueexertionallimitationweightgainpoorappetitecough

Signstachycardia,tachypneaedemajugularvenousdistensionpulmonaryralespleuraleffusionhepato/splenomegalyascitescardiomegalyS3gallopDyspnea

ClinicalPresentationsexertionalshortnessofbreathcoughorthopneaparoxyxmalnocturnaldyspneasevererespiratorydistressrespiratoryfailureNYHAFunctionalClassificationClassI:

patientswithcardiacdiseasebutno limitationofphysicalactivityClassII: ordinaryactivitycausesfatigue, palpitations,dyspneaoranginalpainClassIII:

lessthanordinaryactivitycauses fatigue,palpitations,dyspneaoranginaClassIV:symptomsevenatrestQuestion7

Edemainheartfailuretakesthefollowingform:PeripheraledemaSacraledemaAbdominaldistentionanasarcaAnyoftheaboveEdema

ClinicalPresentationswhere-peripheral,sacral,generalizedobjectiveweightgainbloatingabdominaldistensionQuestion8

Signsofrightheartfailureincludeallthefollowingexcept:PeripheraledemaPulmonaryralesElevatedjugularveinshepatomegalyPleuraleffusionsLeftvsRightHeartFailureLeftHeartFailurepulmonarycongestionRightHeartFailureperipheraledemasacraledemaelevatedJVPasciteshepatomegalysplenomegalypleuraleffusionQuestion9

Adiagnosisofheartfailureisbestextablishedonthebasisofthefollowing:Dyspneaatrest,increasedheartsizeonchestXrayandelevatedjugularveinsDyspneawithstairclimbing,increasedheartsizeonchestXrayandheartrateof105Restdyspnea,interstitialedemaonchestXray,andelevatedjugularveinsOrthopnea,flowredistributiononchestXRay,andcracklesinlungbasesPND,bilateralpleuraleffusionsandcracklesinlungbasesCriteriaforDiagnosisofCHFHISTORY

Pointsrestdyspnea 4orthopnea 4PND 3dyspneawalkingonlevel 2dyspneaonclimbing 1CHESTX-Rayalveolarpulmonaryedema 4interstitialpulmedema 3bilateralpleuraleffusion 3CTratio>0.50 3flowredistribution 2PHYSICAL

PointsHR91-110 1HR>110 2JVP>6cm 2JVP>6cm&hepatom 3lungcracklesinbase 1lungcracklesabovebase 2wheezing 3S3 38-12points-definiteCHF5-7points-possibleCHF<5points-unlikelyCHFQuestion10

Allthefollowingmedicationscanprecipitateheartfailureinsusceptiblepatientexcept:metoprololspironolactoneprocainamidediltiazemrosiglitazonePrecipitatingCausesofHeartFailure1.ischemia2.changeindiet,drugsorboth3.increasedemotionalorphysicalstress4.cardiacarrhythmias(eg.atrialfib)5.infection6.concurrentillness7.uncontrolledhypertension8.Newhighoutputstate(anemia,thyroid)9.pulmonaryembolism10.Mechanicaldisruption(suddenMR,VSD,AR)Question11

Thefollowinginvestigationsshouldalwaysbecarriedoutinpatientpresentingwithheartfailureexcept:RenalfunctiontestsAventilation-perfusionscanBloodcountsElectrocardiogramEchocardiogramInvestigationsforHeartFailure

EKGevidenceofischemia,infarction,LVH,RVHrhythmanalysisChestX-RaycardiacsizeevidenceofpulmonaryvascularityBloodworkCBC,renalfunction,electrolytesAssessmentofLVFunctionQuestion12

PatientA.B.presentswithclearsignsofleftheartfailureandrespondsquicklytostandardtherapy.Follow-upassessmentrevealsnormalLVsystolicfunction.Themostlikelyunderlyingcauseofthispatient’sheartfailureis:DiastolicdysfunctionMitralvalvedisruptionPulmonaryembolismDilatedcardiomyopathyIschemicheartdiseaseHeartFailurewithNormalLVsystolicfunctionbetweensymptomaticepisodesischemiasuddenincreaseinmyocardialdemandsdiastolicLVdysfunctionQuestion13

Thefollowingmechanismscontributetomyocardialdysfunctioninheartfailurepatients:IncreasedcirculatingepinephrineIncreasedcirculatingnorepinephrineIncreasedaldosteroneproductionIncreasedangiotensinproductionalloftheaboveRationaleforTreatmentofHeartFailureLVdysfunctionsympatheticactivation

Renin-angiotensin

Adrenalstimulation

epinephrinenorepinephrineangiotensinIaldosteroneangiotensinIIQuestion14

Allofthefollowinghavebeenshowntoimproveprognosisinpatientswithheartfailureexcept:digoxincarvedilolenalaprilmetoprololramiprilMedicalManagementofHeartFailureDrugsthatimprovesymptomsfurosemidethiazidediureticsspironolactonedigoxinACEInhibitorsbetablockersaldosteroneantagonistsDrugsthatimproveprognosisACEinhibitorsbetablockersspironolactone*RationaleforTreatmentofHeartFailureLVdysfunctionsympatheticactivation

Renin-angiotensin

Adrenalstimulation

epinephrinenorepinephrineangiotensinIaldosteroneangiotensinIIBABsACEIsARBsspironolactoneBetaBlockerTrialsMortalityperyearEnalaprilvsPlaceboinSymptomaticCHF

CONSENSUSProbabilityofDeathMonthsQuestion15

Thefollowingarealladverseeffectsofbetablockersexcept:bronchospasmbradycardiahypotensiondepressionanxietyBetaBlockers

AdverseEffectsexcessivefatiguebradycardia,heartblockhypotensionreactiveairwaysmooddisturbances,depressionintermittentclaudicationimpotence

BetaBlockersinHeartFailure

PracticalTipsstartwithlowdoses(3.125-6.25mgcarvedilolbidor6.25-12.5mgmetoprololbid)increasedoseslowlyatintervalsof2weeksormoreavoidinpatientswithbronchospasmoradvancedheartblockwithoutpacemakerimprovementsymptomaticallyandobjectivelymaybeslowavoidabruptwithdrawl

Question16

ThefollowingarealladverseeffectsofACEInhibitorsexcept:RenaldysfunctionbradycardiahypotensioncoughhyperkalemiaACEInhibitors

AdverseEffectshypotensionrenaldysfunctionhyperkalemiacoughskinrashtastedisturbanceangioneuroticedema

Question17

Currentevidencesupportsthefollowingapproachwithrespecttodigoxin:ShouldbeusedinallpatientswithLVdysfunctionShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimprovesymptomstatusShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimproveprognosisShouldbeusedacutelyinpatientswithnewonsetheartfailureDigoxinhasnoroleinheartfailurepatientsDigitalisandotherInotropicDrugs

RecommendationstoimprovesymptomsandreducehospitalizationsinpatientsinsinusrhythmwhoremainsymptomaticonACEIspatientsinatrialfibrillationandLVfailureparenteraluseofdopaminergicagentsorphosphodiesteraseinhibitorsnotrecommendedroutinely,butmaybeusedinselectpatientswithintractableheartfailureQuestion18

CurrentevidencesupportsthefollowingapproachwithrespecttoAngiotensinreceptorantagonists:ShouldbeusedinallpatientswithLVdysfunctionShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimprovesymptomstatusShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimproveprognosisShouldbeusedinpatientsunabletotolerateACEInhibitorsHavenoroleinheartfailurepatientsAngiotensinReceptorBlockers

IndicationsmaybeconsideredforpatientsunabletotolerateACEIsAngiotensinReceptorBlockers

AdverseEffectshypotensionrenaldysfunctionhyperkalemia

Question19

CurrentevidencesupportsthefollowingapproachwithrespecttoAldosteroneantagonists:ShouldbeusedinallpatientswithLVdysfunctionShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimprovesymptomstatusShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimproveprognosisShouldbeusedinpatientswithsevereheartfailuretoimprovesymptomsShouldbeusedinpatientswithsevereheartfailuretoimprovesymptomsandprognosisAldosteroneAntagonistsinHeartFailure

EvidenceRALEStrial1663patientswithclassIII-IVheartfailurealreadyonACEIrandomizedtospironolactone(25mgod)vsplaceboafter2years,30%reductioninmortalityintreatmentgroupAldosteroneAntagonistsinHeartFailure

IndicationsPatientswithseveresymptomaticheartfailurewhoarealreadyonstandardmedicationsQuestion20

Currentevidencesupportsthefollowingapproachwithrespecttodiuretics:ShouldbeusedinallpatientswithLVdysfunctionShouldbeusedonlyinpatientswithactiveheartfailureShouldbeusedallpatientswhohavehadsymptomaticheartfailuretopreventrecurrencesShouldbeusedinallpatientswithsevereLVdysfunctionHavenoroleinheartfailurepatientsDiureticsinHeartFailureveryusefulformanagementofacutecongestivestateproducerapidsymptomreliefhavenoprognosticadvantageinstablepatientsDiureticsinHeartFailure

AgentsUsedfurosemidehydrochlorthiazidemetolazoneQuestion21

Thefollowingarealladverseeffectsoffurosemideexcept:renaldysfunctionskinrashhypotensionhyponatremiahyperkalemiaDiureticsinHeartFailure

AdverseEffectselectrolytedisturbances(K,Na)hypotensionrenaldysfunctionrashototoxicity(ethacrynicacid,furosemide)Question22

Thefollowingarealloptionstoconsiderinpatientswithhighlysymptomaticandrefractoryheartfailureexcept:revascularizationresynchronizationtherapycardiactransplantationplasmapheresisdialysisPatientswith:hypertensionCADDMriskforCMPPatientswith:priorMILVsystolicdysfunctionasymptomaticvalvediseasePatientswith:knownstructuralheartdiseaseSOBfatigue

exercisetolerancePatientswith:markedsymptomsdespitefulltherapyTherapytreatRFsencourageexercisediscouragealcoholTherapyallforStageAACEIsBABsTherapyallforStagesAandBdirueticsdigoxindietaryrestrictionsTherapyallforABCassistdevicestransplantationStructuralheartdiseaseSymptomsofHeartFailureRefractorySymptomsSTAGEASTAGEBSTAGECSTAGEDAtriskQuestion23

Thefollowingallsupportthediagnosisofacutepericarditisexcept:typicalchestdiscomfortSTelevationonEKGhistoryofaprecedingviralillnessS4galloppericardialfrictionrubAcutePericarditis

DiagnosticCriteriachestpainpericardialfrictionrubEKGchangesQuestion24

TheearliestEKGchangesseeninacutepericarditis:STsegmentdepressionSTsegmentelevationhyperacuteTwavesTwavedepressionPRdepressionEKGinAcutePericarditis1.

DiffuseSTsegmentelevation

(exceptaVRandV1)+PRsegmentdepression2.STnormalizes,Twavesflatten3.TwavesinvertwhereSTswereelevated4.ReturntonormalpatternQuestion25

Pericardialtamponadeshouldbesuspectedinthefollowingsituations:enlargedheartshadowonchestXrayunexplainedhypotensionunexplainedseveredyspneaexaggeratedinspiratorydeclineinBPalloftheabovePericardialTamponade

PhysicalExaminationFindingshypotensiontachycardiatachypneadistantheartsoundselevatedJVPpulsusparadoxusQuestion26

Causesofper