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Heart Failure - Coggle Diagram
Heart Failure
Pathophysiology
Infection
Hypoxemia
Tachycardia
Increased metabolic demands
Increased demand on heart
Fever
Anemia
Increased heart rate to meet peripheral tissue
Increased cardiac demand
Pulmonary edema
Increased pulmonary arterial pressure
Increased right ventricular afterload
Pregnancy
Increased need for tissue perfusion
Increased cardiac output
Arrhythmia
Decrease diastolic filling
Cardiac ischemia
Loss of "atrial kick"
Increased atrial pressure
Abnormal intraventricular conduction
Decreased cardiac output
Complex pathophysiological changes that are progressive
Longstanding hypertension
Excess mechanical stress on the ventricles
Structural changes of myocardial hypertrophy
Left ventricle dilation
Systolic dysfunction
Ventricle is unable to eject an adequate amount of bloof
Ischemic heart disease
Diminished coronary perfusion of the myocardium
Weakens the strength of contractility in the ventricles
Diastolic dysfunction
Inability of the ventricle to fill with sufficient amount of blood
Infective endocarditis
Emotional stress
Extreme conditions
Valvular damage
Increased cardiac demand
Inflammation
Fever
Excess physical activity
Dietary intake
Management & Pharmacotherapy
Identify and treat underlying causes
Decrease cardiac workload
Order rest until baseline "dry weight"
Vasodilators
Can be used for those who cannot tolerate ACEIs
Encourage weight loss if appropriate
control HTN
Individualized depending on comorbitities and history
Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors
Decrease volume overload
Diuretics
Thiazides for mild HD
Loop diuretics for severe HF
Dosages can be increased during an exacerbation
Sodium restricted diet less than 2g per day
Optimize left ventricular function
ACEIs
Serum potassium must be less than 5.5 mEq/L
Angioedema possible adverse reaction
Counteracts many of the neurohumoral changes that affect the sympathetic nervous system and effect fluid balance via the RAS
ARBs
For patients who cannot tolerate ACEIs
Lower risk of chronic cough and angioedema than ACEIs
Correct ventricular dyssyncrhony
Ivabradine (Corlanor)
SA node modulator
When added to beta-blockers, can assist in keeping the heart rate at 70 bpm or lower
Convert to sinus rhythm
Biventricular pacing
Implantable defibraillator
Cardiac resynchronization therapy (CRT)
For those with an EF less than 35%, a QRS greater than 120 ms or NYHA class III or IV
Anticoagulation
Warfarin (Coumadin)
PT/INR monitoring
Direct thrombin inhibitors
Factor Xa inhibitors
Reduce mortality
Beta-adrenergic blockers
Slows heart rate and limits peripheral arterial vasoconstriction
Patient education
Regular exercise
Cardiac rehabilitation programs
Elevate lower extremities
Fluid restrictions based on HF status
Alcohol discouraged, no more than 1 drink per day
Influenza, pneumococcal and COVID-19 vaccines
Psychological support
Counseling on prognosis of HF to understand the rationale for decisionmaking
Complete an advance directive, given the risk of cardiac arrest
Encouragement for the patient to take responsibility in their own personal care
When to and not to go to ED (signs and symptoms of exacerbations)
Heart Transplant
Indicated for patients with end stage heart failure
Used in cardiogenic shock, severe anginal symptoms, restrictive and hypertrophic cardiomyopathies
Absolute contraindications: patients with life expectancy < 2 years despite transplant, irreversible pulmonary hypertension, active substance use, severe symptomatic cerebrovascular disease
LVAD
Bridge to heart transplant
Portable battery-operated, mechanical pump, assists the left ventricle to pump blood to the rest of the body
Complications: CVA, infection, right sided dysfunction, and hemolysis
Diagnosis
Medical history
Diagnostic testing
Labs
BNP > 500 pg/mL
Serum electrolyte panel
Hypokalemia
Secondary to diuretic therapy or activation of he RAAS
Hyperkalemia
Renal failure
Hyponatremia
Secondary to diuretic therapy or genuine
Arterial blood gas
Liver function tests
May show hepatic congestion and decreased hepatic bloodflow
T4 and TSH
May show that HF is aggravated by hypo/hyperthyroidism
Imaging
CXR
Alterations in cardiac silhouette, cardiothoracic ratio, and cardiac chamber enlargement
Pulmonary venous congestion, alveolar edema and pleural effusions
EKG
May help to diagnose underlying causes
arrhythmias, MI, LVH
Echocardiogram
Diagnostic test to confirm HF
EF can be estimated
Cardiac wall thickness
Heart valve defects
Right-heart catheterization
Measures intracardiac pressure
HPI (subjective)
Common chief complaints
Cough, dyspnea on exertion, orthopnea, PND or chest pain
OLDCARTS / OLDCLASS
CNS symptoms
Confusion, difficulty concentrating, impaired memory, delirium, insomnia, anxiety, headaches, near-syncope
Systemic complaints
Fatigue, generalized weakness
Physical Exam (Objective)
General appearance
Breathlessness, DOE, pallor in extremities, distended peripheral veins, JVD, skeletal or connective tissue deformities, edema, jaundice, ascites, anasarca
Cardiac
Lateral and downward shift of the PMI (cardiac enlargement)
S3 heart sound
New murmurs
Respiratory
Dyspnea
Wet crackles
Pink frothy sputum (pulmonary edema)
Wheezing
Dullness on percussion (pleural effusion)
Vital signs
Tachycardia
Pulsus alternans
Atrial fibrillation
Rapid and shallow respirations
Differential Diagnoses
Anxiety
COPD
Asthma
Pneumonia
Venous insufficiency
Hepatic cirrhosis
Pericardial effusion
Epidemiological concepts
Lifetime likelihood of developing heart failure is approximately 20% for those >40 years old
Designated as a new epidemic in 1997
Women are 2x more likely to develop HFpEF than men
Diagnosed in 10% of the population by the time they reach 70 yrs old
Prevalence in the U.S is estimated between 1.9% to 2.6%
6.5 million adults in the US are affected
Technology & resources
Apps
myHeart
Activity diary, cardiac rehab & education
Nonprofits
The HeartBrothers Foundation
Heart Failure Society of America (HFSA)
Heart Failure Patient Foundation
Smart scales
Body Pod
Garmin
Wearable devices
Garmin, AppleWatch
Track activity and heart rate
Monitoring
Remote telemetry monitoring
Biventricular pacing
Implantable Cardioverter Defibriliators (ICDs)
Cardiac resynchronization therapy
Daily standing weights
Cardiac Implantable Electronic Devices
Follow-up and Referral
Primary care
Discuss quality of life
Sexual function
Mental health status
Sleep quality
Outlook on life
Appetite
Social activities
Encourage patient to communicate all signs, symptoms, fears and concerns
Frequency of follow-up depends on underlying cause
Every 3 months if stable and no changes to care
Home-care surveillance
Decreases the need for hospitalization
Improve functional status
Address social determinants of health
Food insecurity
Health literacy
Cardiology referral
Recommended at onset of symptoms but should not delay treatment
Acute HF
Usually requires hospitalization for aggressive management
Joint Commission mandated discharge requirements
Documented EF
If less than 40% must be prescribed an ACEI or ARB
Counseling on smoking cessation
Medication reconcilliation
Palliative
For high morbidity/mortality
Improves quality of life and symptoms management in those with advanced HF
Symptom management: including dyspnea, edema, fatigue, as well as psychological symptoms including depression and anxiety