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PAEA Outpatient/Family Medicine EOR Topics
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PAEA Outpatient/Family Medicine EOR Topicswhat is the most common cause of heart failure? specifically left sided? right
sided? Correct Ans - -MC is CAD (coronary artery disease)
-L sided: *CAD* & HTN
-R sided: *L sided HF* & pulmonary dz
decreased ejection fraction, thin ventricular walls, dilated LV chamber, and an
S3 gallop (filling of dilated ventricle) is associated with systolic or diastolic
heart failure? Correct Ans - systolic (MC form of CHF)
*(the sound is actually heard in the diastole though)
-memory trick: "sys-to-lic" 3 consonants = S3
normal ejection fraction, thick ventricular walls, narrowed LV chamber, and
an S4 gallop (atrial contraction into a stiff ventricle) is associated with systolic
or diastolic heart failure? Correct Ans - diastolic
-memory trick: "di-a-sto-lic" 4 consonants = S4
what are the causes of systolic vs diastolic heart failure? Correct Ans -
-systolic: post *MI*, *dilated cardiomyopathy*, myocarditis
-diastolic: *HTN*, *LVH*, *elderly*, valvular heart dz, hypertrophic or
restrictive cardiomyopathy, constrictive pericarditis
when the metabolic demands of the body exceed normal cardiac function (d/t
thyrotoxicosis, wet beriberi, severe anemia, AV shunting, Paget's disease of
the bone) this is termed ________ heart failure Correct Ans - high-output
*fairly uncommon
-low-output HF is just d/t problem w/ myocardial contraction, ischemia, or
chronic HTN
what are some causes of acute vs chronic heart failure? Correct Ans - -
acute: *largely systolic*; hypertensive crisis, acute MI, papillary muscle
rupture
-chronic: dilated cardiomyopathy (systolic), valvular dz (diastolic)
,explain class I-IV New York Heart Association functional classes Correct
Ans - -class I: *no sx's*, *no limitation* during ordinary physical activity
-class II: *mild sx's* (dyspnea or angina), *slight limitation* during ordinary
activity
-class III: *comfortable only at rest* (sx's caused maked limitation in activity
even with minimal exertion
-class IV: *sx's even while at rest*, severe limitations, inability to carry out
physical activity
what compensations does the body make when heart failure (can be due to
something that causes either inc pre/afterload or dec contractility) begins?
Correct Ans - 1. sympathetic nervous system activation
2. myocyte hypertrophy/remodeling
3. RAAS activation: fluid overload
the following are signs/sx's of what sided heart failure?
inc pulmonary venous pressure, dyspnea, orthopnea, rales/rhonchi, chronic
non-productive cough with pink frothy sputum, HTN, Cheyne-Stokes
breathing, S3 or S4, pale skin/cool extremities, sinus tachy, fatigue Correct
Ans - L-sided HF
the following are signs/sx's of what sided heart failure?
inc systemic venous pressure, peripheral edema, JVD, anorexia, N/V,
hepatosplenomegaly, RUQ tenderness, hepatojugular reflex (inc JVP with liver
palpation) Correct Ans - R-sided HF
-CXR showing Kerley B lines (alternate flow tracts), cardiomegaly, pleural
effusion, pulmonary edema
-echo with dec EF
-inc BNP on labs
are all signs of? Correct Ans - heart failure
*BNP released from atrium with preload too high (volume overload)
what drugs have shown to decrease mortality rates in pts with heart failure?
Correct Ans - *ACE inhibitors* (-prils), ARBs, *beta-blockers* (-lols),
hydralazine + nitrates, spironolactone
,in pts who experience the following common side effects of an ACE inhibitor
to treat heart failure, what is the alternative medication?
-1st dose hypotension, renal insufficiency, hyperkalemia, cough, angioedema
Correct Ans - ARBs (-sartans)
what vasodilators are often used to treat heart failure? Correct Ans -
hydralazine + nitrates
-good for african americans
-safe in pregnancy
-acts to dec pre/afterload
-used if pt not able to tolerate ACEi/ARBs/BB or if more control needed
what is the most effective treatment for symptoms of heart failure?
Correct Ans - diuretics
-loop diuretics (-semides) act on inc excretion of Na, Cl, K, H2O (so can go
hypo on these electrolytes), other s/e: hyperglycemia, hyperuricemia
-K-sparing diuretics (spironolactone, eplerenone) aldosterone antagonists;
s/e: hyperkalemia, gynecomastia with spirono
-HCTZ or metolazone (thiazide like diuretic)- s/e: hyponatremia/kalemia,
hyperuricemia, hyperglycemia
what medications are used to treat acute severe heart failure? Correct Ans
- *sympathomimetics* (positive inotropes to inc contractility)
-*digoxin*: but has a narrow therapeutic index (can cause arrhythmias,
seizures, dizziness, GI upset, visual disturbances, gynecomastia); toxicity =
downsloping ST segment; antidote: Digoxin Immune Fab
-*dobutamine*: inc contractility (B1 agonist), peripheral vasodilation
-*dopamine*: inc contractility
giving a synthetic BNP, Nesiritide, works by what mechanism to treat heart
failure? Correct Ans - -dec RAAS activity
-inc Na+/H2O excretion
why are beta-blockers started after ACE inhibitors/diuretics in heart failure?
Correct Ans - want to decrease afterload/preload before slowing down the
heart rate
, at what EF do heart failure patients need to receive an implantable
cardioverter defibrillator? Correct Ans - EF <35% because they
tolerate arrhythmias poorly and there is inc mortality rate
what medication used to treat *systolic* heart failure is a selective sinus node
inhibitor that slows the sinus rate? Correct Ans - *ivabradine*: dec
mortality rate in pts w/ EF ≤35%, in sinus rhythm, w/ resting pulse ≥70bpm,
& already maxed out on BB dose or unable to take BB
what medication used to treat *systolic* heart failure works by increasing
levels of natriuretic peptides? Correct Ans - *sacubitril-valsartan*:
decreases mortality rate in class II-IV HF w/ reduced EF
what is the treatment for acute pulmonary edema/congestive (aka
decompensated) heart failure? Correct Ans - *LMNOP*
-*L*asix: removes fluids- improves sx's
-*M*orphine: reduces preload reducing heart strain
-*N*itrates: vasodilator to reduce pre/afterload
-*O*xygen
-*P*osition: upright to dec venous return
if severe may also need inotropic support
hypertension is defined as ____/____ blood pressures on ____ or more visits
Correct Ans - ≥130/80 on 2 or more visits
-stage 1 is 130-139/80-89
-stage 2 is ≥140/90
although primary HTN makes up 95% of cases, when should secondary HTN
be considered? what are some causes of secondary HTN? Correct Ans -
-if refractory to antihypertensives or severely elevated
-causes: *renal artery stenosis*, fibromuscular dysplasia, atherosclerosis, 1°
hyperaldosteronism, pheochromocytoma, cushing's syndrome, coarctation of
the aorta, sleep apnea, EtOH, OCPs, COX-2 inhibitors
what are the complications of HTN? Correct Ans - -CV (CAD, HF, MI,
LVH, aortic dissection, aortic aneurysm, PVD)
-neurologic (TIA, CVA, rutured aneurysms, encephalopathy)
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