1、Question 1Ten year survival after the onset of heart failure:80-90%60-79%40-59%20-39%Under 20% 2020/10/181Question 1Ten year survival aPrognosis in Heart Failure Men over 45 years of AgeSurviving (%)Years from Diagnosis2020/10/182Prognosis in Heart Failure MePrognosis in Heart Failure Women over 45

2、years of AgeSurviving (%)Years from Diagnosis2020/10/183Prognosis in Heart Failure WoQuestion 2Potential underlying causes of heart failure include:Coronary artery diseaseHemochromatosisMitral regurgitationVentricular septal defectall of the above2020/10/184Question 2Potential underlyinHeart Failure

3、The Final Common Pathwayischemic diseasevalvular diseasecardiomyopathypericardial diseasehypertensioncongenital HeartFailure2020/10/185Heart FailureThe Final CommonQuestion 3The pathophysiology of heart failure can best be described as:a failure of protective mechanismsactivation of harmful pathways

4、introduction of pathogenic influencesinappropriate activation of normal mechanismsall of the above2020/10/186Question 3The pathophysiologyPhysiologic Response to Heart FailureLV Dysfunction Renal-AdrenalCarotid and LA Baroreceptors Renin-AngiotensinAldosteroneSympathetic OutputSodiumand fluidretenti

5、ontachycardiavasoconstriction2020/10/187Physiologic Response to Heart Question 4Physiologic effects of Angiotensin II include:vasoconstrictionactivation of thirstsodium retentionaldosterone releaseall of the above2020/10/188Question 4Physiologic effectsRenin-Angiotensin SystemReninAngiotensin IAngio

6、tensin II decreasedrenal perfusion decreasedNa deliverysympathetic activityAVP ReleasevasoconstrictionaldosteroneIncreased thirstNE releasesodium retentiondecreased GFR2020/10/189Renin-Angiotensin SystemReninAQuestion 5The following is a feature of the heart failure state:reduced circulating catecho

7、laminesincreased left ventricular end diastolic pressurereduced plasma volumeincreased renal sodium excretionreduced pulmonary capillary wedge pressure2020/10/1810Question 5The following is a Compensatory Mechanisms in Heart Failureincreased preloadincreased sympathetic toneincreased circulating cat

8、echolaminesincreased Renin-angiotensin-aldosteroneincreased vasopressinincreased atrial natriuretic factor2020/10/1811Compensatory Mechanisms in HeaQuestion 6Patients with early heart failure typically present with:No symptomsDyspnea on exertion onlyDyspnea with minimal activityDyspnea at restAcute

9、respiratory distress2020/10/1812Question 6Patients with earlyHeart Failure Clinical Manifestations Symptomsdyspneafatigueexertional limitationweight gainpoor appetitecough Signstachycardia, tachypneaedemajugular venous distensionpulmonary ralespleural effusionhepato/splenomegalyascitescardiomegalyS3

10、 gallop2020/10/1813Heart Failure Clinical ManifeDyspnea Clinical Presentationsexertional shortness of breathcoughorthopneaparoxyxmal nocturnal dyspneasevere respiratory distressrespiratory failure2020/10/1814Dyspnea Clinical PresentatioNYHA Functional ClassificationClass I: patients with cardiac dis

11、ease but no limitation of physical activityClass II: ordinary activity causes fatigue, palpitations, dyspnea or anginal painClass III: less than ordinary activity causes fatigue, palpitations, dyspnea or angina Class IV: symptoms even at rest2020/10/1815NYHA Functional ClassificationQuestion 7Edema

12、in heart failure takes the following form:Peripheral edemaSacral edemaAbdominal distentionanasarcaAny of the above2020/10/1816Question 7Edema in heart failEdema Clinical Presentationswhere - peripheral, sacral, generalizedobjective weight gainbloatingabdominal distension2020/10/1817Edema Clinical Pr

13、esentationsQuestion 8Signs of right heart failure include all the following except:Peripheral edemaPulmonary ralesElevated jugular veinshepatomegalyPleural effusions2020/10/1818Question 8Signs of right hearLeft vs Right Heart FailureLeft Heart Failurepulmonary congestionRight Heart Failureperipheral

14、 edemasacral edemaelevated JVPasciteshepatomegalysplenomegalypleural effusion2020/10/1819Left vs Right Heart FailureLefQuestion 9A diagnosis of heart failure is best extablished on the basis of the following:Dyspnea at rest, increased heart size on chest X ray and elevated jugular veinsDyspnea with

15、stair climbing, increased heart size on chest X ray and heart rate of 105Rest dyspnea, interstitial edema on chest X ray, and elevated jugular veinsOrthopnea, flow redistribution on chest X Ray, and crackles in lung basesPND, bilateral pleural effusions and crackles in lung bases2020/10/1820Question

16、 9A diagnosis of hearCriteria for Diagnosis of CHFHISTORY Points rest dyspnea4 orthopnea4 PND3 dyspnea walking on level2 dyspnea on climbing1CHEST X-Ray alveolar pulmonary edema4 interstitial pulm edema3 bilateral pleural effusion3 CT ratio 0.503 flow redistribution2PHYSICAL Points HR 91-1101 HR 110

17、2 JVP 6 cm2 JVP 6 cm & hepatom3 lung crackles in base1 lung crackles above base2 wheezing3 S338-12 points - definite CHF5-7 points - possible CHF 5 points - unlikely CHF2020/10/1821Criteria for Diagnosis of CHFHQuestion 10All the following medications can precipitate heart failure in susceptible pat

18、ient except:metoprololspironolactoneprocainamidediltiazemrosiglitazone2020/10/1822Question 10All the following Precipitating Causes of Heart Failure1. ischemia2. change in diet, drugs or both3. increased emotional or physical stress4. cardiac arrhythmias (eg. atrial fib)5. infection6. concurrent ill

19、ness7. uncontrolled hypertension8. New high output state (anemia, thyroid)9. pulmonary embolism10. Mechanical disruption (sudden MR, VSD, AR)2020/10/1823Precipitating Causes of Heart Question 11The following investigations should always be carried out in patient presenting with heart failure except:

20、Renal function testsA ventilation-perfusion scanBlood countsElectrocardiogramEchocardiogram2020/10/1824Question 11The following inveInvestigations for Heart Failure EKGevidence of ischemia, infarction, LVH, RVHrhythm analysisChest X-Raycardiac sizeevidence of pulmonary vascularityBlood workCBC, rena

21、l function, electrolytesAssessment of LV Function2020/10/1825Investigations for Heart FailuQuestion 12Patient A.B. presents with clear signs of left heart failure and responds quickly to standard therapy. Follow-up assessment reveals normal LV systolic function. The most likely underlying cause of t

22、his patients heart failure is:Diastolic dysfunctionMitral valve disruptionPulmonary embolismDilated cardiomyopathyIschemic heart disease2020/10/1826Question 12Patient A.B. preseHeart Failure with Normal LV systolic function between symptomatic episodesischemiasudden increase in myocardial demandsdia

23、stolic LV dysfunction2020/10/1827Heart Failure with Normal LV sQuestion 13The following mechanisms contribute to myocardial dysfunction in heart failure patients:Increased circulating epinephrineIncreased circulating norepinephrineIncreased aldosterone productionIncreased angiotensin productionall o

24、f the above2020/10/1828Question 13The following mechRationale for Treatment of Heart FailureLV dysfunctionsympathetic activation Renin-angiotensin Adrenalstimulation epinephrinenorepinephrineangiotensin Ialdosteroneangiotensin II2020/10/1829Rationale for Treatment of HeaQuestion 14All of the followi

25、ng have been shown to improve prognosis in patients with heart failure except:digoxincarvedilolenalaprilmetoprololramipril2020/10/1830Question 14All of the followiMedical Management of Heart FailureDrugs that improve symptomsfurosemidethiazide diureticsspironolactonedigoxinACE Inhibitorsbeta blocker

26、saldosterone antagonistsDrugs that improve prognosisACE inhibitorsbeta blockersspironolactone*2020/10/1831Medical Management of Heart FaRationale for Treatment of Heart FailureLV dysfunctionsympathetic activation Renin-angiotensin Adrenalstimulation epinephrinenorepinephrineangiotensin Ialdosteronea

27、ngiotensin IIBABsACEIsARBsspironolactone2020/10/1832Rationale for Treatment of HeaBeta Blocker TrialsMortality per year2020/10/1833Beta Blocker TrialsMortality pEnalapril vs Placebo in Symptomatic CHFCONSENSUSProbability of DeathMonths2020/10/1834Enalapril vs Placebo in SymptoQuestion 15The followin

28、g are all adverse effects of beta blockers except:bronchospasmbradycardiahypotensiondepressionanxiety2020/10/1835Question 15The following are Beta BlockersAdverse Effectsexcessive fatiguebradycardia, heart blockhypotensionreactive airwaysmood disturbances, depressionintermittent claudicationimpotenc

29、e 2020/10/1836Beta BlockersAdverse EffectseBeta Blockers in Heart FailurePractical Tipsstart with low doses (3.125-6.25 mg carvedilol bid or 6.25-12.5 mg metoprolol bid)increase dose slowly at intervals of 2 weeks or moreavoid in patients with bronchospasm or advanced heart block without pacemakerim

30、provement symptomatically and objectively may be slowavoid abrupt withdrawl 2020/10/1837Beta Blockers in Heart FailureQuestion 16The following are all adverse effects of ACE Inhibitors except:Renal dysfunctionbradycardiahypotensioncoughhyperkalemia2020/10/1838Question 16The following are ACE Inhibit

31、orsAdverse Effectshypotensionrenal dysfunctionhyperkalemiacoughskin rashtaste disturbanceangioneurotic edema 2020/10/1839ACE InhibitorsAdverse EffectsQuestion 17Current evidence supports the following approach with respect to digoxin:Should be used in all patients with LV dysfunctionShould be used c

32、hronically in patients with controlled heart failure to improve symptom statusShould be used chronically in patients with controlled heart failure to improve prognosisShould be used acutely in patients with new onset heart failureDigoxin has no role in heart failure patients2020/10/1840Question 17Cu

33、rrent evidence sDigitalis and other Inotropic DrugsRecommendationsto improve symptoms and reduce hospitalizations in patients in sinus rhythm who remain symptomatic on ACEIspatients in atrial fibrillation and LV failureparenteral use of dopaminergic agents or phosphodiesterase inhibitors not recomme

34、nded routinely, but may be used in select patients with intractable heart failure 2020/10/1841Digitalis and other Inotropic Question 18Current evidence supports the following approach with respect to Angiotensin receptor antagonists:Should be used in all patients with LV dysfunctionShould be used ch

35、ronically in patients with controlled heart failure to improve symptom statusShould be used chronically in patients with controlled heart failure to improve prognosisShould be used in patients unable to tolerate ACE InhibitorsHave no role in heart failure patients2020/10/1842Question 18Current evide

36、nce sAngiotensin Receptor BlockersIndicationsmay be considered for patients unable to tolerate ACEIs2020/10/1843Angiotensin Receptor BlockersAngiotensin Receptor BlockersAdverse Effectshypotensionrenal dysfunctionhyperkalemia 2020/10/1844Angiotensin Receptor BlockersQuestion 19Current evidence suppo

37、rts the following approach with respect to Aldosterone antagonists:Should be used in all patients with LV dysfunctionShould be used chronically in patients with controlled heart failure to improve symptom statusShould be used chronically in patients with controlled heart failure to improve prognosis

38、Should be used in patients with severe heart failure to improve symptomsShould be used in patients with severe heart failure to improve symptoms and prognosis2020/10/1845Question 19Current evidence sAldosterone Antagonists in Heart FailureEvidenceRALES trial1663 patients with class III-IV heart fail

39、ure already on ACEI randomized to spironolactone (25 mg od) vs placeboafter 2 years, 30% reduction in mortality in treatment group 2020/10/1846Aldosterone Antagonists in HeaAldosterone Antagonists in Heart FailureIndicationsPatients with severe symptomatic heart failure who are already on standard m

40、edications 2020/10/1847Aldosterone Antagonists in HeaQuestion 20Current evidence supports the following approach with respect to diuretics:Should be used in all patients with LV dysfunctionShould be used only in patients with active heart failureShould be used all patients who have had symptomatic h

41、eart failure to prevent recurrencesShould be used in all patients with severe LV dysfunction Have no role in heart failure patients2020/10/1848Question 20Current evidence sDiuretics in Heart Failurevery useful for management of acute congestive stateproduce rapid symptom reliefhave no prognostic adv

42、antage in stable patients2020/10/1849Diuretics in Heart FailureveryDiuretics in Heart FailureAgents Usedfurosemidehydrochlorthiazidemetolazone2020/10/1850Diuretics in Heart FailureAgeQuestion 21The following are all adverse effects of furosemide except:renal dysfunctionskin rashhypotensionhyponatrem

43、iahyperkalemia2020/10/1851Question 21The following are Diuretics in Heart FailureAdverse Effectselectrolyte disturbances (K, Na)hypotensionrenal dysfunctionrashototoxicity (ethacrynic acid, furosemide)2020/10/1852Diuretics in Heart FailureAdvQuestion 22The following are all options to consider in pa

44、tients with highly symptomatic and refractory heart failure except:revascularizationresynchronization therapycardiac transplantationplasmapheresisdialysis2020/10/1853Question 22The following are Patients with: hypertension CAD DM risk for CMPPatients with: prior MI LV systolic dysfunction asymptomat

45、ic valve diseasePatients with: known structural heart disease SOB fatigue exercise tolerancePatients with:marked symptoms despite full therapyTherapytreat RFsencourage exercisediscourage alcoholTherapyall for Stage AACEIsBABsTherapyall for Stages A and Bdirueticsdigoxindietary restrictionsTherapyall

46、 for ABCassist devices transplantation Structural heart diseaseSymptoms of Heart FailureRefractory SymptomsSTAGE ASTAGE BSTAGE CSTAGE DAt risk2020/10/1854Patients with:Patients with:PaQuestion 23The following all support the diagnosis of acute pericarditis except:typical chest discomfortST elevation

47、 on EKGhistory of a preceding viral illnessS4 galloppericardial friction rub2020/10/1855Question 23The following all Acute Pericarditis Diagnostic Criteriachest painpericardial friction rubEKG changes2020/10/1856Acute Pericarditis DiagnostiQuestion 24The earliest EKG changes seen in acute pericardit

48、is:ST segment depressionST segment elevation hyperacute T wavesT wave depression PR depression2020/10/1857Question 24The earliest EKG cEKG in Acute Pericarditis1. Diffuse ST segment elevation (except aVR and V1) + PR segment depression2. ST normalizes, T waves flatten3. T waves invert where STs were

49、 elevated4. Return to normal pattern2020/10/1858EKG in Acute Pericarditis1. Question 25Pericardial tamponade should be suspected in the following situations:enlarged heart shadow on chest X rayunexplained hypotensionunexplained severe dyspneaexaggerated inspiratory decline in BPall of the above2020/

50、10/1859Question 25Pericardial tamponPericardial TamponadePhysical Examination Findingshypotensiontachycardiatachypneadistant heart soundselevated JVPpulsus paradoxus2020/10/1860Pericardial TamponadePhysicalQuestion 26Causes of pericardial effusions include all of the following except:hypertensive crisi