Cram The Pance - S1E21 Heart Failure

Episode Date: April 27, 2021

Heart Failure review for your Pance, Panre and Eor’s.►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

Okay, so today we're going to be doing heart failure, which is pretty important for the board, so you do need to be familiar with it. I need you some ways to remember the things that you need to know and just focus on the high yield stuff for today. As always, thank you so much for the reviews, the likes. Thank you for everybody that's checked out my YouTube page as well. Seeing a lot of positive comments coming in there, so it's definitely much appreciated. And if you wouldn't mind leaving me a like or a review on either Apple Podcasts or my YouTube channel, I would really appreciate it if it is helping you.

So let's get started with heart failure. So what is heart failure? I'm sure all of us are pretty familiar with this, but heart failure is a clinical syndrome that results from either a structural or a functional disorder of the heart. So you have either an impairment of the filling of the heart or an impairment of the ability of the heart to adequately pump blood. Now predisposing factors, there's one that you really have to know

that you have to be familiar with because it's the most common cause overall of 60 to 65% of cases of heart failure. The predisposing factor is coronary artery. disease. So absolutely know that one. Coronary artery disease. That's really important. Majority of cases are from that. A few more that you need to be familiar with. Hypertension and ovular heart disease like aortic stenosis are big ones, but they're becoming less prevalent as the years go on due to improvements in early detection and treatment, but they are still predisposing factors. Diabetes, diabetes, obesity, and then, of course,

the lesser, the less common causes like doxorubicin and dilated cardiomyopathy, amydois and restrictive cardiomyopathy. But overall, if you remember coronary artery artery disease, you'll probably get the question right on the exam. And the next thing you need to know is the different types of heart failure. So that's important as well because that's going to help you understand the clinical manifestations and treatment options and things like that. So obviously we have different parts of the heart.

And like I said, the clinical manifestations are all dictated relating to the part of the heart that is affected. First let's start with the sides of the heart. We have a right and we have a left side of the heart. left side of the heart. And the first thing that you should be aware of is that while you can only have exclusive left-sided heart failure, you can have exclusive right-sided heart failure. It's actually not that common. It's more common for both to coexist. So most of the time, you're going to have right-and-left-sided heart failure at the same time. But it is possible to just have

left-sided only heart failure, normally in like an acute MI, so a coronary artery disease, long-standing hypertension. And then it's also possible to just have right-sided, exclusive of heart failure and patients with pulmonary disorders like pulmonary hypertension, COPD, and actually the most common cause of right-sided heart failure is actually left-sided heart failure. And why is that? Well, if we think about the path, though, it makes more sense. We already discussed that pulmonary disorders like pulmonary hypertension can lead to right-sided

heart failure, and that's because you have this increased pressure in the lungs. The right side of the heart is pumping blood to the lungs. So you have this increased pressure in the lungs. It's going to hypertrophy the right side of the heart, making it's going to hypertrophy the right side of the heart, make it harder for it to pump, and it leads to heart failure. So think about left-sided heart failure now causing right-sided heart failure. Well, left-sided heart failure, the fluid's backing up into where it came from, which is the lungs. So left-sided heart failure is causing all this excess fluid to back up into the lungs. All that excess fluid is going to increase the pressure

in the lungs, which is going to lead to ultimately right-sided heart failure. So that's why left-sided heart failure is actually the most common cause of right-sided heart failure because of all that backed up fluid, increasing the pressure, right side having to pump harder, and the most ultimately leading to a hypertrophy of the right side of the heart. So that's the right and the left side of the heart. That's the different variations with heart failure with that. The other variation you're going to see is systolic and diastolic dysfunction or systolic and diastolic heart failure. Now, the terms that they use for these are systolic is heart failure with reduced ejection fraction and diastolic is heart failure with preserved ejection fraction. That's the proper way

to say these, but I'm not going to say that because it takes too long. So if I say systolic, think of heart failure with reduced ejection fraction, diastolic, preserved ejection fraction. So let's start with systolic, aka heart failure with reduced ejection fraction. So systolic is a pumping problem. The ventricles, for whatever reason, have become weak and baggy. They're stretched out. They can't pump the way they used to. They're just baggy. They have no strength anymore. Normally, this is going to be a post-MI patient, dilated cardiomyopathy, but just thinking, systolic, you have these weak, baggy ventricles. They can't pump the way they used to, and because of that, you have this decreased ejection fraction. An ejection fraction, if you're not familiar with it,

it's the measurement of volume of blood that's pumped out of the left ventricle with each contraction. Normally is a normal patient's going to be around 50 to 70%. These patients are generally going to be actually under 40% ejection fraction. So systolic, you're going to have decreased ejection fraction. And then on a physical exam, be familiar that they may have an S3 Gallup. All right, let's talk about an S3. An S3, although it can be heard in healthy young children and adults, it's usually abnormal in patients over the age of 40 years, suggesting an enlarged or dilated ventricular chamber. An S3 gallop is often an early finding of heart failure associated with dilated cardiomyopathy. It's more frequently hurt in systolic rather than

diastolic heart failure. So if you see an S3 mentioned in an adult on an exam question, you should be thinking systolic heart failure, so heart failure with reduced ejection fraction. So S3 is more common in systolic, and S4, which will go over in a minute, is more common in diastolic. How do you remember that? Sistolic, systolic has three syllables, so remember it's associated with an S3, and diastolic has four syllables, so it's associated with an S4. Quick and easy way to remember the two. Now, diastolic heart failure, which is heart failure, which is heart failure with preserved ejection fraction. So as it says, preserve, the ejection fraction is normally not decreased. You have the opposite. The ventricles are actually stiff. They're sometimes

thickened. They can't relax. So the problem's not with pumping, but it's with receiving blood. They can't expand to fill the blood during diastole. They're stiffen, they're thick. So again, it's not a pumping problem. So ejection fraction is normally either normal or sometimes even elevated. The ventricles just can't expand to fill with adequate blood. which can also cause backup and other problems with heart failure as well. And in diastolic, you're normally going to hear an S4 gallop. All right, so S4. S4 when heard, is usually an abnormal finding,

especially in young children and adults, and a palpable S4 is always abnormal regardless of age. Usually the presence of an S4 is due to the forceful atrial contraction against a stiff, non-compliant ventricle, like we see in diastolic heart failure. So it is more common in diastolic heart failure, or heart failure with preserved ejection fraction. Remember, diastolic has four syllables, diastolic, four syllables, so think S4.

And diastolic heart failure you're normally going to see in different cardiomyopathes, valvular heart disease, hypertension, those are some of the predisposing factors for that. So again, systolic is a pumping problem. You have this baggy ventricle, it can't pump blood out. Diastolic, you have this stiffened, thick ventricle that can't receive blood. It can't fill the way it used to. It can't get as much blood in there, but no problem pumping. So ejection fraction is preserved.

Now, clinical manifestations, well, it's all related to whether it's right or left-sided heart failure. Remember what I said before that normally this is going to coexist. So most of the time, you're going to see symptoms of both right and left-sided heart failure. But again, it's possible to have just exclusive right- or left-sided heart failure. So in both right and left-sided heart failure, the blood is backing up. So whether it's systolic, the ventricles don't pump enough blood out or diastolic. the ventricles don't relax, can't receive all the blood from the atrium. Both cases, you have this backing up of blood and the symptoms are all related to where it's backing up to. So if you have,

and it's basically where it came from, so if you have left-sided heart failure, well, what's providing the left side of the heart with blood? The pulmonary veins from the lungs. So if you have left-sided heart failure, the blood's going to back up into the pulmonary vein and back into the lungs. And that's why with left-sided heart failure, the most common symptom is going to be dyspnea because you have these lungs full of fluid. Orthopnea is another big one. Orthopnea is dyspnea while lying flat. So these patients lay down within a few minutes, they're out of breath and they're coughing. So they may have a chronic cough as well. They may have some frothy pink sputum that can be seen. So left-sided heart failure is all related to the lungs. And you can remember that by L for left-sided

heart failure, think of lungs. So as soon as you see left side of heart failure, think of lungs. All pulmonary symptoms like that. That's because, again, left side of the heart connects to the lungs. It's going to back up into the lungs where it came from. Now, right side of the heart, the way I remember that, L, left side it is for lungs. R is going to be rest of the body because it's going to go everywhere else, the rest of the body. So R, so it provides the right side of the heart with blood. It's the inferior vinakeva and the superior vinakeva, which connect to pretty much everything. So these patients are going to have peripheral edema. They may have a pitting edema on the legs, jugular venous distension. It's because the blood from the right atrium is backing up into the jugular

vein. So you take a look at their neck. You'll see this distended jugular vein. Blood can also back up into the GI system, the liver. They may have nausea vomiting, something known as hepatodugular reflux, which is when you push on the liver, you palpate the liver and push into it, it actually causes an increased JVP. So you push on their liver and you look at their neck and all of a sudden you see the venous distended, the jugular vein distended. So those are your clinical manifestations of the right and the left sides. Remember, left side lungs, right side is going to be rest of the body. But again, most of the time these are going to coexist. You're normally going to have both. One other thing I wanted to mention before we move on to diagnosis is something that I don't think is that important,

but it's very easy to remember. So in the case, they ask you one question. Let's just go over really quick because it's it's pretty easy to um to memorize so that's the new york heart association functional class so these are four classes that are used to somewhat guide treatment and different therapies but um you just need to to know a few things to be able to to remember this for the exam so there's four classes there's class one two three and four as you move along in the classes the symptoms get worse so let's knock out class one and four really quick because this is the easiest so class one new year card association functional class. Class one, no symptoms. They have heart failure, but they have no symptoms. No problems at all. Class four, they're going to have symptoms even at rest. So they're

sitting down, they're laying down, they can't breathe, they're having all of these problems. It never gets better. Even when they're resting, they're having symptoms. So that's class one and four. Remember one, no symptoms, four symptoms even at rest. Class three is going to be their only comfortable at rest. They have even the regular daily activities, their ADLs, their activities of daily living, walking around, doing the dishes, minor things that you and me would have no issues with. They're having dyspnea and problems, even with that. They're only comfortable at rest. And then class two is kind of like kind of in between. They're going to have mild symptoms. Most of their ADLs, they're going to be okay. They exert themselves a little bit more. They may start to develop some symptoms. They're not

completely asymptomatic like class one. They just have mild symptoms. So again, Class one, no symptoms, class four symptoms at rest. Class three, only comfortable at rest. And class two is just basically mild symptoms. That's your New York Heart Association class. All right, so let's move on to diagnosis. There's really four diagnostic tests that you need to be familiar with. Those four tests, your best test is going to be an echo.

Your first test, like your initial test, is going to be a chest x-ray. And then a couple other labs like your BNP and then an ECG. So let's start and move our way down the line. So let's do your first test. if they ask you, what's your initial test you'll do for a patient suspecting heart failure? It's going to be a chest x-ray. Now, chest x-ray is not diagnostic for congestive heart failure. It's just not specific enough, but it is a good initial test.

And what are you going to see on a chest x-ray that you need to know to suspect congestive heart failure? Well, there's something known as cephalization of flow. Cephalization of flow. And what this is, is due to all the back flow of blood into the lungs, you have this increased pulmonary pressure, which actually causes the vascular flow to migrate up the lungs and go all the way to the apacees. So because of the cephalization of flow, you're going to have two key findings, those key terms that you need to be familiar with that you need to know cause from the cephalization of flow. That's curly B lines, K-E-R-L-E-Y-B lines, and then butterfly or bowing appearance in chest X-ray. Of course, you're going to have cardiomegaly, plural effusion,

But, you know, they're not going to ask you a question about that. They're going to ask you about these key findings. So what are curly B lines? These are due to lymphatic engorgement or edema at the lung periphery. So at the sides of the lungs and a congestive heart failure patient. And at the sides or the periphery of the lungs on chest x-ray, you're going to see these short little tiny one to two centimeter thin lines. So these one to two centimeters little radio opaque lines that most of the time,

unless you're pretty good at reading chest x-rays, you probably completely miss. but a radiologist will see that and know that it's related to congestive heart failure. Potentially, there's other causes again. And the other thing you should be familiar with is something known as Batwing or Butterfly Appearance. This is better with a visual. So check out my YouTube channel. I'm going to have pictures of all of these when I'm going through the video.

But this is another cause from the accumulation of fluid. But in these cases, the fluid is filling the hylar and the perihilar region of the lungs. And because of the location of the edema, you're going to have this batwing appearance So these white opacities in the lungs, and it looks like the wings of a batwing or a bird or whatever you want to think, a butterfly. So it's just the location of the fluid overloaded in the lungs. So that's the initial test that you'll do. Again, it's not really going to be diagnostic, but it's a good first test to kind of give

you an idea that maybe this patient does have CHF. Okay. So another initial test that you'll do, especially if they're coming into the ER, is something known as BNP. you'll also hear it known as pro bnp, and that is either B-type natuoretic peptide. It also used to be called brain natuoretic peptide, but as the newer name for it is B-type naturetic peptide. So what this is, BNP is this peptide that's secreted by the heart to regulate blood pressure

and fluid in the body, and it's released when you have the ventricle stretching. So that's the body's way of knowing, okay, the ventricles are stretching. overloaded from fluid. They don't exactly know why. So they release this and it's pumped out to kind of regulate and make some changes in the blood pressure and regulate the fluids in the body. Now, BNP is also pumped out during renal failure. It can be decreased in obese patients. So it's not 100% specific, but it's a good rule out test because if you do a BNP in a patient, you suggest has heart failure and it's zero or it's completely normal, less than 100. It's a chance that they don't have heart failure. Generally, the number that you're looking for is a B&P over 100. You should be thinking

there's a pretty good chance that this patient could have heart failure. So BMP over 100, you should be suspecting heart failure, but be aware there's other things that can elevate it as well. So that's another good lab test to do. And it's really good in guiding treatment when you have like decompensated heart failure to see the response to treatment. But you should know that one as well. That's your BNP or pro BNP. Another one that's, it's not a bad test, but it's again, not going to be is your ECG. So it's another good rule out test. And the reason it's a good rule out test is because if this patient has systolic heart failure, so heart failure with reduced ejection fraction, if they have a normal ECG, there's a very small chance that they have heart failure. It's a 98%

predictive value if it's negative that they don't have heart failure. So, but the other than the flip side of that, if they have preserved ejection fraction, a lot of times the ECG is going to be normal. So again, a good rule out test for systolic, but not so much for diastolic. And again, if it's positive, if you do see abnormalities on ECG, doesn't mean it's heart failure. So another good rule out test. But again, not diagnostic. Now, the best test overall is going to be your echo. So your echo is going to measure your ejection fraction. It's going to measure or evaluate the ventricular wall, see if they're thinning, like in systolic heart failure. It's going to be able to get a really good idea of the function of the heart and to diagnose heart failure.

So overall, Echo is going to be your best test. That's the one you really need to be familiar with and know for the exam if they do ask you what your best test is. Okay, so let's move on to treatment. So treatment of systolic heart failure, aka heart failure with reduced ejection fraction. Let's start with some lifestyle interventions. Then we'll hit the meds, which is the highest yield component for the exam. So to start, of course, associated conditions and underlying causes should be appropriately

managed, coronary artery disease, valve disease, associated conditions like hypertension, diabetes should all be properly managed. And then as far as lifestyle modifications, of course, cessation of smoking is essential, abstinence from alcohol consumption or least restricting alcohol, avoidance of obesity, and then restricting sodium intake. Depending on the source, the specific number can vary, so I wouldn't focus too much on a specific number. But up-to-date does suggest less than three grams a day. And in patients with more severe or refractory heart failure, restricted fluid intake to 1.5 to 2 liters a day may be recommended. And of course, daily weight monitoring to detect fluid accumulation is also recommended.

Let's move on to our pharmacologic therapy because this is what you really need to know for the exam. So these meds are the primary therapy for heart failure with reduced ejection fraction. These are the four that you absolutely need to know. These meds not only improves symptoms, but most importantly prolong patient survival. So four meds or classes you need to know in patients with heart failure with reduced ejection fraction. These will typically be combination therapy with one agent from each of the following classes. So these classes are AR&Is, beta blockers, MRAs, and SGLT2 inhibitors. Let's start with our ARNIs or our class, which is our renin angiotensin system inhibitors.

We have a number of options, ARNIs, ACE inhibitors, ARBs, which do you choose? That would be ARNIs, specifically, Sycubatril Valsartin, which is also known as Entresto. That's the brand name, and you'll see this being utilized very often. It's an angiotensin receptor, neprilicin inhibitor. neprilicin inhibitor, which is composed of an ARNB, an inhibitor of neprilicin, which is an enzyme that degrades natuarratic peptides, bradychinin, and other vasoactive peptides. And it's preferred over aces and arbs due to improved efficacy relative to these other classes. And in patients who can't tolerate ARNI therapy or due to cost can't obtain it, aces and ARBs are an option,

but ARNI is the preferred class, so it should be the focus for the exam. Next is going to be beta blockers. Specifically, metoprolol, carvetol, and bisroprolol are the preferred. agents as these beta blockers have demonstrated mortality benefit, unlike the other medications in the beta blockler class, which lack comparable evidence. Next is going to be our mineral cord cord receptor antagonist. That's apleranone and spyrinolactone. Aplernone is usually preferred over spiroinolactone due to a lower risk of endocrine side effects like gynechomasty and impotence.

And then finally we have our SGLT2 inhibitors. These are amazing drugs. We use them in diabetes, KD, and of course heart failure. So our sodium glucose co-transporter to inhibitors like apicaloflozin, which is Farsiga or Empiglofosen, which is Jardians. So those are the four meds or classes you need to know. There is one other med that does have proven mortality benefit. That's hydrolyzine plus nitrate, but this is not a first-line med and really just a backup option

for patients who cannot tolerate an AR&I or an ACE or an R. So I want you to remember these for the exam. This is super important. It's probably the highest yield thing to know for heart failure. So here's a mnemonic to help you remember them. To remember the main meds you need to know for management of heart failure with reduced ejection fraction, aka systolic heart failure, remember, bash the heart to make it beat harder. Bash the heart to make it beat harder helps you remember the meds with proven mortality benefit in systolic heart failure. Bash is spelled B-A-S-H-E.

So let's start with B, that's again going to be our beta blockers, metoprolacarvacarvac. Next, the A-Stanis for ARNI. Our angiotensin receptor blocker and a prolacin inhibitor, which is SACUBITR-VAL-Sartin. ACE inhibitors or ARBs are an eye backup, which also start with A. If an AR&I is not appropriate or affordable. Next is going to be our SGLT2s, our sodium glucose co-transporter two inhibitors, Dapaglozin, epiglozine, epiglozine. Next, hydrolysis plus nitrate.

Again, this is not a first-line med, but it is a medication with proven mortality benefit, so it is appropriate here. Also helps the mnemonic work. So it's good to be aware of, but really we're only going to use this again. If any of our A medications, AR&Is, ACEs or ARBs, were not tolerated or not appropriate for whatever reason, maybe patients with. hypercalemia or kidney dysfunction. So again, just know this med does have proven mortality benefit, but it's not first line.

And then finally, we have our mineralicorticoid receptor antagonists, which are epleranone and spyrnal lactone. And in this case, we're using the E for BASH because Eplurinone is preferred over spyrnalactone due to its more favorable side effect profile. And therefore, it's the one you should know. Okay, again, meds you need to know for systolic heart failure with proven mortality benefit, Bash, BAS, H, the heart to make it beat harder, beta blockers, A-R-N-I's, S-L-T-2, hydrolyzein and eplerone. Know those and you should be good for the exam. Now there are other medications.

These are more for symptomatic relief. So diuretics like furoasamide will be used in patients with persistent volume overload to help eliminate clinical evidence of fluid retention. This obviously plays a large role in patients with acutely decompensated heart failure and the diuretic most commonly used will be furoosomide. And then we have some secondary options. So the secondary options are in patients who cannot tolerate the primary regimen or have residual heart failure symptoms, despite optimal therapy, these are not commonly used, so I don't think you need to memorize them, but just be aware that they do exist. This is going to be Eva-Bradin, Verisagwat, digoxin, hydrolym, plus nitrate that we talked about before. Again, so don't really need to focus too much

on these. These aren't high yield, but these are secondary or backup options if our primary therapy can't be utilized for whatever reason. All right, so treatment of heart failure with preserved ejection fraction or diastolic heart failure is a little different than systolic heart failure and that there is no clear evidence that pharmacologic therapy or other therapies reduce the risk of mortality in these patients. So if you're feeling overwhelmed and maybe you want to skip a section, this would be the one as there are no high-yield meds to know here. In general, you'll treat these patients associated conditions just like you would anyone else, hypertension, aphib, coronary artery disease, etc. You'll suggest dying and exercise, cardiac rehab. And if you want to

just remember one med class, this would probably be it as up-to-date recommends this as initial therapy for most patients. And that's going to be an SGLT to inhale. inhibitor like Empicalflosen or Dapagal-Flozin. This is going to be initial therapy for most patients. So this would be the one if you want to remember one med class. This is the one to know. Second line would be a mineralicorticoid receptor antagonist. So like spyrnalactone or a pleranone. And in this case, there is an additional agent called pheneranone, which is a newer non-steroidal mineralicord-cord-cord receptor antagonist. You're obese patients, we can use GLP1 receptor agonists like somaglite or twozeptide. These meds have shown benefit in patients,

with obesity and heart failure with preserved dejection fraction. And then the patients with volume overload, you'll use diuretics, just like we were talking about before. This is usually going to be a loop diuretic like thurosomide. So bottom line here, if you want to remember one med class for heart failure with preserved dejection fraction, let it be SGLT two inhibitors, but not a lot to know here otherwise, so it wouldn't waste too much time. All right.

And remember one last thing about the treatment. Outside of your pharmacologic treatment, there's some mechanical devices. So as these patients progress with heart failure, once they get to like stage four, the rejection of fractions under 35%. The treatment, in addition to pharmacologic therapy, is actually going to include a left ventricular assist device, which is an implantable device that helps the failing heart to contract with mechanical assistance. They also may have an AICD implanted, which is an automatic implantable cardiovertor defibrillator.

These were patients, again, in the last stages. And ultimately, once they get to stage four, death normally occurs within a year without heart transplant. So once you get to that point, you just kind of use everything you can to preserve life as long as possible. Okay, so that is heart failure. Thank you so much as always. I know I said it in the beginning and I'll say it every time because I do appreciate the comments. It really does make my day.