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NR 603 WK 3 FOCUS QUIZ TOPICS
WEEK 3 QUIZ – CH 116, 188-122, 126 AND 211 Primary care a collaborative practice
Heart Failure (ch 121)
Congestive heart failure (CHF) risks
- HTN - MI, CAD - DM - Metabolic syndrome
- Drug Abuse - PVD - Valvular heart disease. - Cardiomyopathies
CHF typical presentation
- Fatigue - decrease in exercise tolerance - SOB - Cough, rales
- JVD/edema - Palpitations - Anorexia, early satiety
- Wt gain >2 lb in 1 day >5 lb in 1 wk
- AMS (elderly) - S3
NYHA Classification of CHF
* Class I*********Cardiac disease without resulting limitation of physical activity
* Class II*******Slight limitation of physical activity - comfortable at rest, but ordinary physical activity results
in fatigue, palpitation, dyspnea, or anginal pain
* Class III******Marked limitations in physical activity - comfortable at rest, but less than ordinary
physical activity causes fatigue, palpitation, dyspnea, or anginal pain
* Class IV******Inability to carry on any physical activity without discomfort - or symptoms at rest
AHA/ACC 2009 - staging system of heart
HFrEF stands for
- Heart failure with reduced ejection fraction (EF < 40%) - Systolic failure
HFpEF stands for
- Heart failure with preserved ejection fraction - Varying definitions: EF > 40, 45, 50, or 55%. - Diastolic failure
HFmrEF stands for
- Heart failure with mid-range ejection fraction - EF 40-49%
CHF Diagnosis orders
* CXR. * CBC, CMP, UA. * Lipid profile. * TSH
* BNP (B-type natriuretic peptide)
- 200-400 pg/ml - likely moderate CHF - > 400 pg/ml - likely moderate to severe CHF - poorer prognosis
- Not part of routine OP eval
- Useful in acute dyspnea to r/o CHF
* Cardiac enzymes * EKG * Echo/TEE
CHF treatment & management
* Meds - start w at least two
, 2
NR 603 WK 3 FOCUS QUIZ TOPICS
- ACEI * Mainstay of therapy * if K < 5.5
- Beta-blockers * Carvedolol (Coreg)
- Aldosterone antagonists * Aldactone 25-50 mg po daily (target)
- Diuretics - symptom mgmt. * Lasix po or IV * Zaroxolyn (good addition if lasix insufficient)
- Digoxin
- Statin if hx MI
* Referral
CHF treatment & management : ACE targets
- linisopril 20-35 mg daily - enalopril 10-20 mg BID
- captopril 50 mg TID - ramipril 5 mg BID (10 mg daily)
CHF treatment & management : Beta blocker targets
* Carvedilol 25-50 mg BID 50 mg BID if > 85 kg
* Metoprolol 150-200 mg daily
* Bisoprolol 5-10 mg daily 10 mg qd if > 85 kg
**CHF treatment & management : 2016 guidelines**
* ACEI - first line; ARB – second - Level 1A evidence
* ARNI - ARB combined w neprilysin
- Neprilysin degrades natriuretic peptides, bradykinin, adrenomedullin and other vasoactive peptides.
(Eg. valsaran/sacubitril - Entresto - target 97/103 mg BID)
- RCT - reduced composite endpoint of CV death or hospitalization by 20% - Caution - hypotension, renal
insufficiency; angioedema
- Replaces ACE or ARB - stop - minimum 36 hour washout - Use in chronic symptomatic HFrEF (< 40%)
NYHA class II or III
Other management guidelines for CHF
* Risk reduction - HTN, lipids, obesity, DM, tobacco use, known cardiotoxic agents
* Sodium restriction (ideally 1500 mg) * Treatment of sleep disorders/OSA
* Wt loss if morbidly obese * Exercise & cardiac rehab
* Anticoagulation in Afib * Statins only if hx of MI or meet other criteria
* Omega-3 supplementation - 10-20% reduction in risk of fatal/non-fatal CV event in HF
Top 10 challenges of CHF management
* Recognize HF signs & symptoms
* Treat reversible causes - Ischemia, CAD, valve dysfunction, thyroid, A-fib, OSA
* Initiate proven therapies - ACEI & B-blockers
Reach target doses of meds
Distinguish ACE cough
- ACE - dry, hacking, doesn't change with position - CHF - moist, worse with recumbency
* Monitor lytes when starting or changing drug doses
Address nonpharm issues
- NSAIDs promote Na & water retention - ETOH is negative inotrope - CCBs, TZDs
NR 603 WK 3 FOCUS QUIZ TOPICS
WEEK 3 QUIZ – CH 116, 188-122, 126 AND 211 Primary care a collaborative practice
Heart Failure (ch 121)
Congestive heart failure (CHF) risks
- HTN - MI, CAD - DM - Metabolic syndrome
- Drug Abuse - PVD - Valvular heart disease. - Cardiomyopathies
CHF typical presentation
- Fatigue - decrease in exercise tolerance - SOB - Cough, rales
- JVD/edema - Palpitations - Anorexia, early satiety
- Wt gain >2 lb in 1 day >5 lb in 1 wk
- AMS (elderly) - S3
NYHA Classification of CHF
* Class I*********Cardiac disease without resulting limitation of physical activity
* Class II*******Slight limitation of physical activity - comfortable at rest, but ordinary physical activity results
in fatigue, palpitation, dyspnea, or anginal pain
* Class III******Marked limitations in physical activity - comfortable at rest, but less than ordinary
physical activity causes fatigue, palpitation, dyspnea, or anginal pain
* Class IV******Inability to carry on any physical activity without discomfort - or symptoms at rest
AHA/ACC 2009 - staging system of heart
HFrEF stands for
- Heart failure with reduced ejection fraction (EF < 40%) - Systolic failure
HFpEF stands for
- Heart failure with preserved ejection fraction - Varying definitions: EF > 40, 45, 50, or 55%. - Diastolic failure
HFmrEF stands for
- Heart failure with mid-range ejection fraction - EF 40-49%
CHF Diagnosis orders
* CXR. * CBC, CMP, UA. * Lipid profile. * TSH
* BNP (B-type natriuretic peptide)
- 200-400 pg/ml - likely moderate CHF - > 400 pg/ml - likely moderate to severe CHF - poorer prognosis
- Not part of routine OP eval
- Useful in acute dyspnea to r/o CHF
* Cardiac enzymes * EKG * Echo/TEE
CHF treatment & management
* Meds - start w at least two
, 2
NR 603 WK 3 FOCUS QUIZ TOPICS
- ACEI * Mainstay of therapy * if K < 5.5
- Beta-blockers * Carvedolol (Coreg)
- Aldosterone antagonists * Aldactone 25-50 mg po daily (target)
- Diuretics - symptom mgmt. * Lasix po or IV * Zaroxolyn (good addition if lasix insufficient)
- Digoxin
- Statin if hx MI
* Referral
CHF treatment & management : ACE targets
- linisopril 20-35 mg daily - enalopril 10-20 mg BID
- captopril 50 mg TID - ramipril 5 mg BID (10 mg daily)
CHF treatment & management : Beta blocker targets
* Carvedilol 25-50 mg BID 50 mg BID if > 85 kg
* Metoprolol 150-200 mg daily
* Bisoprolol 5-10 mg daily 10 mg qd if > 85 kg
**CHF treatment & management : 2016 guidelines**
* ACEI - first line; ARB – second - Level 1A evidence
* ARNI - ARB combined w neprilysin
- Neprilysin degrades natriuretic peptides, bradykinin, adrenomedullin and other vasoactive peptides.
(Eg. valsaran/sacubitril - Entresto - target 97/103 mg BID)
- RCT - reduced composite endpoint of CV death or hospitalization by 20% - Caution - hypotension, renal
insufficiency; angioedema
- Replaces ACE or ARB - stop - minimum 36 hour washout - Use in chronic symptomatic HFrEF (< 40%)
NYHA class II or III
Other management guidelines for CHF
* Risk reduction - HTN, lipids, obesity, DM, tobacco use, known cardiotoxic agents
* Sodium restriction (ideally 1500 mg) * Treatment of sleep disorders/OSA
* Wt loss if morbidly obese * Exercise & cardiac rehab
* Anticoagulation in Afib * Statins only if hx of MI or meet other criteria
* Omega-3 supplementation - 10-20% reduction in risk of fatal/non-fatal CV event in HF
Top 10 challenges of CHF management
* Recognize HF signs & symptoms
* Treat reversible causes - Ischemia, CAD, valve dysfunction, thyroid, A-fib, OSA
* Initiate proven therapies - ACEI & B-blockers
Reach target doses of meds
Distinguish ACE cough
- ACE - dry, hacking, doesn't change with position - CHF - moist, worse with recumbency
* Monitor lytes when starting or changing drug doses
Address nonpharm issues
- NSAIDs promote Na & water retention - ETOH is negative inotrope - CCBs, TZDs
