心衰问答专业知识宣贯.pptx

单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Question 1,Ten year survival after the onset of heart failure:,80-90%,60-79%,40-59%,20-39%,Under 20%,Prognosis in Heart Failure,Men over 45 years of Age,Surviving(%),Years from Diagnosis,Prognosis in Heart Failure,Women over 45 years of Age,Surviving(%),Years from Diagnosis,Question 2,Potential underlying causes of heart failure include:,Coronary artery disease,Hemochromatosis,Mitral regurgitation,Ventricular septal defect,all of the above,Heart Failure,The Final Common Pathway,ischemic disease,valvular disease,cardiomyopathy,pericardial disease,hypertension,congenital,Heart,Failure,Question 3,The pathophysiology of heart failure can best be described as:,a failure of protective mechanisms,activation of harmful pathways,introduction of pathogenic influences,inappropriate activation of normal mechanisms,all of the above,Physiologic Response to Heart Failure,LV Dysfunction,Renal-Adrenal,Carotid and LA,Baroreceptors,Renin-,Angiotensin,Aldosterone,Sympathetic,Output,Sodium,and fluid,retention,tachycardia,vasoconstriction,Question 4,Physiologic effects of Angiotensin II include:,vasoconstriction,activation of thirst,sodium retention,aldosterone release,all of the above,Renin-Angiotensin System,Renin,Angiotensin I,Angiotensin II,decreased,renal perfusion,decreased,Na delivery,sympathetic,activity,AVP Release,vasoconstriction,aldosterone,Increased thirst,NE release,sodium retention,decreased GFR,Question 5,The following is a feature of the heart failure state:,reduced circulating catecholamines,increased left ventricular end diastolic pressure,reduced plasma volume,increased renal sodium excretion,reduced pulmonary capillary wedge pressure,Compensatory Mechanisms in Heart Failure,increased preload,increased sympathetic tone,increased circulating catecholamines,increased Renin-angiotensin-aldosterone,increased vasopressin,increased atrial natriuretic factor,Question 6,Patients with early heart failure typically present with:,No symptoms,Dyspnea on exertion only,Dyspnea with minimal activity,Dyspnea at rest,Acute respiratory distress,Heart Failure,Clinical Manifestations,Symptoms,dyspnea,fatigue,exertional limitation,weight gain,poor appetite,cough,Signs,tachycardia,tachypnea,edema,jugular venous distension,pulmonary rales,pleural effusion,hepato/splenomegaly,ascites,cardiomegaly,S3 gallop,Dyspnea,Clinical Presentations,exertional shortness of breath,cough,orthopnea,paroxyxmal nocturnal dyspnea,severe respiratory distress,respiratory failure,NYHA Functional Classification,Class I,:,patients with cardiac disease but no limitation of physical activity,Class II,:,ordinary activity causes fatigue,palpitations,dyspnea or anginal pain,Class III,:,less than ordinary activity causes fatigue,palpitations,dyspnea or angina,Class IV,:,symptoms even at rest,Question 7,Edema in heart failure takes the following form:,Peripheral edema,Sacral edema,Abdominal distention,anasarca,Any of the above,Edema,Clinical Presentations,where-peripheral,sacral,generalized,objective weight gain,bloating,abdominal distension,Question 8,Signs of right heart failure include all the following,except,:,Peripheral edema,Pulmonary rales,Elevated jugular veins,hepatomegaly,Pleural effusions,Left vs Right Heart Failure,Left Heart Failure,pulmonary congestion,Right Heart Failure,peripheral edema,sacral edema,elevated JVP,ascites,hepatomegaly,splenomegaly,pleural effusion,Question 9,A 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 veins,Dyspnea with stair climbing,increased heart size on chest X ray and heart rate of 105,Rest dyspnea,interstitial edema on chest X ray,and elevated jugular veins,Orthopnea,flow redistribution on chest X Ray,and crackles in lung bases,PND,bilateral pleural effusions and crackles in lung bases,Criteria for Diagnosis of CHF,HISTORY,Points,rest dyspnea4,orthopnea4,PND3,dyspnea walking on level2,dyspnea on climbing1,CHEST X-Ray,alveolar pulmonary edema4,interstitial pulm edema3,bilateral pleural effusion3,CT ratio 0.503,flow redistribution2,PHYSICAL,Points,HR 91-1101,HR 1102,JVP 6 cm2,JVP 6 cm&hepatom3,lung crackles in base1,lung crackles above base2,wheezing3,S33,8-12,points-definite CHF,5-7 points -possible CHF,5 points -unlikely CHF,Question 10,All the following medications can precipitate heart failure in susceptible patient,except,:,metoprolol,spironolactone,procainamide,diltiazem,rosiglitazone,Precipitating Causes of Heart Failure,1.,ischemia,2.,change in diet,drugs or both,3.,increased emotional or physical stress,4.,cardiac arrhythmias(eg.atrial fib),5.,infection,6.,concurrent illness,7.,uncontrolled hypertension,8.,New high output state(anemia,thyroid),9.,pulmonary embolism,10.,Mechanical disruption(sudden MR,VSD,AR),Question 11,The following investigations should always be carried out in patient presenting with heart failure,except,:,Renal function tests,A ventilation-perfusion scan,Blood counts,Electrocardiogram,Echocardiogram,Investigations for Heart Failure,EKG,evidence of ischemia,infarction,LVH,RVH,rhythm analysis,Chest X-Ray,cardiac size,evidence of pulmonary vascularity,Blood work,CBC,renal function,electrolytes,Assessment of LV Function,Question 12,Patient 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 this patients heart failure is:,Diastolic dysfunction,Mitral valve disruption,Pulmonary embolism,Dilated cardiomyopathy,Ischemic heart disease,Heart Failure with Normal LV systolic function between symptomatic episodes,ischemia,sudden increase in myocardial demands,diastolic LV dysfunction,Question 13,The following mechanisms contribute to myocardial dysfunction in heart failure patients:,Increased circulating epinephrine,Increased circulating norepinephrine,Increased aldosterone production,Increased angiotensin production,all of the above,Rationale for Treatment of Heart Failure,LV dysfunction,sympathetic,activation,Renin-,angiotensin,Adrenal,stimulation,epinephrine,norepinephrine,angiotensin I,aldosterone,angiotensin II,Question 14,All of the following have been shown to improve prognosis in patients with heart failure,except,:,digoxin,carvedilol,enalapril,metoprolol,ramipril,Medical Management of Heart Failure,Drugs that improve symptoms,furosemide,thiazide diuretics,spironolactone,digoxin,ACE Inhibitors,beta blockers,aldosterone antagonists,Drugs that improve prognosis,ACE inhibitors,beta blockers,spironolactone*,Rationale for Treatment of Heart Failure,LV dysfunction,sympathetic,activation,Renin-,angiotensin,Adrenal,stimulation,epinephrine,norepinephrine,angiotensin I,aldosterone,angiotensin II,BABs,ACEIs,ARBs,spironolactone,Beta Blocker Trials,Mortality per year,Enalapril vs Placebo in Symptomatic CHF,CONSENSUS,Probability of Death,Months,Question 15,The following are all adverse effects of beta blockers,except,:,bronchospasm,bradycardia,hypotension,depression,anxiety,Beta Blockers,Adverse Effects,excessive fatigue,bradycardia,heart block,hypotension,reactive airways,mood disturbancesdepression,intermittent claudication,impotence,Beta Blockers in Heart Failure,Practical Tips,start 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 more,avoid in patients with bronchospasm or advanced heart block without pacemaker,improvement symptomatically and objectively may be slow,avoid abrupt withdrawl,Question 16,The following are all adverse effects of ACE Inhibitors,except,:,Renal dysfunction,bradycardia,hypotension,cough,hyperkalemia,ACE Inhibitors,Adverse Effects,hypotension,renal dysfunction,hyperkalemia,cough,skin rash,taste disturbance,angioneurotic edema,Question 17,Current evidence supports the following approach with respect to digoxin:,Should be used in all patients with LV dysfunction,Should be used chronically in patients with controlled heart failure to improve symptom status,Should be used chronically in patients with controlled heart failure to improve prognosis,Should be used acutely in patients with new onset heart failure,Digoxin has no role in heart failure patients,Digitalis and other Inotropic Drugs,Recommendations,to improve symptoms and reduce hospitalizations in patients in sinus rhythm who remain symptomatic on ACEIs,patients in atrial fibrillation and LV failure,parenteral use of dopaminergic agents or phosphodiesterase inhibitors not recommended routinely,but may be used in select patients with intractable heart failure,Question 18,Current evidence supports the following approach with respect to Angiotensin receptor antagonists:,Should be used in all patients with LV dysfunction,Should be used chronically in patients with controlled heart failure to improve symptom status,Should be used chronically in patients with controlled heart failure to improve prognosisShould be used in patients unable to tolerate ACE Inhibitors,Have no role in heart failure patients,Angiotensin Receptor Blockers,Indications,may be considered for patients unable to tolerate ACEIs,Angiotensin Receptor Blockers,Adverse Effects,hypotension,renal dysfunction,hyperkalemia,Question 19,Current evidence supports the following approach with respect to Aldosterone antagonists:,Should be used in all patients with LV dysfunction,Should be used chronically in patients with controlled heart failure to improve symptom status,Should be used chronically in patients with controlled heart failure to improve prognosis,Should be used in patients with severe heart failure to improve symptoms,Should be used in patients with severe heart failure to improve symptoms and prognosis,Aldosterone Antagonists in Heart Failure,Evidence,RALES trial,1663 patients with class III-IV heart failure already on ACEI randomized to spironolactone(25 mg od)vs placebo,after 2 years,30%reduction in mortality in treatment group,Aldosterone Antagonists in Heart Failure,Indications,Patients with severe symptomatic heart failure who are already on standard medications,Question 20,Current evidence supports the following approach with respect to diuretics:,Should be used in all patients with LV dysfunction,Should be used only in patients with active heart failure,Should be used all patients who have had symptomatic heart failure to prevent recurrences,Should be used in all patients with severe LV dysfunction,Have no role in heart failure patients,Diuretics in Heart Failure,very useful for management of acute congestive state,produce rapid symptom relief,have no prognostic advantage in stable patients,Diuretics in Heart Failure,Agents Used,furosemide,hydrochlorthiazide,metolazone,Question 21,The following are all adverse effects of furosemide,except,:,renal dysfunction,skin rash,hypotension,hyponatremia,hyperkalemia,Diuretics in Heart Failure,Adverse Effects,electrolyte disturbances(,K,Na),hypotension,renal dysfunction,rash,ototoxicity,(ethacrynic acid,furosemide),Question 22,The following are all options to consider in patients with highly symptomatic and refractory heart failure,except,:,revascularization,resynchronization therapy,cardiac transplantation,plasmapheresis,dialysis,Patients with:,hypertension,CAD,DM,risk for CMP,Patients with:,prior MI,LV systolic,dysfunction,asymptomatic,valve disease,Patients with:,known structural,heart disease,SOB,fatigue,exercise,tolerance,Patients with:,marked symptoms despite full,therapy,Therapy,treat RFs,encourage,exercise,discourage,alcohol,Therapy,all for Stage A,ACEIs,BABs,Therapy,all for Stages,A and B,diruetics,digoxin,dietary,restrictions,Therapy,all for ABC,assist devices,transplantation,Structural heart disease,Symptoms of Heart Failure,Refractory Symptoms,STAGE A,STAGE B,STAGE C,STAGE D,At risk,Question 23,The following all support the diagnosis of acute pericarditis,except,:,typical chest discomfort,ST elevation on EKG,history of a preceding viral illness,S4 gallop,pericardial friction rub,Acute Pericarditis,Diagnostic Criteria,chest pain,pericardial friction rub,EKG changes,Question 24,The earliest EKG changes seen in acute pericarditis:,ST segment depression,ST segment elevation,hyperacute T waves,T wave depression,PR depression,EKG in Acute Pericarditis,1.,Diffuse ST segment elevation,(except aVR and V1)+PR segment depression,2.,ST normalizes,T waves flatten,3.,T waves invert where STs were elevated,4.,Return to normal pattern,Question 25,Pericardial tamponade should be suspected in the following situations:,enlarged heart shadow on chest X ray,unexplained hypotension,unexplained severe dyspnea,exaggerated inspiratory decline in BP,all of the above,Pericardial Tamponade,Physical Examination Findings,hypotension,tachycardia,tachypnea,distant heart sounds,elevated JVP,pulsus paradoxus,Question 26,Causes of pericardial effusions include all of the following,except,:,hypertensive crisis,breast cancer,myocarditis,lymphoma,renal failure,Pericarditis-,causes,idiopathic,infectious(viral,bacterial,TB),post MI(acute,Dresslers syndrome),neoplastic disease,uremia,radiation,autoimmune disease,drugs,trauma,dissecting aortic aneurysm,myxedema,chylopericardium,Question 27,Constrictive pericarditis should be included in the differential diagnosis of:,acute ischemic syndrome,right sided heart failure,severe unexplained chest pain,acute respiratory failure,acute renal failure,Constrictive Pericarditis,Differential Diagnosis,right heart failure,hepatic failure,renal failure,restrictive cardiomyopathy,Question 28,The most common site of infection in patients with Infectious Endocaridits:,Aortic valve,Mitral valve,Tricuspid valve,Pulmonic valve,Endocardial surface of left ventricle,Sites of Infection,Question 29,The most common infecting organism in patients with right sided endocarditis:,Staph epidermidis,Staph aureus,Strep viridans,Strep faecalis,Enterococci,Infective Endocarditis,Microorganisms Responsible,Question 30,Underlying predispositions to the development of Infectious Endocarditis include:,Diabetes mellitus,Old age,Intravenous drug abuse,History of rheumatic fever,All of the above,Predisposing Conditions,rheumatic heart disease,congenital heart disease,mitral valve prolapse,degenerative heart disease,parenteral drug abuse,Diabetes mellitus,old age,