Dosages of 25 mg once daily or less are recommended, and blood chemistry values should be checked at regular intervals (eg, at 1, 4, 8, and 12 weeks following initiation). Sciences, Culinary Arts and Personal A schedule for up-titration of ACE inhibitors has never been clearly defined, but increasing the dosage on a weekly basis is reasonable. This guideline covers diagnosing and managing acute heart failure or possible acute heart failure in people aged 18 and over. Patients who undergo cardiac resynchronization pacing therapy (so-called biventricular pacing) with synchro- nized pacing via right ventricular and coronary sinus leads may show significant hemodynamic and symptomatic improvement.21 Implantable cardioverter defibrillators (ICDs) are often used in association with biventricular pacing. He had a previous 90% LAD blockage and 50% […] 1. Publication Committee for the VMAC (Vasodilatation in the Management of Acute CHF) Investigators. The past several years have witnessedimportant advances in the evaluationand management of chronic heart failure(HF). 9ICDs have evolved as an important treatment modality for primary and secondary prevention of sudden cardiac death (especially when chronic HF is attributable to ischemia). Consider a hydralazine-nitrate combination in patients with this potentially life-threatening side effect. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. Fun Trivia. Which of the following conditions can cause congestive heart failure? © 2020 MJH Life Sciences™ and Patient Care Online. 2BNP belongs to a family of naturally occurring hormones that are synthesized in the cardiac ventricles. Before admitted to the hospital, patient was taking frusemide 40mg, aspirin 150mg, metoprolol 50mg, amlodipine 10mg, and simvastatin 40mg for his hypertension and heart failure. shortness-of-breath scale, and the Minnesota Living with Heart Failure Questionnaire were applied. In cases of acute exacerbation of HF or acute renal insufficiency, temporary withdrawal of these drugs may be necessary. Kuck KH, Cappato R, Siebels J, Ruppel R. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: the Cardiac Arrest Study Hamburg (CASH). Generally, patients with severe rash or intolerable cough resulting from ACE inhibitor use (about 5% to 8%) should be switched to an ARB. An ECG can assess underlying rhythm or conduction abnormalities and detect evidence of myocardial infarction (MI). Some caveats. Patients enrolled in the study also were very closely monitored to ensure a relatively low rate of renal insufficiency and hyperkalemia. Heart Failure Heart failure (HF) often called congestive heart failure (CHF) is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body. Assessing … Biventricular pacing for heart failure. Nevertheless, these agents remain relatively underused, in part because they can be difficult to titrate. Nesiritide. Contact us by phone at (877) 266-4919, or by mail at 100 View Street #202, Mountain View, CA 94041. Is anticoagulation routinely recommended in patients with advanced chronic HF? Common conditions that may falsely elevate plasma BNP levels include age, significant renal dysfunction, and surgery (especially cardiothoracic procedures).Significance of BNP levels. We also advise patients to adjust their diuretic dosages in order to maintain their dry weight, much as patients with diabetes can maintain glycemic control by adjusting insulin dosages. Maintaining a regular diet and exercise program. It is an alternate term to describe high blood pressure caused by diabetes. The absence of clinical HF is not a compelling reason to stop up-titration, nor is mild to moderate renal insufficiency (serum creatinine levels of less than 3 mg/dL). For example, the Assessment of Treatment With Lisinopril and Survival (ATLAS) trial showed only a slight improvement in a composite end point of mortality and hospital admissions when high doses of lisinopril (32.5 to 35 mg/d) were compared with low doses (2.5 to 5 mg/d).11 The usual practice is to titrate the ACE inhibitor first and then start the β-blocker. The past several years have witnessed important advances in the evaluation and management of chronic heart failure (HF). What are the key elements in an overall management program? Pitt B, Zannad F, Remme WJ, et al, for the Randomized Aldactone Evaluation Study Investigators. Buxton AE, Lee KL, Fisher JD, et al, for the Multicenter Unsustained Tachycardia Trial Investigators. Cheng V, Kazanagra R, Garcia A, et al. to them later with the "Go To First Skipped Question" button. The recently approved point-of-care BNP assay enables clinicians to measure plasma BNP levels at the bedside. Choose your answers to the questions and click 'Next' to see the next set of questions. Collective experience has suggested that the most important determinant of good response to pacing therapy remains the “quality” of the resynchronization- that is, the optimization of lead placement site as well as timing of interventricular and atrioventricular delays. Carvedilol, perhaps the most extensively studied, has the greatest hypotensive effect when therapy is initiated because of concomitant blockade of α1-adrenergic receptors.12 Metoprolol succinate was tolerated as well as placebo in the Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF).13 However, generic metoprolol tartrate should not be substituted for the proprietary agent, because its efficacy has not yet been demonstrated. 3. Regarding the pathophysiology of heart failure: Myocardial failure leads to an increase in circulating volume. Cohn JN, Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. A nurse is performing an initial assessment on a client who is being admitted to the hospital for exacerbation of heart failure. Only after careful synthesis of information from this workup can a decision be made about which diagnostic tests to perform.Textbooks usually provide an exhaustive list of tests for initial assessment. Pitt B, Poole-Wilson PA, Segal R, et al. Earn Transferable Credit & Get your Degree. If a candidate leaves the room before the end of the exam, s/he will not be authorised the re-enter the room nor acces… 3Consider both classes of drugs for every patient with chronic HF, regardless of disease severity.1 Tens of thousands of patients with chronic systolic HF have been treated with these agents in clinical studies worldwide; results show a remarkable improvement in morbidity and mortality. Comorbidities such as lipid abnormalities and suboptimal blood pressure or glycemic control must be optimally managed. Are all ACE inhibitors and β-blockers equivalent? Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. An update on nesiritide for treatment of decompensated heart failure. Rheumatic fever However, preliminary studies did not show improvement in a subset of these patients. Fainting or syncope occurs because the brain does not temporarily get enough blood. Plasma levels of BNP often correspond to the severity of underlying cardiac dysfunction and can provide relatively reliable prognostic information, thus making BNP measurement a potential “white cell count” for chronic HF.3A bedside BNP assay. ACE inhibitors should therefore remain first-line agents for chronic HF unless contraindicated. It is often described as shortness of breath, breathlessness, difficulty in breathing, etc.During the early stages of heart failure, dyspnea usually occurs only during physical activity, but later dyspnea could occur even at rest. This observation warrants further testing (eg, in the upcoming Valsartan in Acute Myocardial Infarction [VALIANT] trial). It is the buildup of fat and other plaques within the heart. Complaints of tolerance reduction due to dyspnea and/or fatigue on exertion. awake after 2 hrs. It is still unclear which patients will benefit from resynchronization therapy. Which of the following actions can a patient take to make significant progress toward avoiding congestive heart failure? Drugs such as β-blockersand spironolactone have been shownto reduce morbidity and mortality, andstrategies that employ new devices,such as pacing and defibrillator therapy,are evolving. Coronary Artery Disease 4. Moss AJ, Zareba W, Hall WJ, et al. This means the body is congested with fluid. Pulmonary edema 9. 7It was once thought that oral anticoagulation was warranted because of the heightened risk of clot formation in the failing myocardium, but this therapy is not advocated in the latest guidelines.1 Some experts suggest a benefit for patients at high risk, such as those with a history of atrial fibrillation, mitral regurgitation, stroke, LV thrombus, or large anterior MI.18 A large-scale clinical study (the Warfarin and Antiplatelet Therapy in Chronic Heart Failure [WATCH] trial) is now under way to determine whether anticoagulation with warfarin, clopidogrel, or aspirin will reduce morbidity and mortality in patients with chronic HF. Based on your results, we'll create a customized Test Prep Plan just for you! 2. Extreme sensitivity to changes in temperature, Patients with heart disease can have fluid accumulate in the lungs. Weight loss, increase in appetite, swelling, Shortness of breath only after activity, weight gain, increased energy. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomized trial-the Losartan Heart Failure Survival Study ELITE II. Sometimes these agents can be initiated together (especially when β-blockers are likely to be beneficial, as in a hypertensive patient with tachycardia). Early patient education is necessary to foster an understanding of the importance of compliance with medication and dietary regimens. Packer M, Poole-Wilson PA, Armstrong PW, et al, for the ATLAS Study Group. However, cost and personnel considerations will be major obstacles to more widespread use. All HF-CAT scales demonstrated good construct validity through high correlations with the corresponding SF-36 Health Survey physical function (r 0.87), vitality occures with heart failure. The general rule is to ascertain whether there are any correctable causes of HF, as well as to determine comorbidities and complications (from the disease itself as well as from drug therapy for other conditions). Hunt SA, Baker DW, Chin MH, et al. This quiz will help you understand what it is and how to avoid it. When is ICD therapy recommended? A lack of consensus still exists regarding the need for routine coronary angiography in the initial assessment of chronic HF.1 Nevertheless, documentation of the presence or absence of coronary artery disease is very useful, because myocardial ischemia is an underlying cause of chronic HF in almost two thirds of patients. You will also ask about their other medical concerns later, but you need to know their primary one first. Captopril is usually a good choice in the inpatient setting because it has a short half-life and can be up-titrated easily to target dosages before a switch is made to longer-acting formulations to enhance compliance. Spironolactone can be added to the regimen of patients with advanced HF-for example, following recurrent HF exacerbation despite optimal ACE inhibitor (and β-blocker) therapy. To date, there has been only 1 large-scale clinical study of spironolactone (the Randomized Aldactone Evaluation Study [RALES]).17 It demonstrated a 35% reduction in morbidity and mortality in patients with advanced HF (LVEF, 35% or less; New York Heart Association [NYHA] class III or IV) randomly assigned to spironolactone, 25 mg/d. Which of the following statements describes edema? Even though concerns regarding concomitant use of ACE inhibitors and aspirin have emerged from several post-hoc analyses and small-scale clinical trials, many experts believe that this drug combination poses minimal risk.19 However, aspirin may offset some of the benefits of ACE inhibitors.20Until definitive evidence dictates otherwise, aspirin should not be withheld from patients with ischemic cardiomyopathy. Three β-blockers-carvedilol, metoprolol succinate, and bisoprolol- are currently approved for the treatment of chronic HF. Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. Our recommendation is thus to use those ACE inhibitors studied in the large clinical trials because of their proven efficacy (see Table 2). This is captured by adding a finding with a valid LOINC code using the Checklist widget in a note. A few good presenting problem questions are: 1. What is the role of spironolactone? What is the estimated annual cost of heart failure in the United States? Packer M, Bristow MR, Cohn JN, et al, for the US Carvedilol Heart Failure Study Group. Patient does not allergic to any medication and he does not take any traditional medicines at home. 10 key steps to assess volume status in patients with congestive heart failure are discussed including evaluating jugular venous pressure (JVP), edema, chest X-ray, echocardiography and BNP levels. Patients with heart failure can have fluid accumulate in the lungs. Dyspnea is one of the common symptoms of heart failure and refers to the awareness of discomfort while breathing. It is best to establish initially the level of aggressiveness and the cost-effectiveness of the pharmacotherapeutic protocol and to determine whether the focus of therapy is to improve survival, relieve symptoms, or both. Connolly SJ, Gent M, Roberts RS, et al. The past several years have witnessedimportant advances in the evaluationand management of chronic heart failure(HF). Clinical data and the results of randomized trials suggest that appropriate candidates may be those with moderate to severe chronic systolic HF (LVEF, less than 35%; NYHA class III or IV) and those with ventricular dyssynchrony manifested as a wide QRS of more than 120 to 150 milliseconds (especially with a left bundle branch block pattern) despite optimal drug therapy. Heart Failure 7. A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study. Guidelines. 10. This effect was noted in 10% of men in the RALES trial. All rights reserved. An accurate assessment still relies on such basic clinical skills as a comprehensive history taking and physical examination. Premium members get access to this practice exam along with our entire library of lessons taught by subject matter experts. 5No; these 2 classes are not equivalent. Effect of nesiritide versus dobutamine on short-term outcomes in the treatment of patients with acutely decompensated heart failure. Spend your time wisely! Read each question carefully and choose the best answer. Lying down inc volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Overview Heart Failure – Case Study Mr. Jones, a 69-year old male, presents to the Emergency Department (ED) after visiting his primary physician complaining of general fatigue for 4 days, shortness of breath, and abdominal discomfort. The diagnosing and assessing chronic heart failure path for the chronic heart failure pathway. The condition is diagnosed with echocardiography and blood tests. Angioedema has also occurred with both agents, especially in African Americans. A similar incidence of renal insufficiency (serum creatinine greater than 3 mg/dL) and hyperkalemia (serum potassium greater than 6 mEq/dL) has been observed with ARBs and ACE inhibitors. Another name for shortness of breath is: Which of the following defines congestive heart failure? 2 Echocardiography frequently demonstrates some mitral regurgitation and a thick left ventricle with a small LV cavity. The Nurses’ Guide to Commonly Asked Questions About Heart Failure The University of Ottawa Heart Institute 2 Changes in the health care environment have resulted in shorter lengths of stay for patients, making it difficult for them to receive necessary information to speed their recovery. 4. Details You are to develop a concept map for the topic systolic heart failure and answer three questions related to an acute exacerbation systolic heart failure. 1 . A patient in the CCU with chronic heart failure is prescribed an ACE inhibitor. Koglin J, Pehlivanli S, Schwaiblmair M, et al. Guidelines for patient selection for nesiritide therapy are still evolving. Adjustments to diuretic dosage (eg, an increase to reduce fluid retention) and ACE inhibitor dosages (eg, a reduction to maintain adequate blood pressure) are often required during β-blocker up-titration when symptoms of light-headedness or fluid retention develop. There is still no generally accepted definition of this condition; patients typically are elderly women, often overweight and with a long history of systemic hypertension and/or diabetes mellitus with associated LV hypertrophy. We asked doctors to explain what heart failure actually is (hint: it's probably not what you're imagining), the signs to watch for, and most important, what it means to live with this chronic conditio Consensus statement on indications, guidelines for use, and recommendations for follow-up of implantable cardioverter defibrillators. Which of the following conditions significantly increases the risk of developing congestive heart failure? Click it to see your results. Head-to-head studies will probably not be done, so a definitive answer is unlikely. Graham SP. Choose your answers to the questions and click 'Next' to see the next set of questions. One common error is to initiate the drug without close follow- up of clinical and renal function. Use your “cash” card to insure appropriate assessment of all patients. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Are beneficial effects of angiotensin-converting enzyme inhibitors attenuated by aspirin in patients with heart failure? Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. The assay, which uses an arbi- trary cut-off of 100 pg/mL, is highly sensitive and specific in determining whether cardiac dysfunction is the cause of dyspnea.4 If a patient presents with dyspnea and low BNP levels, it is unlikely that cardiac causes are involved. The rationale for obtaining a thyroid function test, general chemistry panel, and complete blood cell count is that they are inexpensive and may provide valuable information. Further studies on long-term morbidity and mortality are needed before this expensive (more than $30,000) form of therapy can be more routinely recommended. Hobbs RE, Mills RM, Young JB. Hall D. Controversies in heart failure. Ponikowski P, Voors AA, Anker SD, et al. Angina 2. Many experts initiate β-blockers before ACE inhibitors are fully maximized. Small mechanistic studies have suggested similar improvement in surrogate end points (eg, LV remodeling), but survival data are not comparable so far.14 Two large-scale randomized controlled trials of losar- tan (Losartan Heart Failure Survival Study [ELITE II]15) and valsartan (Valsartan Heart Failure Trial [Val- HeFT]16) failed to show that these agents reduced mortality more than standard doses of ACE inhibitors. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. Services, Heart Disease & Heart Failure Chapter Exam. back B-type natriuretic peptide (BNP) has recently been used as a screening tool for identifying structural heart disease in the general population. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995Guidelines for the Evaluation and Management of Heart Failure). You can skip questions if you would like and come back to them later with the `` to! Elkayam U very closely monitored to ensure a relatively low rate of renal,. And Pacing Group defibrillator study ( CIDS ): a randomized trial of the following can. 2020 MJH Life Sciences™ and patient Care Online Living with heart failure have more nitroglycerin. 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2020 heart failure assessment questions