Harrison's Hour - Heart Failure

The correct answer is JVP. JVP stands for Jugular Venous Pressure, which is a measurement used to estimate the pressure in the right atrium of the heart. By assessing the height of the jugular venous pulsations, healthcare professionals can determine the pressure in the right atrium, which can be indicative of various cardiovascular conditions. Therefore, JVP provides an estimation of right atrial pressure.

The first line of therapy in volume overload with congestion is Furosemide. Furosemide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the loop of Henle in the kidneys, leading to increased urine output and decreased fluid volume. It is commonly used to treat conditions such as congestive heart failure and edema. Spironolactone and Eplerenone are potassium-sparing diuretics that are typically used as adjunctive therapy in patients who are at risk for hypokalemia. Hydrochlorothiazide is a thiazide diuretic that is mainly used for hypertension and not typically the first choice for volume overload with congestion.

Ventricular remodeling refers to the changes in the left ventricular (LV) mass, volume, shape, and composition that occur after cardiac injury and/or abnormal hemodynamic loading conditions. This process involves structural changes in the heart, such as hypertrophy (increase in muscle mass), dilation (increase in chamber size), and fibrosis (scarring). These changes can lead to impaired cardiac function and contribute to the progression of heart failure. Therefore, ventricular remodeling is the most appropriate explanation for the given condition.

The correct answer is b. NYHA II. This classification is based on the New York Heart Association (NYHA) functional classification system for heart failure. NYHA II represents mild limitation of physical activity, with symptoms occurring during ordinary activity. NYHA I represents no limitation of physical activity, NYHA III represents marked limitation of physical activity, and NYHA IV represents symptoms at rest.

The measurement of B-type natriuretic peptide (BNP) is useful for establishing prognosis or disease severity in chronic HF and can be useful to achieve optimal dosing of medical therapy in select clinically euvolemic patients. BNP is a hormone that is released by the heart in response to increased pressure and stretching of the heart muscle. Elevated levels of BNP indicate increased stress on the heart and can help in determining the severity of heart failure. Monitoring BNP levels can help in adjusting medication dosages to achieve optimal treatment outcomes.

Digoxin is the correct answer because it is a drug that exerts a mild inotropic effect, meaning it increases the force of contraction of the heart. It also attenuates carotid sinus baroreceptor activity, which helps to decrease the sensitivity of the baroreceptors and lower blood pressure. Additionally, digoxin has sympathoinhibitory effects, meaning it inhibits sympathetic nervous system activity. Furosemide is a diuretic, enalapril is an ACE inhibitor, and carvedilol is a beta blocker, none of which have the same effects as digoxin.

Acute decompensated heart failure is the correct answer because it accurately describes the heterogenous clinical syndrome that leads to the need for hospitalization. This syndrome is characterized by a combination of decreased cardiac performance, renal dysfunction, and alteration in vascular compliance. The term "acute decompensated" indicates that the heart failure has worsened suddenly, leading to the need for immediate medical intervention.

Dilated cardiomyopathy is a condition characterized by the enlargement of the heart chambers, leading to weakened and stretched heart muscles. This can result in decreased contractility and impaired ejection fraction (EF), which is the percentage of blood pumped out of the heart with each contraction. Therefore, dilated cardiomyopathy can cause depressed EF in heart failure. Hypertrophic cardiomyopathy is characterized by thickened heart muscles but does not typically cause depressed EF. Restrictive cardiomyopathy involves stiffening of the heart muscles, which can also impair EF. Thyrotoxicosis, a condition caused by excessive thyroid hormone production, can lead to increased heart rate and contractility, which would not cause depressed EF.

Orthopnea is a clinical manifestation of heart failure where there is difficulty breathing while lying flat. This occurs because when a person lies down, fluid that has accumulated in the splanchnic circulation and lower extremities is redistributed into the central circulation, including the lungs. This fluid accumulation in the lungs leads to shortness of breath and the need to sit or stand upright to alleviate the symptoms.

Patients with ischemic cardiomyopathy and multivessel coronary artery disease are often recommended to undergo coronary artery bypass grafting (CABG). This procedure involves taking a healthy blood vessel from another part of the body, usually the leg or chest, and using it to bypass the blocked or narrowed coronary arteries. By doing so, blood flow to the heart muscle is restored, reducing symptoms and improving overall heart function. CABG is considered a more effective treatment option compared to coronary angioplasty or optimal medical therapy alone in these patients.

Cardiac cachexia refers to the severe muscle wasting and weight loss that occurs in patients with advanced heart failure. It is a strong predictor of poor prognosis and is associated with increased mortality rates. The presence of cardiac cachexia indicates a more advanced stage of heart failure and suggests that the disease has progressed to a point where the body is unable to maintain adequate nutrition and muscle mass. Therefore, the presence of cardiac cachexia in a patient with heart failure indicates a poor overall prognosis.

Ventricular arrhythmia is the cause of sudden cardiac death (SCD) in approximately half of patients with heart failure (HF), especially in HFrEF (heart failure with reduced ejection fraction) patients in the early stages of the disease. Ventricular arrhythmias are abnormal heart rhythms that originate in the ventricles, the lower chambers of the heart. These arrhythmias can disrupt the normal electrical activity of the heart and cause it to beat irregularly or stop altogether, leading to sudden cardiac death. Therefore, ventricular arrhythmia is a significant concern in patients with HF and can contribute to their increased risk of SCD.

Propranolol is not recommended for use in patients with heart failure with reduced ejection fraction (HFrEF) because it has negative inotropic effects and can worsen heart failure symptoms. Carvedilol, metoprolol succinate, and bisoprolol are all beta-blockers that have been shown to improve outcomes in patients with HFrEF and are recommended for use in this population.

Fatigue and shortness of breath (SOB) are the cardinal symptoms of heart failure (HF). Fatigue is a common symptom experienced by individuals with HF due to the decreased ability of the heart to pump blood effectively, leading to reduced oxygen and nutrient supply to the body's tissues. SOB occurs due to fluid accumulation in the lungs, causing difficulty in breathing. These symptoms are key indicators of HF and should be monitored and managed to prevent further complications.

Hypertension, or high blood pressure, can lead to heart failure with preserved ejection fraction (EF). This occurs when the heart muscle becomes stiff and is unable to relax properly, leading to decreased filling of the heart chambers and reduced blood flow. Hypertension causes increased pressure within the blood vessels, which can lead to structural changes in the heart over time. These changes can result in diastolic dysfunction, where the heart is unable to relax and fill properly during the resting phase of the cardiac cycle. This can ultimately lead to heart failure with preserved EF.

The cornerstones of therapy for congestive heart failure (CHF) are ACE inhibitors (ACE-I) and beta blockers (BB). ACE inhibitors help to reduce the workload on the heart by dilating blood vessels and reducing fluid buildup. Beta blockers help to slow the heart rate and improve the heart's pumping ability. Together, these medications can help to improve symptoms, reduce hospitalizations, and improve survival in patients with CHF.

Cheyne-Stokes respiration is a type of periodic respiration characterized by alternating periods of hyperventilation and apnea. It is usually associated with low cardiac output and is caused by a decreased sensitivity of the respiratory center to arterial oxygen levels. This decreased sensitivity leads to a delayed response in adjusting the respiratory rate, resulting in the characteristic pattern of Cheyne-Stokes respiration. Therefore, option c, which states increased sensitivity of the respiratory center to arterial oxygen, is incorrect.

Cor Pulmonale, often referred to as pulmonary heart disease, is defined as altered RV structure and/or function in the context of chronic lung disease. It is not limited to developing only in chronic changes in the pulmonary vasculature. Other causes can include chronic obstructive pulmonary disease (COPD), pulmonary embolism, and sleep apnea. The most common cause of right heart failure (RHF) is actually left heart failure (LHF), not Cor Pulmonale.

Omega-3 polyunsaturated fatty acids have been shown to be associated with modestly improved clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). These fatty acids have anti-inflammatory and antiarrhythmic properties, and they may also improve endothelial function and reduce oxidative stress. Several clinical trials have demonstrated that omega-3 supplementation can reduce mortality and hospitalizations in patients with HFrEF. Therefore, omega-3 polyunsaturated fatty acids are recommended as a treatment option for patients with HFrEF.

MRI is considered the gold standard for assessing left ventricular (LV) mass and volume because it provides detailed and accurate images of the heart. It allows for precise measurement of LV mass and volume, which are important indicators of heart function and can help diagnose and monitor conditions such as heart failure. MRI provides high-resolution images and can capture both anatomical and functional information about the heart, making it a reliable and comprehensive tool for assessing LV mass and volume.