1 00:00:00,520 --> 00:00:02,359 Speaker 1: Okay, so said, they're going to be doing heart failure, 2 00:00:02,759 --> 00:00:04,480 which is pretty important for the board, so you do 3 00:00:04,480 --> 00:00:06,120 you need to be familiar with it. They give you 4 00:00:06,160 --> 00:00:07,679 some ways to remember the things that you need to 5 00:00:07,719 --> 00:00:09,880 know and just focus on the high yield stuff for today. 6 00:00:10,080 --> 00:00:12,759 As always, thank you so much for the reviews the likes, 7 00:00:13,240 --> 00:00:15,519 but thank you for everybody that's checked out my YouTube 8 00:00:15,519 --> 00:00:18,320 page as well. Seeing a lot of positive comments coming 9 00:00:18,359 --> 00:00:21,399 in there, so it's definitely much appreciated. And if you 10 00:00:21,440 --> 00:00:23,679 wouldn't mind leaving me a like or a review on 11 00:00:23,760 --> 00:00:26,280 either Apple Podcast or my YouTube channel, I would really 12 00:00:26,280 --> 00:00:28,440 appreciate it if it is helping you. So let's get 13 00:00:28,440 --> 00:00:31,000 started with heart failure. So what is heart failure. I'm 14 00:00:31,000 --> 00:00:32,600 sure all of us are pretty familiar with this, but 15 00:00:33,000 --> 00:00:36,880 heart failure is a clinical syndrome that results from either 16 00:00:36,880 --> 00:00:39,920 a structural or a functional disorder of the heart. So 17 00:00:39,920 --> 00:00:42,119 you have either an impairment of the felling of the 18 00:00:42,119 --> 00:00:44,399 heart or an impairment of the ability of the heart 19 00:00:44,439 --> 00:00:48,799 to adequately pump blood. Now predisposing factors, there's one that 20 00:00:48,840 --> 00:00:50,520 you really have to know that you have to be 21 00:00:50,560 --> 00:00:53,640 familiar with because it's the most common cause overall. Sixty 22 00:00:53,679 --> 00:00:56,560 to sixty five percent of cases of heart failure. The 23 00:00:56,600 --> 00:00:59,640 predisposing factor is coordinary art or disease, so absolutely no 24 00:00:59,759 --> 00:01:03,560 that coronary artery disease. That's really important. Majority of cases 25 00:01:03,560 --> 00:01:05,159 are from that. A few more that you need to 26 00:01:05,159 --> 00:01:08,599 be familiar with. Hypertension and valvular heart disease like aortic 27 00:01:08,640 --> 00:01:11,879 stenosis are big ones, but they're becoming less prevalent as 28 00:01:11,920 --> 00:01:14,719 the years go on to improvements in early detection and treatment, 29 00:01:15,359 --> 00:01:20,120 but they are still predisposing factors. Diabetes, diabetes, obesity, and 30 00:01:20,120 --> 00:01:23,319 then of course the lesser, the less common causes like 31 00:01:23,400 --> 00:01:28,959 dox rubisin and dilated cardia myopathy, amoidosis and restrictive restrictive cardiomiopathy. 32 00:01:29,040 --> 00:01:32,480 But overall, if you remember cordinary ardor disease, you'll probably 33 00:01:32,480 --> 00:01:35,439 get the question right on the on the exam. And 34 00:01:35,439 --> 00:01:37,439 the next thing you need to know is the different 35 00:01:37,480 --> 00:01:40,120 types of heart failure. So that's important as well because 36 00:01:40,159 --> 00:01:43,000 that's going to help you understand the clinical manifestation and 37 00:01:43,079 --> 00:01:45,439 treatment options and things like that. So obviously we have 38 00:01:45,480 --> 00:01:47,640 different parts of the heart, and like I said, the 39 00:01:47,640 --> 00:01:51,439 clinical manifestations are all dictated relating to the part of 40 00:01:51,480 --> 00:01:54,239 the heart that is affected. First, let's start with the 41 00:01:54,319 --> 00:01:55,920 sides of the heart. We have a right and we 42 00:01:55,959 --> 00:01:57,920 have a left side of the heart. And the first 43 00:01:57,920 --> 00:02:00,400 thing that you should be aware of is that you 44 00:02:00,439 --> 00:02:04,400 can only have like exclusive left sided heart failure. You 45 00:02:04,439 --> 00:02:07,120 can have exclusive right sided heart failure. It's actually not 46 00:02:07,159 --> 00:02:11,039 that common. It's more common for both to coexist. So 47 00:02:11,120 --> 00:02:12,800 most of the time you can have right and left 48 00:02:12,800 --> 00:02:14,919 sided heart failure at the same time. But it is 49 00:02:15,000 --> 00:02:18,439 possible to just have left sided only heart failure normally 50 00:02:18,520 --> 00:02:21,039 in like an acute mi so cordinary art or disease, 51 00:02:21,719 --> 00:02:24,960 long standing hypertension. And then it's also possible to just 52 00:02:25,039 --> 00:02:28,479 have right sided exclusive heart failure and patients with pulmonary 53 00:02:28,479 --> 00:02:32,479 disorders like pulmonary hypertension COPD. And actually the most common 54 00:02:32,560 --> 00:02:35,599 cause of right sided heart failure is actually left sided 55 00:02:35,599 --> 00:02:38,879 heart failure. And why is that, Well, if we think 56 00:02:38,879 --> 00:02:41,599 about the path help it makes more sense. We already 57 00:02:41,599 --> 00:02:45,639 discussed that pulmonary disorders like pulmonary hypertension can lead to 58 00:02:45,719 --> 00:02:47,680 right sided heart failure, and that's because you have this 59 00:02:47,800 --> 00:02:50,199 increased pressure in the lungs. The right side of the 60 00:02:50,240 --> 00:02:52,560 heart is pumping blood to the lungs. So you have 61 00:02:52,560 --> 00:02:54,879 this increased pressure in the lungs, it's going to hyperch 62 00:02:54,919 --> 00:02:56,280 re fee the right side of the heart, make it 63 00:02:56,319 --> 00:02:58,840 harder for it to pump, and it leads to heart failure. 64 00:02:59,280 --> 00:03:02,080 So think about left sided heart failure now causing right 65 00:03:02,159 --> 00:03:05,280 side and heart failure. Well, left sided heart failure, the 66 00:03:05,319 --> 00:03:08,159 fluid's backing up into where it came from, which is 67 00:03:08,199 --> 00:03:10,560 the lungs. So left sided heart failure is causing all 68 00:03:10,599 --> 00:03:13,039 this excess fluid to back up into the lungs. All 69 00:03:13,080 --> 00:03:15,960 that excess fluid is going to increase the pressure in 70 00:03:16,120 --> 00:03:18,919 the lungs, which is going to lead to ultimately right 71 00:03:18,960 --> 00:03:22,039 sided heart failure. So that's why left sided heart failure 72 00:03:22,080 --> 00:03:24,479 is actually the most common cause of right side and 73 00:03:24,479 --> 00:03:26,639 heart failure because of all that backed up fluid, increasing 74 00:03:26,719 --> 00:03:29,639 the pressure right side having to pump harder, and almost 75 00:03:29,719 --> 00:03:32,039 ultimately leading to a hypertrophy of the right side of 76 00:03:32,039 --> 00:03:34,599 the heart. So that's the right and the left side 77 00:03:34,599 --> 00:03:36,560 of the heart. That's the different variations with heart failure. 78 00:03:36,560 --> 00:03:38,800 With that, the other variation you're going to see is 79 00:03:39,199 --> 00:03:44,439 systolic in diastolic dysfunction or systemic and distolic heart failure. Now, 80 00:03:44,439 --> 00:03:47,599 the terms that they use for these are systolic is 81 00:03:47,719 --> 00:03:51,680 heart failure with reduced dejection fraction, and diastolic is heart 82 00:03:51,680 --> 00:03:55,240 failure with preserved dejection fraction. So that's the proper way 83 00:03:55,280 --> 00:03:56,560 to save these, but I'm not going to say that 84 00:03:56,560 --> 00:03:58,520 because it takes too long. So if I say systolic, 85 00:03:58,800 --> 00:04:01,840 think of heart failure with reduce subjection fraction diastolic preserved 86 00:04:01,840 --> 00:04:05,840 dejection fraction. So let's start with systolic aka heart failure 87 00:04:05,840 --> 00:04:10,080 with reduced ejection fraction. So systolic is a pumping problem. 88 00:04:10,280 --> 00:04:13,719 The ventricles for whatever reason, have become weak and bag 89 00:04:13,719 --> 00:04:16,040 either are stretched out, they can't pump the way they 90 00:04:16,160 --> 00:04:21,600 used to. They're just baggy. They have no strength anymore. Normally, 91 00:04:22,279 --> 00:04:24,079 this is going to be a post m I patient 92 00:04:24,120 --> 00:04:28,160 and dilated cardiomyopathy. But just thinking systolic, you have these weak, 93 00:04:28,360 --> 00:04:30,720 baggy ventricles. They can't pump the way they used to, 94 00:04:31,079 --> 00:04:33,879 and because of that, you have this decreased dejection fraction. 95 00:04:34,279 --> 00:04:36,519 An ejection fraction if you're not familiar with it, it's the 96 00:04:36,519 --> 00:04:39,199 measurement of volume of blood that's pumped out of the 97 00:04:39,279 --> 00:04:43,439 left ventricle with each contraction. Normally, is a normal patient's 98 00:04:43,439 --> 00:04:46,480 gonna be around fifty to seventy percent. These patients are 99 00:04:46,480 --> 00:04:50,240 generally going to be actually under forty percent ejection fraction, 100 00:04:50,360 --> 00:04:53,560 So systolic you're gonna have decreased dejection fraction, and then 101 00:04:53,600 --> 00:04:56,360 a physical exam be familiar that they may have an 102 00:04:56,519 --> 00:04:58,759 S three gallop. All right, let's talk about an S 103 00:04:58,800 --> 00:05:01,199 three and S three. Although it can be heard in 104 00:05:01,240 --> 00:05:04,279 healthy young children and adults, it's usually abnormal in patients 105 00:05:04,319 --> 00:05:07,439 over the age of forty years, suggesting an enlarge or 106 00:05:07,480 --> 00:05:10,920 dilated ventricular chamber. An S three gallop is often an 107 00:05:10,959 --> 00:05:14,920 early finding of heart failure associated with dilated cardiomyopathy. It's 108 00:05:14,920 --> 00:05:18,399 more frequently heard in systolic rather than diastolic heart failure. 109 00:05:18,560 --> 00:05:20,360 So if you see an S three mentioned in an 110 00:05:20,399 --> 00:05:23,519 adult on an exam question, you should be thinking systolic 111 00:05:23,519 --> 00:05:26,560 heart failure, so heart failure with reduced ejection fraction. So 112 00:05:26,680 --> 00:05:29,120 S three is more common in systolic and S four, 113 00:05:29,160 --> 00:05:30,879 which will go over in a minute, is more common 114 00:05:30,879 --> 00:05:34,639 in diastolic. How do you remember that systolic cista lick 115 00:05:34,800 --> 00:05:37,439 has three syllables, so remember it's associated with an S 116 00:05:37,480 --> 00:05:40,920 three and di stall lick has four syllables, so it's 117 00:05:40,920 --> 00:05:43,399 associated with an S four. Quick and easy way to 118 00:05:43,399 --> 00:05:47,079 remember the two. Now diastolic heart failure, which is heart 119 00:05:47,079 --> 00:05:50,560 failure with preserved ejection fraction. So as it says preserve 120 00:05:50,600 --> 00:05:53,920 the ejection fraction is normally not decrease. You have the opposite. 121 00:05:54,120 --> 00:05:58,839 The ventricles are actually stiff, they're sometimes thickened. It can't relax. 122 00:05:59,120 --> 00:06:02,560 So the problems not with pumping, but it's with receiving blood. 123 00:06:02,600 --> 00:06:05,560 They can't expand to fill the blood during diastol they're 124 00:06:05,600 --> 00:06:09,040 stiff in they're thick so again it's not a pumping problem. 125 00:06:09,600 --> 00:06:14,120 So ejection fraction is normally either normal or sometimes even elevated. 126 00:06:14,480 --> 00:06:17,000 The ventricles just can't expand to fill it thatadequate blood, 127 00:06:17,000 --> 00:06:19,839 which can also cause backup and heard other problems with 128 00:06:19,879 --> 00:06:23,560 heart failure as well. And in diastolic you're normally going 129 00:06:23,560 --> 00:06:26,120 to hear an S four gallop, all right, So S 130 00:06:26,199 --> 00:06:29,040 four S four when heard is usually an abnormal finding, 131 00:06:29,160 --> 00:06:32,680 especially in young children and adults, and a palpable S 132 00:06:32,759 --> 00:06:36,399 four is always abnormal regardless of age. Usually the presence 133 00:06:36,439 --> 00:06:38,759 of an S four is due to the forceful atrial 134 00:06:38,800 --> 00:06:42,399 contraction against a stiff non compliant ventricle like we see 135 00:06:42,439 --> 00:06:45,279 in diastolic heart failure, So it is more common in 136 00:06:45,360 --> 00:06:48,920 diastolic heart failure or heart failure with preserved dejection fraction. 137 00:06:49,240 --> 00:06:53,920 Remember diastolic has four syllables, diestolic four syllables, so think 138 00:06:54,120 --> 00:06:57,120 S four and diastolic car failure. You're normally going to 139 00:06:57,160 --> 00:07:01,439 see in different cardiomyopathies, valvular heart disease, use, hypertension. Those 140 00:07:01,439 --> 00:07:03,800 are some of the predisposing fractors for that. So again, 141 00:07:03,879 --> 00:07:06,639 systolic is a pumping problem. You have this baggy ventricle, 142 00:07:06,639 --> 00:07:09,759 it can't pump blood out. Diastolic you have this stiffened, 143 00:07:09,959 --> 00:07:12,800 thick ventricle that can't receive blood. It can't fill the 144 00:07:12,800 --> 00:07:14,600 way you used to, can't get as much blood in there, 145 00:07:14,680 --> 00:07:19,279 But no problem pumping, So ejection fraction is preserved. Now 146 00:07:19,279 --> 00:07:22,959 clinical manifestations, well, it's all related to whether it's right 147 00:07:23,160 --> 00:07:25,759 or left sided heart failure. Remember what I said before 148 00:07:26,000 --> 00:07:28,920 that normally these are going to coexist, so most of 149 00:07:28,959 --> 00:07:31,639 the time you're going to see symptoms of both right 150 00:07:31,680 --> 00:07:34,480 and left sided heart failure. But again it's possible to 151 00:07:34,480 --> 00:07:38,160 have just exclusive right or left sided heart failure. So 152 00:07:38,519 --> 00:07:40,720 in both right and left sided heart failure, the blood 153 00:07:40,759 --> 00:07:43,480 is backing up. So whether it's systolic the ventricles don't 154 00:07:43,480 --> 00:07:46,519 pump enough blood out or diastolic the ventricles don't relax, 155 00:07:46,639 --> 00:07:49,639 you can't receive all the blood from the atrium. Both cases, 156 00:07:49,680 --> 00:07:52,040 you have this backing up of blood and the symptoms 157 00:07:52,079 --> 00:07:55,160 are all related to where it's backing up to. So 158 00:07:55,319 --> 00:07:58,160 if you have and it's basically where it came from. 159 00:07:58,240 --> 00:08:00,600 So if you have left sided heart failure, well, what's 160 00:08:00,639 --> 00:08:03,480 providing the left side of the heart with blood the 161 00:08:03,519 --> 00:08:06,160 pulmonary veins from the lungs. So if you have left 162 00:08:06,199 --> 00:08:08,360 side and heart failure, the blood's going to back up 163 00:08:08,480 --> 00:08:11,160 into the pulmonary vein and back into the lungs. And 164 00:08:11,199 --> 00:08:13,800 that's why with left sided heart failure, the most common 165 00:08:13,839 --> 00:08:16,079 symptom is going to be dyspnea because you have these 166 00:08:16,160 --> 00:08:19,399 lungs full of fluid. Or thopnia is another big one. 167 00:08:19,480 --> 00:08:23,120 Or thopnia is dyspania while lying flat. So these patients 168 00:08:23,160 --> 00:08:25,439 lay down within a few minutes, they're out of breath 169 00:08:25,439 --> 00:08:27,959 and they're coughing, so they may have a chronic cough 170 00:08:28,000 --> 00:08:31,000 as well. They may have some frothy pink sputum that 171 00:08:31,040 --> 00:08:33,879 can be seen. So left sided heart failure is all 172 00:08:33,919 --> 00:08:36,159 related to the lungs. And you can remember that by 173 00:08:37,039 --> 00:08:39,600 L for left sided heart failure, think of lungs. So 174 00:08:39,600 --> 00:08:41,200 as soon as you see left side of heart failure, 175 00:08:41,200 --> 00:08:45,240 think of lungs. All pulmonary symptoms like that. That's because 176 00:08:45,279 --> 00:08:47,559 again left side of the heart connects to the lungs. 177 00:08:47,559 --> 00:08:49,159 It's going to back up into the lungs where it 178 00:08:49,200 --> 00:08:51,320 came from. Now, right side of the heart. The way 179 00:08:51,360 --> 00:08:54,399 I remember that l left sided is for lungs. R 180 00:08:54,519 --> 00:08:56,480 is going to be rest of the body because it's 181 00:08:56,480 --> 00:08:58,519 going to go everywhere else the rest of the body, 182 00:08:58,559 --> 00:09:00,960 so are so it provides the right side of the 183 00:09:01,000 --> 00:09:03,120 heart with blood. It's the inferior of be in a 184 00:09:03,159 --> 00:09:05,720 caba and the superior vena caba, which connect to pretty 185 00:09:05,759 --> 00:09:09,120 much everything. So these patients are going to have peripheral edema, 186 00:09:09,200 --> 00:09:11,320 they may have like pitting a dima on the legs, 187 00:09:11,960 --> 00:09:14,720 jugular venus distension. It's because the blood from the right 188 00:09:14,720 --> 00:09:17,360 atrium is backing up into the jugular vein. So you 189 00:09:17,360 --> 00:09:19,639 take a look at their neck, you'll see this distended 190 00:09:19,720 --> 00:09:23,000 jugular vein. Blood can also back up into the GI system. 191 00:09:23,080 --> 00:09:25,919 The liver. They may have knowledge of vomiting something known 192 00:09:25,960 --> 00:09:29,320 as a pado jugular reflux, which is when you push 193 00:09:29,399 --> 00:09:31,960 on the liver, you palpate the liver and push into it. 194 00:09:31,960 --> 00:09:34,519 It actually causes an increased JVPCE. So you push on 195 00:09:34,559 --> 00:09:36,200 their liver and you look at their neck and all 196 00:09:36,200 --> 00:09:38,960 of a sudden you see the jugular venus distended, the 197 00:09:39,000 --> 00:09:41,799 jugular vein extended. So those are your clinical manifestations of 198 00:09:41,840 --> 00:09:43,799 the right and the light the left sides. Remember left 199 00:09:43,799 --> 00:09:46,039 side lungs. Right side is going to be the rest 200 00:09:46,080 --> 00:09:47,879 of the body. But again, most of the time these 201 00:09:47,879 --> 00:09:49,960 are going to co exist. You're normally going to have both. 202 00:09:50,600 --> 00:09:53,120 One other thing I wanted to mention before you move 203 00:09:53,159 --> 00:09:56,320 on to diagnosis is something that I don't think is 204 00:09:56,360 --> 00:09:58,639 that important, but it's very easy to remember. So in 205 00:09:58,679 --> 00:10:00,720 the case they ask you one question, let's just go 206 00:10:00,759 --> 00:10:04,360 over it really quick because it's it's pretty easy to memorize. 207 00:10:04,559 --> 00:10:07,840 So that's the New York Heart Association functional class. So 208 00:10:07,879 --> 00:10:11,320 these are four classes that are used to somewhat guide 209 00:10:11,399 --> 00:10:15,279 treatment and different therapies. But you just need to know 210 00:10:15,360 --> 00:10:17,639 a few things to be able to remember this for 211 00:10:17,679 --> 00:10:20,799 the exam. So there's four classes. There's class one, two, three, 212 00:10:20,840 --> 00:10:23,000 and four. As you move along in the classes, the 213 00:10:23,039 --> 00:10:25,840 symptoms get worse. So let's knock out class one and 214 00:10:25,919 --> 00:10:28,000 four really quick because those are the easiest. So Class 215 00:10:28,080 --> 00:10:32,360 one New York Card Association Functional Class Class one no symptoms. 216 00:10:32,480 --> 00:10:35,080 They have heart failure, but they have no symptoms, no 217 00:10:35,200 --> 00:10:38,240 problems at all. Class four they're going to have symptoms 218 00:10:38,320 --> 00:10:41,440 even at rest. So they're sitting down, they're laying down, 219 00:10:41,519 --> 00:10:44,159 they can't breathe, they're having all of these problems. It 220 00:10:44,200 --> 00:10:47,679 never gets better. Even when they're resting, they're having symptoms. 221 00:10:47,799 --> 00:10:50,440 So that's class one and four. Remember one, no symptoms, 222 00:10:50,480 --> 00:10:54,399 four symptoms even at rest. Class three is going to 223 00:10:54,440 --> 00:10:57,440 be their only comfortable at rest. They have even the 224 00:10:57,559 --> 00:11:00,759 regular daily activities their ADLs. Their activity is a daily living, 225 00:11:01,039 --> 00:11:04,159 walking around, doing the dishes, minor things that you and 226 00:11:04,240 --> 00:11:08,080 me would have no issues with. They're having dyspnea and problems. 227 00:11:08,120 --> 00:11:11,000 Even with that, they're only comfortable at rest. And then 228 00:11:11,039 --> 00:11:13,799 class two is kind of like kind of in between. 229 00:11:14,440 --> 00:11:17,080 They're gonna have mild symptoms. Most of their ADLs, they're 230 00:11:17,080 --> 00:11:19,440 gonna be okay. They exert themselves a little bit more, 231 00:11:19,440 --> 00:11:22,440 they may start to develop some symptoms. They're not completely 232 00:11:22,480 --> 00:11:25,360 asymptomatic like Class one, they just have mild symptoms. So 233 00:11:25,399 --> 00:11:28,320 again Class one no symptoms, Class four symptoms at rest, 234 00:11:28,600 --> 00:11:31,200 Class three only comfortable at rest, and the Class two is 235 00:11:31,240 --> 00:11:34,000 just basically mild symptoms. That's the New York Cart Association 236 00:11:34,159 --> 00:11:36,480 class all right, So let's move onto diagnosis. There's really 237 00:11:36,600 --> 00:11:39,559 four diagnostic tests that you need to be familiar with. 238 00:11:39,600 --> 00:11:41,960 Those four tests, your best test is going to be 239 00:11:42,000 --> 00:11:45,120 an ECHO. Your first test, like your initial test is 240 00:11:45,159 --> 00:11:46,879 going to be a chess X, right, and then a 241 00:11:46,879 --> 00:11:51,159 couple other labs like your BNP, and then an ECG. 242 00:11:52,000 --> 00:11:53,600 So let's start and move our way down the line. 243 00:11:53,600 --> 00:11:55,279 So let's do your first test. If they ask you, 244 00:11:55,320 --> 00:11:58,519 what's your initial test they'll do for patients suspecting heart failure, 245 00:11:58,600 --> 00:12:00,879 it's going to be a chest X right now. Chest 246 00:12:01,000 --> 00:12:04,240 X ray is not diagnostic for congestive heart failure. It's 247 00:12:04,240 --> 00:12:07,759 just not specific enough, but it is a good initial test. 248 00:12:07,919 --> 00:12:09,440 And what are you gonna see on a chest X 249 00:12:09,519 --> 00:12:13,360 ray that you need to know to suspect congestive heart failure? Well, 250 00:12:13,360 --> 00:12:17,559 there's something known as cephalization of flow cephalization of flow, 251 00:12:18,000 --> 00:12:20,799 and what this is is due to all the back 252 00:12:21,039 --> 00:12:24,360 flow of blood into the lungs, you have this increased 253 00:12:24,360 --> 00:12:29,200 pulmonary pressure which actually causes the vascular flow to migrate 254 00:12:29,279 --> 00:12:32,159 up the lungs and go all the way to the apecs. 255 00:12:32,399 --> 00:12:34,519 So because of the cephilization of flow, you're gonna have 256 00:12:34,559 --> 00:12:37,519 two key findings, those key terms that you need to 257 00:12:37,519 --> 00:12:39,320 be familiar with, that you need to know cause from 258 00:12:39,320 --> 00:12:43,600 the cephilization of flow, that's curly B lines k E 259 00:12:43,759 --> 00:12:47,440 R L E Y B lines and then butterfly or 260 00:12:47,519 --> 00:12:50,639 bowing appearance in chest X ray. Of course you're gonna 261 00:12:50,639 --> 00:12:53,679 have cardiomegaly plural effusion, but you know they're not gonna 262 00:12:53,679 --> 00:12:55,799 ask you a question about that. They're gonna ask you 263 00:12:55,840 --> 00:12:58,440 about these key findings. So what are curly B lines. 264 00:12:59,120 --> 00:13:03,200 These are due to lymphatic encorgement or edema at the 265 00:13:03,279 --> 00:13:06,039 lung periphery, so at the sides of the lungs and 266 00:13:06,080 --> 00:13:09,039 a congestive heart failure patient. And at the sides or 267 00:13:09,080 --> 00:13:11,080 the periphery of the lungs on chest sticks where you're 268 00:13:11,120 --> 00:13:14,600 gonna see these short, little tiny one to two centimeter 269 00:13:14,759 --> 00:13:17,399 thin lines. So these one to two centimeters little radio 270 00:13:17,399 --> 00:13:20,480 opaque lines that most of the time, unless you're pretty 271 00:13:20,480 --> 00:13:22,759 good at reading chest x raason, you probably completely miss. 272 00:13:23,200 --> 00:13:25,200 But a radiologist will see that and know that it's 273 00:13:25,240 --> 00:13:28,519 related to congestive heart failure. Potentially, there's other causes again, 274 00:13:29,200 --> 00:13:30,639 and the other thing you should be familiar with is 275 00:13:30,679 --> 00:13:33,240 something known as bat wing or butterfly appearance. This is 276 00:13:33,279 --> 00:13:35,519 better with a visual, so check out my YouTube channel. 277 00:13:35,519 --> 00:13:37,279 We gonna have pictures of all of these what I'm 278 00:13:37,320 --> 00:13:40,879 going through the video. But this is another cause from 279 00:13:40,879 --> 00:13:44,399 the accumulation of fluid. But in these cases, the fluid 280 00:13:44,519 --> 00:13:47,440 is filling the high lar in the peri hyla region 281 00:13:47,480 --> 00:13:50,320 of the lungs, and because of the location of the edema, 282 00:13:50,679 --> 00:13:53,000 you're gonna have this bat wing appearance with these white 283 00:13:53,000 --> 00:13:55,480 opacities in the lungs and it looks like the wings 284 00:13:55,519 --> 00:13:57,320 of a bat wing or a bird or whatever you 285 00:13:57,360 --> 00:13:59,720 want to think of butterfly. So it's just the location 286 00:13:59,799 --> 00:14:04,279 of fluid overloaded in the lungs. So that's the initial 287 00:14:04,320 --> 00:14:07,080 test that you'll do. Again. It's not really going to 288 00:14:07,159 --> 00:14:10,679 be diagnostic, but it's a good first test to kind 289 00:14:10,679 --> 00:14:12,879 of give you an idea that maybe this patient does 290 00:14:12,919 --> 00:14:17,559 have CHF. Okay. So another initial test that you'll do, 291 00:14:17,639 --> 00:14:20,320 especially if they're coming into the ear, is something known 292 00:14:20,480 --> 00:14:23,360 as BNP. You'll also hear it known as pro BNP, 293 00:14:24,080 --> 00:14:28,679 and that is either B type naturetic peptide. It also 294 00:14:28,799 --> 00:14:32,519 used to be called brain naturetic peptide, but as the 295 00:14:32,559 --> 00:14:36,080 newer name for it is B type naturetic peptide. So 296 00:14:36,159 --> 00:14:40,440 what this is BNP is this peptide that's secreted by 297 00:14:40,440 --> 00:14:43,720 the heart to regulate blood pressure and fluid in the body, 298 00:14:44,320 --> 00:14:48,559 and it's released when you have the ventricle stretching. So 299 00:14:48,639 --> 00:14:50,600 that's the body's way of knowing, okay, the ventricles are 300 00:14:50,639 --> 00:14:54,519 stretching or being overloaded from fluid. They don't exactly know why, 301 00:14:54,559 --> 00:14:57,000 so they release this and it's pumped out to kind 302 00:14:57,000 --> 00:14:59,639 of regulate and make some changes in the blood pressure 303 00:15:00,360 --> 00:15:04,360 and regulate the fluids in the body. Now, BNP is 304 00:15:04,559 --> 00:15:07,840 also pumped out during renal failure. It can be decreased 305 00:15:07,879 --> 00:15:11,000 in obese patients. So it's not one hundred percent specific, 306 00:15:11,440 --> 00:15:14,120 but it's a good rule out test because if you 307 00:15:14,200 --> 00:15:16,399 do a BNP in a patient you suggest has heart 308 00:15:16,399 --> 00:15:19,399 failure and it's zero or it's completely normal less than 309 00:15:19,440 --> 00:15:22,720 one hundred good chance that they don't have heart failure. Generally, 310 00:15:22,759 --> 00:15:25,120 the number that you're looking for is a BNP over 311 00:15:25,159 --> 00:15:27,360 one hundred, you should be thinking there's a pretty good 312 00:15:27,399 --> 00:15:29,480 chance that this PATI could have heart failure. So BNP 313 00:15:29,600 --> 00:15:32,120 overall one hundred, you should be suspecting heart failure, but 314 00:15:32,240 --> 00:15:34,720 be aware there's other things that can elevate it as well. 315 00:15:35,279 --> 00:15:37,559 So that's another good lab test to do, and it's 316 00:15:37,600 --> 00:15:41,080 really good in guiding treatment when you have like decompensated 317 00:15:41,080 --> 00:15:43,519 heart failure to see the response that treatment. But you 318 00:15:43,519 --> 00:15:45,799 should know that one as well. That's your BNP or 319 00:15:45,840 --> 00:15:49,799 pro BNP. Another one that's it's not a bad test, 320 00:15:49,879 --> 00:15:52,600 but it's again not going to be diagnostic, is your ECG. 321 00:15:52,840 --> 00:15:55,120 So it's another good rule out test. And the reason 322 00:15:55,159 --> 00:15:57,000 it's a good rule out test is because if this 323 00:15:57,120 --> 00:16:01,399 patient has systolic heart failure so heart failure with reduced 324 00:16:01,399 --> 00:16:05,039 ejection fraction, if they have a normal ECG, there's a 325 00:16:05,240 --> 00:16:07,399 very small chance that they have heart failure. It's a 326 00:16:07,519 --> 00:16:11,960 ninety eight percent predictive value if it's a negative that 327 00:16:12,039 --> 00:16:15,759 they don't have heart failure. But yeah, on the flip 328 00:16:15,799 --> 00:16:18,320 side of that, if they have preserved ejection fraction. A 329 00:16:18,399 --> 00:16:20,320 lot of times the ECG is going to be normal, 330 00:16:20,440 --> 00:16:24,360 so get a good rule out test for systolic, but 331 00:16:24,399 --> 00:16:27,799 not so much for diestolic. And again if it's positive, 332 00:16:27,879 --> 00:16:30,399 if you do see abnormalities on ECG, doesn't mean it's 333 00:16:30,399 --> 00:16:32,919 heart failure. It's another good rule out test, but again 334 00:16:33,399 --> 00:16:37,200 non diagnostic. Now, the best test overall is going to 335 00:16:37,200 --> 00:16:41,120 be your echo. So your your echo is going to 336 00:16:41,159 --> 00:16:44,360 measure your ejection fraction. It's going to measure or evaluate 337 00:16:44,360 --> 00:16:47,519 the ventricular wall see if they're thinning like in systolic 338 00:16:47,639 --> 00:16:50,519 her failure. It's going to be able to get a 339 00:16:50,639 --> 00:16:52,879 really good idea of the function of the heart and 340 00:16:52,879 --> 00:16:55,759 to diagnose heart failure. So overall, echo is going to 341 00:16:55,759 --> 00:16:58,360 be your best test. That's the one you really need 342 00:16:58,399 --> 00:17:01,600 to be familiar with and know for the exam if 343 00:17:01,639 --> 00:17:04,400 they do ask you what your best test is. Okay, 344 00:17:04,440 --> 00:17:07,720 So let's move on to treatment. So treatment of systellic 345 00:17:07,759 --> 00:17:11,440 heart failure aka heart failure with reduced ejection fraction. Let's 346 00:17:11,440 --> 00:17:13,720 start with some lifestyle interventions. Then we'll hit the MEDS, 347 00:17:13,759 --> 00:17:16,119 which is the highest deealed component for the exam. So 348 00:17:16,160 --> 00:17:19,200 to start of course, associated conditions and underlying causes should 349 00:17:19,240 --> 00:17:22,839 be appropriately managed. Coronary art disease, valve disease associated conditions 350 00:17:22,880 --> 00:17:25,640 like hypertension diabetes should all be properly managed, and then 351 00:17:25,680 --> 00:17:29,240 as far as lifestyle modifications, of course, cessation of smoking 352 00:17:29,359 --> 00:17:33,519 is essential, abstinence from alcohol consumption or at least restricting alcohol, 353 00:17:33,839 --> 00:17:38,319 avoidance of obesity, and then restricting sodium intake. Depending on 354 00:17:38,319 --> 00:17:40,400 the source, the specific number can vary, so I wouldn't 355 00:17:40,400 --> 00:17:42,559 focus too much on a specific number, but up to 356 00:17:42,640 --> 00:17:45,319 date does suggest less than three grams a day, and 357 00:17:45,359 --> 00:17:48,759 in patients with more severe or refractory heart failure, restricted 358 00:17:48,799 --> 00:17:51,000 fluid intake to one point five to two liders a 359 00:17:51,079 --> 00:17:54,200 day may be recommended, and of course daily weight monitoring 360 00:17:54,200 --> 00:17:57,720 to detect fluid accumulation is also recommended. Let's move on 361 00:17:57,759 --> 00:18:00,319 to our pharmacologic therapy because this is what you need 362 00:18:00,319 --> 00:18:02,240 to know for the exam. So these meds are the 363 00:18:02,279 --> 00:18:05,880 primary therapy for heart failure with reduced ejection fraction. These 364 00:18:05,920 --> 00:18:07,680 are the four that you absolutely need to know. These 365 00:18:07,720 --> 00:18:11,920 meds not only improve symptoms but most importantly prolonged patients survival. 366 00:18:12,079 --> 00:18:13,839 So for meads or classes you need to know in 367 00:18:13,880 --> 00:18:16,720 patients with heart failure with reduced ejection fraction. These will 368 00:18:16,720 --> 00:18:19,480 typically be combination therapy with one agent from each of 369 00:18:19,519 --> 00:18:22,240 the following classes. So these classes are ar and i's 370 00:18:22,279 --> 00:18:25,920 beta blockers, MRAs, and sglt too inhibitors. Let's start with 371 00:18:26,000 --> 00:18:29,279 our arni's or our class, which is our rien and 372 00:18:29,279 --> 00:18:33,039 angiotenson system inhibitors. We have a number of options arnis 373 00:18:33,119 --> 00:18:36,519 ace inhibitors ARBs, which you choose that would be ar 374 00:18:36,599 --> 00:18:40,400 and I specifically cycubitril valsartan, which is also known as Intresto. 375 00:18:40,440 --> 00:18:42,519 That's the brand name and you'll see this being utilized 376 00:18:42,599 --> 00:18:46,680 very often. It's an angiotensin receptor neprilicin inhibitor, which is 377 00:18:46,759 --> 00:18:49,759 composed of an AR and B an inhibitor of neprilicin, 378 00:18:49,799 --> 00:18:53,200 which is an enzyme that degrades naturitic peptides, bradickinin and 379 00:18:53,279 --> 00:18:56,839 other phasoactive peptides. And it's preferred over aces in ARBs 380 00:18:56,920 --> 00:19:00,160 due to improved efficacy relative to these other classes, and 381 00:19:00,200 --> 00:19:03,240 in patients who can't tolerate ARNI therapy or due to costs, 382 00:19:03,240 --> 00:19:06,000 can't obtain it. Aces and urbs are an option, but 383 00:19:06,279 --> 00:19:08,480 ARNI is the preferred class, so it should be the 384 00:19:08,480 --> 00:19:11,160 focus for the exam. Next is going to be beta blockers, 385 00:19:11,319 --> 00:19:15,519 specifically metoprolol, carbadolol and bisoper law are the preferred agents 386 00:19:15,559 --> 00:19:19,200 as these beta blockers have demonstrated mortality benefit, unlike the 387 00:19:19,240 --> 00:19:23,160 other medications in the beta blocker class which lack comparable evidence. 388 00:19:23,440 --> 00:19:25,920 Next is going to be our MINERALI coord cord receptor 389 00:19:25,960 --> 00:19:29,599 antagonist that's a planinone and spirinal lactone, A playerone is 390 00:19:29,680 --> 00:19:32,519 usually preferred over spirinal lactone due to a lower risk 391 00:19:32,599 --> 00:19:35,920 of endocrine side effects like ganocomasitia and impotence. And then 392 00:19:35,960 --> 00:19:39,240 finally we have our SGLT two inhibitors. These are amazing drugs. 393 00:19:39,240 --> 00:19:42,240 We use them in diabetes CKD and of course part failure. 394 00:19:42,519 --> 00:19:46,480 So our sodium glucose cotransporter to inhibitors like dapicla flows 395 00:19:46,519 --> 00:19:49,480 in which is Farsiga or empical flows in which is Jardiance. 396 00:19:49,720 --> 00:19:51,920 So those are the four meds or classes you need 397 00:19:51,960 --> 00:19:53,759 to know. There is one other med that does have 398 00:19:53,839 --> 00:19:57,319 proven mortality benefit, that's hydrolyzene plus nitrate, but this is 399 00:19:57,359 --> 00:19:59,640 not a first line med and really just a backup 400 00:19:59,680 --> 00:20:02,200 option for patients who cannot tolerate an ar and I 401 00:20:02,640 --> 00:20:04,359 or an ASR and R. So I want you to 402 00:20:04,359 --> 00:20:06,480 remember these for the exam. This is super important. It's 403 00:20:06,480 --> 00:20:08,960 probably the highest yeald thing to know for heart failure. 404 00:20:09,200 --> 00:20:11,680 So here's anomonic to help you remember them. To remember 405 00:20:11,680 --> 00:20:13,480 the main meds you need to know for management of 406 00:20:13,559 --> 00:20:17,599 heart failure with reduced ejection fraction aka systemic heart failure, 407 00:20:17,839 --> 00:20:20,640 remember bash the heart to make it beat harder. Bash 408 00:20:20,720 --> 00:20:22,920 the heart to make it beat harder helps you remember 409 00:20:22,960 --> 00:20:25,799 the meds with proven mortality benefit in systellic heart failure. 410 00:20:26,000 --> 00:20:29,279 BASH is spelled B ashe, so let's start with B. 411 00:20:29,440 --> 00:20:32,160 That's again going to be our beta blockers mitoprol, carveatal 412 00:20:32,200 --> 00:20:34,920 olbit SOAPROLAW. Next to A stands for ar and I, 413 00:20:35,200 --> 00:20:38,559 our angiotensen receptor blocker, and aprilicin inhibitor, which is secure 414 00:20:38,599 --> 00:20:41,480 patrol of al sartan ace inhibitors or ARBs are an 415 00:20:41,680 --> 00:20:44,079 I backup, which also start with A if an AR 416 00:20:44,119 --> 00:20:46,519 and I is not appropriate or affordable. Next is going 417 00:20:46,559 --> 00:20:49,599 to be our sglt twos our sonium glucose cotransporter to 418 00:20:49,759 --> 00:20:53,400 inhibitors to epical flows in epical flows. In next hydroalyzene 419 00:20:53,400 --> 00:20:55,640 plus nitrate. Again, this is not a first line med 420 00:20:55,839 --> 00:20:58,079 but it is a medication with proven mortality benefit, so 421 00:20:58,160 --> 00:21:01,000 it is appropriate. Here also helps them on, so it's 422 00:21:01,000 --> 00:21:02,680 good to be aware of. But really we're only going 423 00:21:02,720 --> 00:21:04,960 to use this again if any of our A medications 424 00:21:05,039 --> 00:21:07,640 aar andies ACES or ARBs were not tolerated or not 425 00:21:07,720 --> 00:21:11,599 appropriate for whatever reason, maybe patients with hyperkalemia or kidney dysfunction. 426 00:21:12,400 --> 00:21:15,200 So again just know this med does have proven mortality benefit, 427 00:21:15,279 --> 00:21:17,200 but it's not first line. And then finally we have 428 00:21:17,440 --> 00:21:20,599 our MINERALI cord cooid receptor antagonists, which are a plaranone 429 00:21:20,640 --> 00:21:22,880 and spirinal lactone. And in this case we're using the 430 00:21:23,000 --> 00:21:26,039 E for BASH because a planaranone is preferred over spyirinal 431 00:21:26,079 --> 00:21:29,160 lactone due to its more favorable side effect profile, and 432 00:21:29,200 --> 00:21:31,400 therefore it's the one you should know. Okay, again, meds 433 00:21:31,400 --> 00:21:33,359 you need to know for systallic heart failure with proven 434 00:21:33,400 --> 00:21:36,799 mortality benefit, bash B ashe the hard to make it 435 00:21:36,880 --> 00:21:40,480 beat harder beta blockers aar andies sgot two hydraulazine and 436 00:21:40,559 --> 00:21:42,640 a plaranone. Know those and you should be good for 437 00:21:42,759 --> 00:21:45,319 the exam. Now there are other medications of these are 438 00:21:45,359 --> 00:21:48,640 more for symptomatic relief, so diuretics like furosamide will be 439 00:21:48,720 --> 00:21:51,599 used in patients with persistent volume overload to help eliminate 440 00:21:51,640 --> 00:21:54,680 clinical evidence of fluid retention. So obviously plays a large 441 00:21:54,759 --> 00:21:57,920 role in patience with acutely decompensated heart failure, and the 442 00:21:58,039 --> 00:22:01,079 diuretic most commonly used will be freeurosimide. And then we 443 00:22:01,160 --> 00:22:04,359 have some secondary options. So the secondary options are in 444 00:22:04,519 --> 00:22:07,680 patients who cannot tolerate the primary regimen or have residual 445 00:22:07,720 --> 00:22:11,359 heart failure symptoms despite optimal therapy. These are not commonly use, 446 00:22:11,400 --> 00:22:12,839 so I don't think you need to menimalize them, but 447 00:22:13,000 --> 00:22:15,079 just be aware that they do exist. This is going 448 00:22:15,119 --> 00:22:18,880 to be EVI a braiden verisiguat digoxin hydrouzene plus nitrate 449 00:22:18,960 --> 00:22:21,559 that we talked about before again, so don't really need 450 00:22:21,680 --> 00:22:23,559 to focus too much on these. These aren't high yield, 451 00:22:23,559 --> 00:22:26,599 but these are secondary or backup options if our primary 452 00:22:26,640 --> 00:22:29,079 therapy can't be utilized for whatever reason. Right, So, treatment 453 00:22:29,119 --> 00:22:32,400 of heart failure with preserved ejection fraction or diestolic car 454 00:22:32,480 --> 00:22:35,559 failure is a little different than systolic car failure that 455 00:22:35,680 --> 00:22:38,759 there is no clear evidence that pharmacologic therapy or other 456 00:22:38,880 --> 00:22:41,839 therapies reduce the risk of mortality in these patients. So 457 00:22:41,920 --> 00:22:44,119 if you're feeling overwhelmed and maybe want to skip a section, 458 00:22:44,279 --> 00:22:46,000 this would be the one, as there are no high 459 00:22:46,039 --> 00:22:48,680 yield meds to know here. In general, you'll treat these 460 00:22:48,759 --> 00:22:52,359 patients associated conditions just like you would anyone else. Hypertension, 461 00:22:52,400 --> 00:22:55,279 a fib coordinary ardor disease, et cetera. You'll suggest die 462 00:22:55,319 --> 00:22:57,519 in an exercise cardiac rehab. And if you want to 463 00:22:57,640 --> 00:23:00,359 just remember one med class, this would probably be as 464 00:23:00,480 --> 00:23:03,079 up to date recommends this as initial therapy for most patients, 465 00:23:03,119 --> 00:23:06,000 and that's going to be an SGLT two inhibitor like 466 00:23:06,079 --> 00:23:08,480 empical flowsen or dapical flows in. This is going to 467 00:23:08,519 --> 00:23:10,880 be initial therapy for most patients, So this would be 468 00:23:10,920 --> 00:23:12,559 the one if you want to remember one med class, 469 00:23:12,720 --> 00:23:14,839 this is the one to know. Second line would be 470 00:23:14,920 --> 00:23:19,640 a MINERALI cord chord receptor antagonist, so like spirriinalactone or 471 00:23:19,680 --> 00:23:21,799 a plaranone, And in this case there is an additional 472 00:23:21,880 --> 00:23:25,799 agent called fenerenone, which is a newer non steroidal mineral 473 00:23:25,920 --> 00:23:29,240 chord cord receptor antagonist. You're obese patients, we can use 474 00:23:29,319 --> 00:23:33,079 GLP one receptor agonists like symaglotide or two zepetide. These 475 00:23:33,160 --> 00:23:36,240 meds have shown benefit in patients with obesity and heart 476 00:23:36,240 --> 00:23:39,880 failure with preserved dejection fraction. And then the patients with 477 00:23:40,039 --> 00:23:42,400 volume overload, you'll use diuretics, just like we were talking 478 00:23:42,400 --> 00:23:44,880 about before. This is usually going to be a loop 479 00:23:44,920 --> 00:23:47,799 diuretic like thurosamide. So bottom line here, if you want 480 00:23:47,799 --> 00:23:50,000 to remember one med class for heart failure with preserved 481 00:23:50,000 --> 00:23:52,880 dejection fraction, let it be SGLT two inhibitors. But not 482 00:23:52,920 --> 00:23:54,559 a lot to know here otherwise, so I wouldn't waste 483 00:23:54,559 --> 00:23:58,279 too much time, all right, And remember one last thing 484 00:23:58,359 --> 00:24:02,480 about the treatment. Outside of your pharmacologic treatment, there's some 485 00:24:02,759 --> 00:24:06,839 mechanical devices. So as these patients progress with heart failure, 486 00:24:07,400 --> 00:24:10,359 once they get to like stage four, their rejection fractions 487 00:24:10,440 --> 00:24:14,200 under thirty five percent, the treatment in addition to pharmacologic 488 00:24:14,319 --> 00:24:17,759 therapy is actually going to include a left ventricular assist device, 489 00:24:18,240 --> 00:24:20,559 which is an implantable device that helps the failing heart 490 00:24:20,559 --> 00:24:24,680 to contract with mechanical assistance. They also may have an 491 00:24:24,720 --> 00:24:30,240 AICDM planet, which is an automatic implantable cardioverter defibrillator. These 492 00:24:30,279 --> 00:24:33,279 are patients again in the last stages, and ultimately once 493 00:24:33,359 --> 00:24:37,599 they get to stage four, death normally occurs within a 494 00:24:37,720 --> 00:24:41,319 year without heart transplant. So once you get to that point, 495 00:24:41,359 --> 00:24:43,519 you just kind of use everything you can to preserve 496 00:24:43,599 --> 00:24:47,039 life as long as possible. Okay, so that is heart failure. 497 00:24:47,799 --> 00:24:50,279 Thank you so much. As always, I know I said 498 00:24:50,279 --> 00:24:51,680 it in the beginning, and I'll say it every time 499 00:24:51,720 --> 00:24:54,359 because I do appreciate the comments. It really does make 500 00:24:54,440 --> 00:24:54,799 my day.