Speaker 1: Okay, so said, they're going to be doing heart failure,
which is pretty important for the board, so you do
you need to be familiar with it. They give you
some ways to remember the things that you need to
know and just focus on the high yield stuff for today.
As always, thank you so much for the reviews the likes,
but thank you for everybody that's checked out my YouTube
page as well. Seeing a lot of positive comments coming
in there, so it's definitely much appreciated. And if you
wouldn't mind leaving me a like or a review on
either Apple Podcast or my YouTube channel, I would really
appreciate it if it is helping you. So let's get
started with heart failure. So what is heart failure. I'm
sure all of us are pretty familiar with this, but
heart failure is a clinical syndrome that results from either
a structural or a functional disorder of the heart. So
you have either an impairment of the felling of the
heart or an impairment of the ability of the heart
to adequately pump blood. Now predisposing factors, there's one that
you really have to know that you have to be
familiar with because it's the most common cause overall. Sixty
to sixty five percent of cases of heart failure. The
predisposing factor is coordinary art or disease, so absolutely no
that coronary artery disease. That's really important. Majority of cases
are from that. A few more that you need to
be familiar with. Hypertension and valvular heart disease like aortic
stenosis are big ones, but they're becoming less prevalent as
the years go on to improvements in early detection and treatment,
but they are still predisposing factors. Diabetes, diabetes, obesity, and
then of course the lesser, the less common causes like
dox rubisin and dilated cardia myopathy, amoidosis and restrictive restrictive cardiomiopathy.
But overall, if you remember cordinary ardor disease, you'll probably
get the question right on the on the exam. And
the next thing you need to know is the different
types of heart failure. So that's important as well because
that's going to help you understand the clinical manifestation and
treatment options and things like that. So obviously we have
different parts of the heart, and like I said, the
clinical manifestations are all dictated relating to the part of
the heart that is affected. First, let's start with the
sides of the heart. We have a right and we
have a left side of the heart. And the first
thing that you should be aware of is that you
can only have like exclusive left sided heart failure. You
can have exclusive right sided heart failure. It's actually not
that common. It's more common for both to coexist. So
most of the time you can have right and left
sided heart failure at the same time. But it is
possible to just have left sided only heart failure normally
in like an acute mi so cordinary art or disease,
long standing hypertension. And then it's also possible to just
have right sided exclusive heart failure and patients with pulmonary
disorders like pulmonary hypertension COPD. And actually the most common
cause of right sided heart failure is actually left sided
heart failure. And why is that, Well, if we think
about the path help it makes more sense. We already
discussed that pulmonary disorders like pulmonary hypertension can lead to
right sided heart failure, and that's because you have this
increased pressure in the lungs. The right side of the
heart is pumping blood to the lungs. So you have
this increased pressure in the lungs, it's going to hyperch
re fee the right side of the heart, make it
harder for it to pump, and it leads to heart failure.
So think about left sided heart failure now causing right
side and heart failure. Well, left sided heart failure, the
fluid's backing up into where it came from, which is
the lungs. So left sided heart failure is causing all
this excess fluid to back up into the lungs. All
that excess fluid is going to increase the pressure in
the lungs, which is going to lead to ultimately right
sided heart failure. So that's why left sided heart failure
is actually the most common cause of right side and
heart failure because of all that backed up fluid, increasing
the pressure right side having to pump harder, and almost
ultimately leading to a hypertrophy of the right side of
the heart. So that's the right and the left side
of the heart. That's the different variations with heart failure.
With that, the other variation you're going to see is
systolic in diastolic dysfunction or systemic and distolic heart failure. Now,
the terms that they use for these are systolic is
heart failure with reduced dejection fraction, and diastolic is heart
failure with preserved dejection fraction. So that's the proper way
to save these, but I'm not going to say that
because it takes too long. So if I say systolic,
think of heart failure with reduce subjection fraction diastolic preserved
dejection fraction. So let's start with systolic aka heart failure
with reduced ejection fraction. So systolic is a pumping problem.
The ventricles for whatever reason, have become weak and bag
either are stretched out, they can't pump the way they
used to. They're just baggy. They have no strength anymore. Normally,
this is going to be a post m I patient
and dilated cardiomyopathy. But just thinking systolic, you have these weak,
baggy ventricles. They can't pump the way they used to,
and because of that, you have this decreased dejection fraction.
An ejection fraction if you're not familiar with it, it's the
measurement of volume of blood that's pumped out of the
left ventricle with each contraction. Normally, is a normal patient's
gonna be around fifty to seventy percent. These patients are
generally going to be actually under forty percent ejection fraction,
So systolic you're gonna have decreased dejection fraction, and then
a physical exam be familiar that they may have an
S three gallop. All right, let's talk about an S
three and S three. Although it can be heard in
healthy young children and adults, it's usually abnormal in patients
over the age of forty years, suggesting an enlarge or
dilated ventricular chamber. An S three gallop is often an
early finding of heart failure associated with dilated cardiomyopathy. It's
more frequently heard in systolic rather than diastolic heart failure.
So if you see an S three mentioned in an
adult on an exam question, you should be thinking systolic
heart failure, so heart failure with reduced ejection fraction. So
S three is more common in systolic and S four,
which will go over in a minute, is more common
in diastolic. How do you remember that systolic cista lick
has three syllables, so remember it's associated with an S
three and di stall lick has four syllables, so it's
associated with an S four. Quick and easy way to
remember the two. Now diastolic heart failure, which is heart
failure with preserved ejection fraction. So as it says preserve
the ejection fraction is normally not decrease. You have the opposite.
The ventricles are actually stiff, they're sometimes thickened. It can't relax.
So the problems not with pumping, but it's with receiving blood.
They can't expand to fill the blood during diastol they're
stiff in they're thick so again it's not a pumping problem.
So ejection fraction is normally either normal or sometimes even elevated.
The ventricles just can't expand to fill it thatadequate blood,
which can also cause backup and heard other problems with
heart failure as well. And in diastolic you're normally going
to hear an S four gallop, all right, So S
four S four when heard is usually an abnormal finding,
especially in young children and adults, and a palpable S
four is always abnormal regardless of age. Usually the presence
of an S four is due to the forceful atrial
contraction against a stiff non compliant ventricle like we see
in diastolic heart failure, So it is more common in
diastolic heart failure or heart failure with preserved dejection fraction.
Remember diastolic has four syllables, diestolic four syllables, so think
S four and diastolic car failure. You're normally going to
see in different cardiomyopathies, valvular heart disease, use, hypertension. Those
are some of the predisposing fractors for that. So again,
systolic is a pumping problem. You have this baggy ventricle,
it can't pump blood out. Diastolic you have this stiffened,
thick ventricle that can't receive blood. It can't fill the
way you used to, can't get as much blood in there,
But no problem pumping, So ejection fraction is preserved. Now
clinical manifestations, well, it's all related to whether it's right
or left sided heart failure. Remember what I said before
that normally these are going to coexist, so most of
the time you're going to see symptoms of both right
and left sided heart failure. But again it's possible to
have just exclusive right or left sided heart failure. So
in both right and left sided heart failure, the blood
is backing up. So whether it's systolic the ventricles don't
pump enough blood out or diastolic the ventricles don't relax,
you can't receive all the blood from the atrium. Both cases,
you have this backing up of blood and the symptoms
are all related to where it's backing up to. So
if you have and it's basically where it came from.
So if you have left sided heart failure, well, what's
providing the left side of the heart with blood the
pulmonary veins from the lungs. So if you have left
side and heart failure, the blood's going to back up
into the pulmonary vein and back into the lungs. And
that's why with left sided heart failure, the most common
symptom is going to be dyspnea because you have these
lungs full of fluid. Or thopnia is another big one.
Or thopnia is dyspania while lying flat. So these patients
lay down within a few minutes, they're out of breath
and they're coughing, so they may have a chronic cough
as well. They may have some frothy pink sputum that
can be seen. So left sided heart failure is all
related to the lungs. And you can remember that by
L for left sided heart failure, think of lungs. So
as soon as you see left side of heart failure,
think of lungs. All pulmonary symptoms like that. That's because
again left side of the heart connects to the lungs.
It's going to back up into the lungs where it
came from. Now, right side of the heart. The way
I remember that l left sided is for lungs. R
is going to be rest of the body because it's
going to go everywhere else the rest of the body,
so are so it provides the right side of the
heart with blood. It's the inferior of be in a
caba and the superior vena caba, which connect to pretty
much everything. So these patients are going to have peripheral edema,
they may have like pitting a dima on the legs,
jugular venus distension. It's because the blood from the right
atrium is backing up into the jugular vein. So you
take a look at their neck, you'll see this distended
jugular vein. Blood can also back up into the GI system.
The liver. They may have knowledge of vomiting something known
as a pado jugular reflux, which is when you push
on the liver, you palpate the liver and push into it.
It actually causes an increased JVPCE. So you push on
their liver and you look at their neck and all
of a sudden you see the jugular venus distended, the
jugular vein extended. So those are your clinical manifestations of
the right and the light the left sides. Remember left
side lungs. Right side is going to be the rest
of the body. But again, most of the time these
are going to co exist. You're normally going to have both.
One other thing I wanted to mention before you move
on to diagnosis is something that I don't think is
that important, but it's very easy to remember. So in
the case they ask you one question, let's just go
over it really quick because it's it's pretty easy to memorize.
So that's the New York Heart Association functional class. So
these are four classes that are used to somewhat guide
treatment and different therapies. But you just need to know
a few things to be able to remember this for
the exam. So there's four classes. There's class one, two, three,
and four. As you move along in the classes, the
symptoms get worse. So let's knock out class one and
four really quick because those are the easiest. So Class
one New York Card Association Functional Class Class one no symptoms.
They have heart failure, but they have no symptoms, no
problems at all. Class four they're going to have symptoms
even at rest. So they're sitting down, they're laying down,
they can't breathe, they're having all of these problems. It
never gets better. Even when they're resting, they're having symptoms.
So that's class one and four. Remember one, no symptoms,
four symptoms even at rest. Class three is going to
be their only comfortable at rest. They have even the
regular daily activities their ADLs. Their activity is a daily living,
walking around, doing the dishes, minor things that you and
me would have no issues with. They're having dyspnea and problems.
Even with that, they're only comfortable at rest. And then
class two is kind of like kind of in between.
They're gonna have mild symptoms. Most of their ADLs, they're
gonna be okay. They exert themselves a little bit more,
they may start to develop some symptoms. They're not completely
asymptomatic like Class one, they just have mild symptoms. So
again Class one no symptoms, Class four symptoms at rest,
Class three only comfortable at rest, and the Class two is
just basically mild symptoms. That's the New York Cart Association
class all right, So let's move onto diagnosis. There's really
four diagnostic tests that you need to be familiar with.
Those four tests, your best test is going to be
an ECHO. Your first test, like your initial test is
going to be a chess X, right, and then a
couple other labs like your BNP, and then an ECG.
So let's start and move our way down the line.
So let's do your first test. If they ask you,
what's your initial test they'll do for patients suspecting heart failure,
it's going to be a chest X right now. Chest
X ray is not diagnostic for congestive heart failure. It's
just not specific enough, but it is a good initial test.
And what are you gonna see on a chest X
ray that you need to know to suspect congestive heart failure? Well,
there's something known as cephalization of flow cephalization of flow,
and what this is is due to all the back
flow of blood into the lungs, you have this increased
pulmonary pressure which actually causes the vascular flow to migrate
up the lungs and go all the way to the apecs.
So because of the cephilization of flow, you're gonna have
two key findings, those key terms that you need to
be familiar with, that you need to know cause from
the cephilization of flow, that's curly B lines k E
R L E Y B lines and then butterfly or
bowing appearance in chest X ray. Of course you're gonna
have cardiomegaly plural effusion, but you know they're not gonna
ask you a question about that. They're gonna ask you
about these key findings. So what are curly B lines.
These are due to lymphatic encorgement or edema at the
lung periphery, so at the sides of the lungs and
a congestive heart failure patient. And at the sides or
the periphery of the lungs on chest sticks where you're
gonna see these short, little tiny one to two centimeter
thin lines. So these one to two centimeters little radio
opaque lines that most of the time, unless you're pretty
good at reading chest x raason, you probably completely miss.
But a radiologist will see that and know that it's
related to congestive heart failure. Potentially, there's other causes again,
and the other thing you should be familiar with is
something known as bat wing or butterfly appearance. This is
better with a visual, so check out my YouTube channel.
We gonna have pictures of all of these what I'm
going through the video. But this is another cause from
the accumulation of fluid. But in these cases, the fluid
is filling the high lar in the peri hyla region
of the lungs, and because of the location of the edema,
you're gonna have this bat wing appearance with these white
opacities in the lungs and it looks like the wings
of a bat wing or a bird or whatever you
want to think of butterfly. So it's just the location
of fluid overloaded in the lungs. So that's the initial
test that you'll do. Again. It's not really going to
be diagnostic, but it's a good first test to kind
of give you an idea that maybe this patient does
have CHF. Okay. So another initial test that you'll do,
especially if they're coming into the ear, is something known
as BNP. You'll also hear it known as pro BNP,
and that is either B type naturetic peptide. It also
used to be called brain naturetic peptide, but as the
newer name for it is B type naturetic peptide. So
what this is BNP is this peptide that's secreted by
the heart to regulate blood pressure and fluid in the body,
and it's released when you have the ventricle stretching. So
that's the body's way of knowing, okay, the ventricles are
stretching or being overloaded from fluid. They don't exactly know why,
so they release this and it's pumped out to kind
of regulate and make some changes in the blood pressure
and regulate the fluids in the body. Now, BNP is
also pumped out during renal failure. It can be decreased
in obese patients. So it's not one hundred percent specific,
but it's a good rule out test because if you
do a BNP in a patient you suggest has heart
failure and it's zero or it's completely normal less than
one hundred good chance that they don't have heart failure. Generally,
the number that you're looking for is a BNP over
one hundred, you should be thinking there's a pretty good
chance that this PATI could have heart failure. So BNP
overall one hundred, you should be suspecting heart failure, but
be aware there's other things that can elevate it as well.
So that's another good lab test to do, and it's
really good in guiding treatment when you have like decompensated
heart failure to see the response that treatment. But you
should know that one as well. That's your BNP or
pro BNP. Another one that's it's not a bad test,
but it's again not going to be diagnostic, is your ECG.
So it's another good rule out test. And the reason
it's a good rule out test is because if this
patient has systolic heart failure so heart failure with reduced
ejection fraction, if they have a normal ECG, there's a
very small chance that they have heart failure. It's a
ninety eight percent predictive value if it's a negative that
they don't have heart failure. But yeah, on the flip
side of that, if they have preserved ejection fraction. A
lot of times the ECG is going to be normal,
so get a good rule out test for systolic, but
not so much for diestolic. And again if it's positive,
if you do see abnormalities on ECG, doesn't mean it's
heart failure. It's another good rule out test, but again
non diagnostic. Now, the best test overall is going to
be your echo. So your your echo is going to
measure your ejection fraction. It's going to measure or evaluate
the ventricular wall see if they're thinning like in systolic
her failure. It's going to be able to get a
really good idea of the function of the heart and
to diagnose heart failure. So overall, echo is going to
be your best test. That's the one you really need
to be familiar with and know for the exam if
they do ask you what your best test is. Okay,
So let's move on to treatment. So treatment of systellic
heart failure aka heart failure with reduced ejection fraction. Let's
start with some lifestyle interventions. Then we'll hit the MEDS,
which is the highest deealed component for the exam. So
to start of course, associated conditions and underlying causes should
be appropriately managed. Coronary art disease, valve disease associated conditions
like hypertension diabetes should all be properly managed, and then
as far as lifestyle modifications, of course, cessation of smoking
is essential, abstinence from alcohol consumption or at least restricting alcohol,
avoidance of obesity, and then restricting sodium intake. Depending on
the source, the specific number can vary, so I wouldn't
focus too much on a specific number, but up to
date does suggest less than three grams a day, and
in patients with more severe or refractory heart failure, restricted
fluid intake to one point five to two liders a
day may be recommended, and of course daily weight monitoring
to detect fluid accumulation is also recommended. Let's move on
to our pharmacologic therapy because this is what you need
to know for the exam. So these meds are the
primary therapy for heart failure with reduced ejection fraction. These
are the four that you absolutely need to know. These
meds not only improve symptoms but most importantly prolonged patients survival.
So for meads or classes you need to know in
patients with heart failure with reduced ejection fraction. These will
typically be combination therapy with one agent from each of
the following classes. So these classes are ar and i's
beta blockers, MRAs, and sglt too inhibitors. Let's start with
our arni's or our class, which is our rien and
angiotenson system inhibitors. We have a number of options arnis
ace inhibitors ARBs, which you choose that would be ar
and I specifically cycubitril valsartan, which is also known as Intresto.
That's the brand name and you'll see this being utilized
very often. It's an angiotensin receptor neprilicin inhibitor, which is
composed of an AR and B an inhibitor of neprilicin,
which is an enzyme that degrades naturitic peptides, bradickinin and
other phasoactive peptides. And it's preferred over aces in ARBs
due to improved efficacy relative to these other classes, and
in patients who can't tolerate ARNI therapy or due to costs,
can't obtain it. Aces and urbs are an option, but
ARNI is the preferred class, so it should be the
focus for the exam. Next is going to be beta blockers,
specifically metoprolol, carbadolol and bisoper law are the preferred agents
as these beta blockers have demonstrated mortality benefit, unlike the
other medications in the beta blocker class which lack comparable evidence.
Next is going to be our MINERALI coord cord receptor
antagonist that's a planinone and spirinal lactone, A playerone is
usually preferred over spirinal lactone due to a lower risk
of endocrine side effects like ganocomasitia and impotence. And then
finally we have our SGLT two inhibitors. These are amazing drugs.
We use them in diabetes CKD and of course part failure.
So our sodium glucose cotransporter to inhibitors like dapicla flows
in which is Farsiga or empical flows in which is Jardiance.
So those are the four meds or classes you need
to know. There is one other med that does have
proven mortality benefit, that's hydrolyzene plus nitrate, but this is
not a first line med and really just a backup
option for patients who cannot tolerate an ar and I
or an ASR and R. So I want you to
remember these for the exam. This is super important. It's
probably the highest yeald thing to know for heart failure.
So here's anomonic to help you remember them. To remember
the main meds you need to know for management of
heart failure with reduced ejection fraction aka systemic heart failure,
remember bash the heart to make it beat harder. Bash
the heart to make it beat harder helps you remember
the meds with proven mortality benefit in systellic heart failure.
BASH is spelled B ashe, so let's start with B.
That's again going to be our beta blockers mitoprol, carveatal
olbit SOAPROLAW. Next to A stands for ar and I,
our angiotensen receptor blocker, and aprilicin inhibitor, which is secure
patrol of al sartan ace inhibitors or ARBs are an
I backup, which also start with A if an AR
and I is not appropriate or affordable. Next is going
to be our sglt twos our sonium glucose cotransporter to
inhibitors to epical flows in epical flows. In next hydroalyzene
plus nitrate. Again, this is not a first line med
but it is a medication with proven mortality benefit, so
it is appropriate. Here also helps them on, so it's
good to be aware of. But really we're only going
to use this again if any of our A medications
aar andies ACES or ARBs were not tolerated or not
appropriate for whatever reason, maybe patients with hyperkalemia or kidney dysfunction.
So again just know this med does have proven mortality benefit,
but it's not first line. And then finally we have
our MINERALI cord cooid receptor antagonists, which are a plaranone
and spirinal lactone. And in this case we're using the
E for BASH because a planaranone is preferred over spyirinal
lactone due to its more favorable side effect profile, and
therefore it's the one you should know. Okay, again, meds
you need to know for systallic heart failure with proven
mortality benefit, bash B ashe the hard to make it
beat harder beta blockers aar andies sgot two hydraulazine and
a plaranone. Know those and you should be good for
the exam. Now there are other medications of these are
more for symptomatic relief, so diuretics like furosamide will be
used in patients with persistent volume overload to help eliminate
clinical evidence of fluid retention. So obviously plays a large
role in patience with acutely decompensated heart failure, and the
diuretic most commonly used will be freeurosimide. And then we
have some secondary options. So the secondary options are in
patients who cannot tolerate the primary regimen or have residual
heart failure symptoms despite optimal therapy. These are not commonly use,
so I don't think you need to menimalize them, but
just be aware that they do exist. This is going
to be EVI a braiden verisiguat digoxin hydrouzene plus nitrate
that we talked about before again, so don't really need
to focus too much on these. These aren't high yield,
but these are secondary or backup options if our primary
therapy can't be utilized for whatever reason. Right, So, treatment
of heart failure with preserved ejection fraction or diestolic car
failure is a little different than systolic car failure that
there is no clear evidence that pharmacologic therapy or other
therapies reduce the risk of mortality in these patients. So
if you're feeling overwhelmed and maybe want to skip a section,
this would be the one, as there are no high
yield meds to know here. In general, you'll treat these
patients associated conditions just like you would anyone else. Hypertension,
a fib coordinary ardor disease, et cetera. You'll suggest die
in an exercise cardiac rehab. And if you want to
just remember one med class, this would probably be as
up to date recommends this as initial therapy for most patients,
and that's going to be an SGLT two inhibitor like
empical flowsen or dapical flows in. This is going to
be initial therapy for most patients, So this would be
the one if you want to remember one med class,
this is the one to know. Second line would be
a MINERALI cord chord receptor antagonist, so like spirriinalactone or
a plaranone, And in this case there is an additional
agent called fenerenone, which is a newer non steroidal mineral
chord cord receptor antagonist. You're obese patients, we can use
GLP one receptor agonists like symaglotide or two zepetide. These
meds have shown benefit in patients with obesity and heart
failure with preserved dejection fraction. And then the patients with
volume overload, you'll use diuretics, just like we were talking
about before. This is usually going to be a loop
diuretic like thurosamide. So bottom line here, if you want
to remember one med class for heart failure with preserved
dejection fraction, let it be SGLT two inhibitors. But not
a lot to know here otherwise, so I wouldn't waste
too much time, all right, And remember one last thing
about the treatment. Outside of your pharmacologic treatment, there's some
mechanical devices. So as these patients progress with heart failure,
once they get to like stage four, their rejection fractions
under thirty five percent, the treatment in addition to pharmacologic
therapy is actually going to include a left ventricular assist device,
which is an implantable device that helps the failing heart
to contract with mechanical assistance. They also may have an
AICDM planet, which is an automatic implantable cardioverter defibrillator. These
are patients again in the last stages, and ultimately once
they get to stage four, death normally occurs within a
year without heart transplant. So once you get to that point,
you just kind of use everything you can to preserve
life as long as possible. Okay, so that is heart failure.
Thank you so much. As always, I know I said
it in the beginning, and I'll say it every time
because I do appreciate the comments. It really does make
my day.