Left heart failure is the most common cause of right heart failure. When anything causes left heart failure — ischemia, valve disease, cardiomyopathy, etc — the left ventricular pressure increases and transmits back to the lungs, causing pulmonary hypertension. This then strains the right heart and eventually causes right heart failure. Know the difference between signs/symptoms of left vs. right heart failure.

Remember the mnemonic PIRATES for the causes of atrial fibrillation. This is quite a comprehensive list:

• Pulmonary embolism, Pulmonary disease, Post-operative
• Ischemic heart disease, Idiopathic (“lone atrial fibrillation”), IV central line (irritating the right atrium)
• Rheumatic valvular disease (mitral stenosis or regurgitation)
• Anemia, alcohol (“holiday heart”), Age, Autonomic tone (vagal atrial fibrillation)
• Thyroid disease (hyperthyroidism)
• Elevated blood pressure (hypertension), Electrocution
• Sleep apnea, Sepsis, Surgery

You will very likely get this one. Congestive heart failure, or CHF, is the number one cause of hospital admission in the United States. Whenever an individual comes in with volume overload from CHF, you must always as the question: “Why did this patient’s heart failure get worse?” The reasons are listed below, from most to least common:

1. Medication non-compliance (not taking diuretics or other medications)
2. Fluid/sodium restriction non-compliance
3. Acute worsening of cardiac output: Arrhythmia; ischemia or acute coronary syndrome; worsening or progression of cardiomyopathy or valve disease.

This one is easy. Beta-blockers, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and spironolactone. If a patient cannot tolerate ACE inhibitors or ARBs, the combination of hydralazine and nitrates are used — and also reduce mortality, especially in African Americans. Note that digoxin and diuretics do not reduce mortality. They are for symptom relief and to prevent heart failure hospitalization only. For you gunners, the Congestive Heart Failure – Systolic Topic Review provides an in-depth summary from pathophysiology to treatment.