19. Pathophysiology of Heart Failure Flashcards by Yash Kapoor

What is heart failure?

• Inability to maintain appropriate blood pressure
• Abnormality of the heart
• Characteristic pattern of haemodynamic, renal, neural and hormonal responses
(• Kidneys receive 35-40% of cardiac output - often fail when heart fails)

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What is the prevalence and incidence of heart failure?

Prevalence - 22m

* Incidence - 2m new cases annually

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What are 5 causes of heart failure?

Arrhythmia - mainly tachycardias
Valve disease - mitral or aortic regurgitation or valve stenosis
Pericardial disease - inflamed and fibrotic, heart can’t relax and pump as well
Congenital heart disease - holes or misconnections
Myocardial disease

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What are 4 types of cardiomyopathy?

Dilated (DCM)
Hypertrophic (can also be obstructive/asymmetrical septal) (HCM/HOCM/ASH)
Arrhythmic Right Ventricular (ARVC)

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What can an overdose on beta blockers lead to?

Decrease in heart rate

* Heart failure type syndrome

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What percentage of MI survivors develop heart failure?

50%

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How are deaths due to heart attacks and heart failure changing?

Heart attacks - declining

* Heart failure - increasing

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What is myocardial remodelling?

MI creates fibrotic and thin wall
Fibrous tissue expands (infarct expansion)
The rest of the heart tries to remodel to maintain normal pumping activity

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What is cardiomyopathy?

Heart disease in the absence of a known causes (5% of heart failure)

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Whats the most common cause of death in young athletes?

Hypertrophic cardiomyopathy

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What are the causes of dilated cardiomyopathy?

Alcohol (myocardial depressant)
Cocaine
Viruses e.g. Cocksackie
Chemotherapeutic and antiviral agents

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What is restrictive cardiomyopathy?

Heart can’t dilate properly
Preserved ejection fraction
Diastolic dysfunction - slow in relaxing
Associated with hypertrophy and scleroderma
Shortness of breath
Can be caused by infiltrative disorders - amyloidosis and sarcoidosis (infiltration of amyloid proteins and granulocytes into the heart muscle)

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What is the most common cause of death in heart failure?

Opportunistic arrhythmia
Sudden death
Acute coronary event

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Give an example of a non-cardiovascular cause of heart failure

Pneumonia
Pulmonary oedema
Metabolic shut down and death

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What changes is hormonal mediators occur in heart failure?

All switched on
Body thinks it’s bleeding to death
Increase in adrenaline and noradrenaline
Salt and water retention using the renin-angiotensin system
Vasoconstrictors produced by endothelial cells increased

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What drugs are useful in heart failure?

Most effective: beta blockers - blocks the sympathetic drive
ACE inhibitors
Aldosterone receptor antagonists - Spironolactone

What can be tested for in the blood for heart failure?

Raised ANP (atrial natriuretic peptide)

* Raised troponin I and T

What is the most common symptom of heart failure?

Tiredness

What is orthopnoea?

Breathlessness when lying down due - need to sleep propped up to decrease the pressure in the atria

What is PND (Paroxysmal Nocturnal Dyspnoea)?

Start sleeping propped up and then slip down
Wake up gasping for air
Need for fresh air
Sign of severe heart failure

Why do heart failure patients have an increased heart rate?

Maintain cardiac output

What is the pulse and venous pressure like in heart failure patients?

Pulse - weak

* Venous pressure - increased due to elevated right sided pressure

Why do heart failure patients have peripheral oedema?

Salt and water retention

What sounds are heard in the heart in a patient with heart failure?

Crepitations of the bases

* Sounds like rubbing hair

What happens to the liver during heart failure?

Increases in size (hepatomegaly)

What are ascites?

* Abnormal accumulation fluid in the abdominal (peritoneal) cavity * Commonly caused by liver cirrhosis

What does a heart failure chest X-Ray look like and how do you take measurements?

* Width of heart may be more than 50% the width of the thorax * Increase in the cardio-thoracic ratio * Measure the widest part of the heart * Measure the distance between opposite ribs at the widest diameter * Compare

What is the New York Association classification of functional capacity?

(• A Functional classification) • Class I - dysfunctioning heart but virtually no symptoms • Class II - slight limitation of physical activity (ordinary activity) • Class III - marked limitation of physical activity (less than ordinary activity) • Class IV - limitation of any physical activity, discomfort at rest

Describe the progression of Heart Failure

* Onset of heart failure * Quality of life plateaus (decreases VERY slowly): sudden death and coronary events can occur during this time * As more coronary events occur, condition progresses from mild to severe * Death

Name 3 syndromes of heart failure

* Acute Heart Failure - associated with pulmonary oedema * Circulatory Shock - associated with cardiogenic shock * Chronic Heart Failure - untreated, congestive, undulating, treated, compensated

What does a patient with a blocked coronary artery look like?

* Sick * Tachycardic * Sweating * Sitting upright in bed * Breathless * Coughing up frothy sputum

What do you give to a patient with Pulmonary Oedema very quickly?

Diuretics to try and get rid of the fluid in the lungs

What can a Coronary Angiography and 2D echocardiogram be used for?

* Coronary Angiography - can show where there is a stricture | * 2D echocardiogram - see how the heart is actually pumping

What 7 things need to be carried out with a patient with suspected heart failure?

1) Establish that patient has heart failure 2) Determine aetiology 3) Identify relevant concomitant disease 4) Assess severity of symptoms 5) Predict prognosis 6) Anticipate complications 7) Choose appropriate treatment 8) Monitor progress and tailor treatment

What are the 3 objectives of treatment in Chronic Heart Failure?

1) Prevention - occurence and progression of myocardial damage - reoccurrence of symptoms 2) Relief of symptoms and signs - eliminate oedema and fluid retention - increase exercise capacity - reduce fatigue and breathlessness 3) Prognosis

What is a drug for atrial fibrillation?

Digoxin

What is the treatment pathway for Heart Failure (in terms of drugs used)?

1) Start ACE inhibitor and titrate upwards 2) Add beta-blocker and titrate upwards, if patient is stable 3) Add spironolactone, if patient remains moderately to severely symptomatic 4) Seek specialist advice for further options (Use diuretic or digoxin if needed)

What devices can you use for treating Severe Heart Failure?

* ICD (implantable cardioverter defibrillator) * Intra-aortic balloon pump * Ventricular assist device