2) heart failure etiology, classification, clinical presentation

Question 1

how can we know if the heart failure is a systolic or a diastolic dysfunction ?

Answer 1

systolic
CHF with reduced stroke volume,
reduced ejection fraction less than 40 percent ( increased end-diastolic volume (EDV)

diastolic
CHF with reduced stroke volume, normal/reduced EDV
PRESERVED EF

Question 2

what is the aetiology of systolic failure (most common) left ventricular ejection fraction is less than 40 percent

Answer 2

cardiac arrhythmia

myocarditis

increased after load - hypertension

DILATED cardiomyopathy - chagas disease , chronic alcohol

mechanical abnormalities - valve diseases

Question 3

etiology of diastolic failure which is less common ?

Answer 3

restrictive cardiomyopathy - idiopathic , CORONARYHD, ARTERIAL HYPERTENSION , COXSACKIE B VIRUS MYOCARDITIS / CHAGAS

hypertrophic cardiomyopathy - GENETIC

pericardial tamponade

constrictive pericarditis

Question 4

what are the general causes which is overlapping fro both systolic and diastolic

Answer 4

coronary artery disease - 1st major cause

myocardial infraction

hypertension - 2ND MAJOR CAUSE

valvular heart disease

diabetes mellitus - 3r major cause

renal disease

Question 5

what are the compensatory mechanism of heart failure ?

Answer 5

increased adrenergic activity -tachycardia,hypertension

RAAS - decrease in renal perfusion
angiotensin 2 - peripheral vasoconstriction - increase afterload :(
efferent arterioles vasoconstriction
aldosterone - increased sodium and water resorption

secretion of BNP (from ventricles)
increased ventricular filling and stretching
counter-regulatory system, to counteract vascular spasm from the adrenergic and RAAS system = decrease in bp

Question 6

what is the classification system of heart failure ?

Answer 6

new york heart association functional classification of heart failure
classes 1 to 4

ACC/AHA stages of heart failure
stages A-D

=========

acute heart failure killip

killip 1 - no signs for heart failure

2 rales , s3 , elevated jvp

3) acute pulmonary edema
4) cardiogenic shock or hypertension systolic bp less than 90

Question 7

describe the new york heart association (NYHA) classification ?

Answer 7

class 1 - no limitation of physical activity 
and no symptoms 

class 2 - slight limitation physical activity (after climbing two flights of stairs) 
comfortable at rest 

class 3 - marked limitation of physical activity (eg during daily activity - dressing ) 
but comfortable at rest 

class 4  - unable to carry out any physical activity 
and signs and symptoms present at rest

Question 8

what is AHA /ACC classification of heart failure which is NEWER

Answer 8

stage A 
high risk for heart failure without any structural heart changes  or symptoms of heart failure 
eg - hypertension
diabetes mellitus 
obesity 
coronary artery disease family history 
peripheral vascular disease 

stage B 
structural heart changes
but without signs and symptoms of heart failure 
eg - prior myocardial infraction 
left ventricular hypertrophy 
ejection fraction reduced 
(class 1- NYHA) 

stage C
structural heart damge with prior or current symptoms of heart failure
eg - fatigue , dyspnea , reduced exercise tolerance
(class 2 and 3)

stage D
refectory heart failure
marked symptoms at rest , despite maximal medical therapy.
(class 4)

Question 9

what are the specific signs and symptoms in left sided heart failure?

Answer 9

symptoms :
paroxysmal nocturnal dyspnea - attacks of severe shortness of breath and coughing
increased venous return due to peripheral edema resorption - the left ventricle cannot give a good output as the right therefor pulmonary congestion occurs

cardiac asthma - increased pressure in the bronchiole arteries and bornchostensosis

signs
bilateral basilar rales
crackles
cyanosis

later - tachypnea
respiratory acidosis- cheyne stokes breathing

Question 10

what are the signs and symptoms of right sided heart failure?

Answer 10

symptoms
abdominal pain and jaundice

signs :
jugular venous distention

kussmaul sign - distention of jugular veins when breathing( constrictive pericarditis and restrictive cardiomyopathy )

hepatojugular reflex

ascitis

hepatosplenomegaly

distended jugular veins

anorexia

ankle/ feet edema - PITTING

Question 11

what factors precipitate to acute decompensated heart failure ?

Answer 11

non adherance to medical regime

acute myocardial ischemia

uncorrected high blood pressure

arrhythmia

negative inotropic drugs-verapamil and nifedipine

Question 12

what are the general major signs and symptoms of heart failure ?

Answer 12

nocturia
fatigue 
tachycardia 
various arrhythmia 
dyspnea 
pluses alternans (left ventricular failure and cardiac tamponade)