28 - Heart Failure Flashcards
Heart Failure
Definition / Cardinal Manifestations
Clinical Syndrome
Inability of the heart to pump enough blood
to meet the metabolic demands of the body
Cardinal Manifestations:
Dyspnea** / **Fatigue** / **Fluid Retention
PROGRESSIVE if NOT TREATED
Ejection Fraction
How is it Measured?
Portion of the total ventricular blood volume that is ejected during each contraction.
Normal: > 50%
ECHCOCARDIAGRAM
&
CARDIAC MRI
most accurate
HF-rEF
Definition
HF-rEF = SYStolic Dysfunction = Dilated Cardiomyopathy
EF** **< 40%
Impaired Ventricular CONTRACTION
Results from:
Loss of Muscle Mass / Pressure / Volume Overload
DILATED / LARGE CHAMBERS
HF-pEF
Definition
HF-pEF = DIAStolic Dysfunction
EF** **> 50%
Impaired Ventricular RELAXATION
Results from:
VENTRICULAR STIFFNESS
THICK WALLS
Heart is strong, but the blood in the cavity is ALREADY NOT ENOUGH
Pathophysiology
HF-pEF
Ventricular Stiffness
LVH = Left Ventricular Hypertrophy – HTN
Myocardial Ischemia (MI)
Infiltrative Diseases: Amyloid / Sarcoid
Endomyocardial Fibrosis
Epidemiology:
50% of HF pts, but associated with less MORTALITY vs rEF
Pathophysiology
HF-rEF
PROGRESSIVE DISEASE
Initial Cardiac Insult:
MI / HTN
Idopathic/genetic - Valve abnormalities
Viral / Alcohol / Drugs / Pregnancy / Tachycardia
VV
PRIMARY DAMAGE
VV
Compensatory Mechanisms
↑Preload/Vasoconstriction/TachyCardia–>Ventricular Remodel
VVV
Secondary Damage by NEUROHORMONES
HF-rEF
Compensatory Mechanisms
↑PRELOAD / ↑AFTERLOAD
Chronic Volume Overload + ↑MVO2
TACHYCARDIA
↓Diastolic Filling Time –> Arythmias
↓B-receptor regulation
VASOCONSTRICTION
- *Neurohormones in HF**
- *BAD NEUROHORMONES –> Vasoconstriction & Na Retention**
RAAS + SNS
Angiotensin 2 - RENIN - NorEpinephrine
Endothelin / Vasopressin / Aldosterone
AT2 –> Cardiac Fibrosis
Renin / NE –> Myocyte Necrosis / Arrhythmias / ↓Inotropy
- *Neurohormones in HF**
- *BENEFICIAL HORMONES** –> VasoDILATION / Natriuretic
- *Nitric Oxide_ / _Natriuretic Peptides (ANP/BNP)**
- *Bradykinin / Prostacyclin**
NO
Vasodilator –> protects against ventricular remodeling
↓BV in HF
Natriuretic Peptides
↑proportional to degree of volume/pressure overload
inhibits RAAS + SNS
Offsets effects of toxic neurohormones
Vasodilation / Promotes natriuresis
Mainstays of HF-rEF Therapy?
- *RAAS INHIBITORS**
- *ACE / ARB / Aldosterone Antagonist**
BETA BLOCKERS
offset the effects of SNS-Activation
Function of BNP in Assessing HF
- *BNP < 100**
- *CAN RULE OUT HEART FAILURE**
- *BNP >400**
- *useful in HF diagnosis**
>450 <50y/o
>900 50-75y/o
>1800 >75y/o
Heart Failure Diagnostic Assessment
Chest X-ray
Cardiomegaly / pulmonary edema
ECG
prior MI / LVH / rhythm
Ejection Fraction
echocardiogram or cardiac MRI
Natiuretic Peptides
BNP/ANP released from myocardial tissue in response to ventricle stretch
HF SYMPTOMS / PHYSICAL EXAM
Backwards Flow
Heart can’t process all the volume –> ↑PRESSURE in previous Vessels
Leaky Fluid –> in other organs
Fluid BACKED UP in Abdominal Space
Ab Pain / Anorexia-Nausea / Bloating-Constipation / Ascites
Fluid Backed up in LUNGS
- *PND = Paroxysmal Nocturnal Dyspnea** (fluid in lungs when SLEEP)
- *Orthopnea / Tachypnea / Dyspnea / COUGH**
- *Bibasilar RALES (RRR) / Pulmonary Edema / S3 GALLOP** / Pleural Effusion
Other
Pitting Edema / JUGULAR VENOUS DISTENSION
HJR = Hepatojugular Reflux / HEPATOMEGALY
HF SYMPTOMS / PE
FORWARD FLOW
Symptoms from NOT ENOUGH OXYGEN –> TISSUES
Dyspnea on Exersion / Exercise Intolerance
Fatigue / Weakness
Tachycardia / Pallor / Cyanosis of Digits
- *Confusion / Alterned Mental Status**
- not enough oxygen reaching BRAIN*
HF Assessment
NYHA
FUNCTIONAL CLASS 1
NYHA Class 1
No Symptoms
w/
Ordinary Physical Activity
HF Assessment
NYHA
FUNCTIONAL CLASS 2
NYHA Class 2
Symptoms
w/
Ordinary Physical Activity
HF Assessment
NYHA
FUNCTIONAL CLASS 3
NYHA Class 3
Symptoms
w/
LESS THAN ORDINARY EXERTION
DAILY ACTIVITES = Dressing Up / Walking / Showering
HF Assessment
NYHA
FUNCTIONAL CLASS 1
NYHA Class 4
Symptoms at REST
Sitting / Standing / Laying
HF Asessment
AHA
STAGE A
AHA STAGE A
- *High Risk for HF**
- *+**
- without Structural Heart Disease or Symptoms*
HF Asessment
AHA
STAGE B
AHA STAGE B
- *Structural Heart Disease = low EF**
- *+**
- without SIGNS or SYMPTOMS*
HF Asessment
AHA
STAGE C
AHA STAGE C
- *Structural Heart Disease = low EF**
- *+**
- *Prior or Current Symptoms**
HF Asessment
AHA
STAGE D
AHA STAGE D
REFRACTORY HF
requiring:
Specialized Interventions = End Stage
HEART FAILURE
Patient Education
- *SODIUM RESTRICTION**
- *fluid restriction ~2L/day –> advanced patients ONLY**
Daily WEIGHTS
Exercise / Weight Reduction
Alcohol Avoidance
DRUGS THAT MAY EXACERBATE HF
NSAIDs / COX-2
Antiarrhythmics / Non-DHP CCB
Chemo Drugs / Gabapenting
Rosiglitazone / Pioglitazone
GLUCOCORTICOIDS
Drugs that may Exacerbate HF
NSAIDs** + **COX-2 Inhibitors
Most AntiArrhythmics / Non-DHP CCBs
Gabapentin / Glucocorticoids
Rosiglitazone / Pioglitazone
SOME Chemotherapeutic Drugs
