7.1 Heart Failure and Hemodynamic Monitoring Flashcards
Heart Failure
- CVD is the leading cause of death
- Incidence/prevalence of HF has not decreased in over 2 decades
- Prognosis is bleak for HF
- Heart Failure is not a diagnosis, it is a constellation of signs and symptoms that result in the heart’s inability to pump blood forward at a sufficient rate to meet the bodies metabolic demands or only has the ability to do it when the cardiac filling pressure is abnormally high
- It is the most severe form of cardiac disease
Heart Failure
- The heart is too weak to pump efficiently. It does not have the cardiac output to meet the bodies metabolic needs
- Can either be caused by messed up heart muscles for contraction or stiff ventricles.
Causes of Heart Failure
FAILURE
F - Faulty Heart Valves (Tricuspid, Mitral, Pulmonic Valve, Aortic Valve) - Stenosis (too narrow) or Regurgitation (leaks back)
A - Arrhythmias (A-Fib or Tachycardia)
I - Infarction (MI, CAD) - Plaque built up in arteries that blocks nutrients going to the heart causing ischemia and cell death.
L - Lineage (Genetics, more at risk)
U - Uncontrolled Hypertension (Silent Killer due to no signs or symptoms) - High pressure causes ventricular stiffening causing it to not fill properly
R - Recreational Drug Use (Cocaine or Alcohol)
E - Envaders (Viruses or Infections)
Types of Heart Failure
- Either issue with contraction or filling (stiff)
Left Sided
- Pulmonary symptoms (crackles, SOB, orthopnea)
- CAN CAUSE RIGHT SIDED HF
Systolic Dysfunction (Left)
- Difficulty with left sided heart contraction
- Patients will have low ejection fraction (less than 40%) - Diagnosis contraction ability of left ventricle (amount of blood that is being contracted out of the ventricle)
- NORMAL EF IS GREATER THAN 50%
- Diagnosed with ECHOCARDIOGRAM, HEART CATHERDIZATION, NUCLEAR STRESS TEST.
Diastolic Dysfunction (Left)
- Difficulty with left sided heart filling
- Ventricle may have become to stiff to fill with blood but contracts normally
- Ejection fraction is normal (because there is not an issue with contraction)
D - Dyspnea
R - Rales (Crackles)
O - Orthopnea (WARNING SIGN)
W - Weakness (extremely tired)
N - Nocturnal Dyspnea (wake up in the middle of the night with extreme breathing difficulties)
I - Increased HR (due to increased backed up blood in heart - tachycardia)
N - Nagging Cough (can be bloody)
G - Gaining Weight (More than 2-3 pounds in a day or 5 pounds in a week is BAD)
Right Sided
- Systemic symptoms (peripheral edema, weight gain, ascites, hepatomegaly)
- Not as common as left sided HF
- Can also be caused by cor pulmonale (as a complication of COPD or long term high pressure in the arteries of the lung and right ventricle)
S - Swelling of hands, legs, liver
W - Weight gain (monitor weight daily)
E - Edema (pitting leg edema)
L - Large Jugular Vein Distension
L - Lethargic (extremely tired)
I - Irregular HR (A-Fib)
N - Nocturia (frequent urination in the middle of the night)
G - Girth (Ascites because of hepatomegaly which can cause difficulty breathing and anorexia due to pushing on the stomach)
Diagnosis
- BNP (B-Type Natriuretic Peptide) - BIOMARKER RELEASED BY VENTRICLE WHEN THERE IS EXCESSIVE PRESSURE ON THE VENTRICLE DUE TO HF (Average is less than 100, greater than 300 is mild, greater than 600 is moderate, greater than 900 is severe)
- Chest X-Ray to look for congestion or enlarged HF
- Echocardiogram
Triggers of Exacerbations
- Poor diet
- Infection
- Uncontrolled A-Fib
- Renal failure (due to fluid overload)
HF Classifications
1 - No limitations on physical activity (activity does not cause fatigue, palpitations, or dyspnea)
2 - Slight limitations on physical activity (activity can cause fatigue, palpitations, or dyspnea)
3 - Marked limitations on physical activity (Comfortable at rest)
4 - Unable to carry any physical activity and symptoms of HF may still persist even at rest.
Stages of HF
A - High risk due to presence of symptoms strongly associated with HF. There is still no objective evidence of CVD or symptoms.
B - Patients who have structural heart diseases associated with HF but no signs/symptoms
C - Patients have current or prior symptoms of HF associated with structural heart disease
D - Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy
Stages of HF Repeated
Pre-CHF
- Disorders that affect the heart or weakness of the heart but no symptoms
Stage 2
- Minor symptoms but otherwise healthy. May have heart conditions but lack definitive symptoms of HF. (Lifestyle change is recommended)
Stage 3
- Symptoms are regular and impact daily activity
Stage 4
- Severe symptoms throughout the day even while at rest.
Enzyme Studies
- Creatine Kinase (in heart muscles)
- Biochemical markers (Myocardial Proteins) - Troponin (I, T, C) - Detectable after MI damage and remains for 6 days
- Neurohormonal Hormones - BNP (Brain-Type Natriuretic Peptide that evaluates HF)
Hemodynamic Diagnostics
- Patient does not respond to empirical therapy for HF
- Differentiation between pulmonary and cardiac causes of respiratory distress
- Complex fluid status
- Pulse Ox
INCLUDES
- Arterial, central venous, pulmonary artery catheters
- These catheters monitor intracardiac and intravascular volume, pressure, and cardiac function
- EVALUATE PATIENT RESPONSE
Arterial Pressure Monitoring
- Invasive blood pressure monitoring through cannulation of a peripheral artery
Complications
- Infection
- Accidental blood loss
- Impaired circulation to extremities
Central Venous Pressure
- Measures pressure of the vena cava
- Estimates preload and right atrial pressure
- Inserted through the jugular vein into the right vena cava by the right atrium.
- NORMAL READING - 8-12 mmHg
Reflects
- Intravascular blood volume
- Right ventricular end-diastolic pressure
- Right ventricular functioning
Complications
- Infection
- Thrombosis
- Air embolism
Invasive Blood Pressure (IBP) Monitoring
- Direct measurement of arterial pressure by inserting catheter into suitable artery
- Cannula is connected to a sterile fluid filled system
Advantages
- Measures BP constantly beat by beat.
- Displays a wave-graph of BP
Pulmonary Artery Monitoring
Measure
- Both right and left ventricular function
- Pulmonary vascular status
- Measures right atrium, right ventricular, pulmonary artery, and pulmonary artery occlusion pressure (wedge pressure)
Complications
- Pneumothorax
- Infection
- Ventricular dysrhythmias
- Pulmonary artery rupture/perforation
OPTIMIZATION
- Monitor for air, blood, and stopcocks in the system
- MAINTAIN CONTINOUS PRESSURE AT 300 mmHg
- Square wave test to determine dynamic response
- Level to the phlebostatic axis and zeroing atmospheric pressure
Intermittent Thermodilution Procedure
- Measures cardiac output
- Ensure accurate amount of injectate volume in the syringe
- Inject volume smooth and rapidly (less than 4 seconds)
- Wait a minute between injections to allow catheter thermistor to return to baseline
Minimally/Non-Invasive Techniques
Bioimpedance (bio-reactive based cardiac output)
- Uses skin electrode sensors on thorax to measure cardiac output
Doppler
- Esophageal doppler measures descending aortic flow velocity
