Acute Decompensated Heart Failure

Question 1

Heart failure is a complex clinical syndrome characterized by systemic perfusion inadequate to meet the body’s metabolic demands as a result of impaired cardiac pump function. Decrease in cardiac output results in inadequate tissue perfusion and pulmonary systemic congestion.

Answer 1

Heart failure is divided into systolic or diastolic failure. It is also sometimes referred to as right- or left-sided heart failure, and most recently preserved or reduced ejection fraction heart failure.

Question 2

Heart failure with reduced ejection fraction (HFrEF) or systolic heart failure (systolic dysfunction) -

Answer 2

Occurs when the heart muscle does not contract with enough force. There is reduced cardiac contractility, so there is not enough oxygen-rich blood pumped throughout the body. An ejection fraction less than 40% indicates systolic heart failure.

Question 3

Heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure (diastolic dysfunction)

Answer 3

Occurs when the heart contracts normally (a normal ejection fraction) but the ventricle does not relax. There is impaired cardiac relaxation and abnormal ventricular filling, and less blood enters the heart during normal filling.

Question 4

What percentage of blood is pumped out of the left ventricle with each heart beat?

Answer 4

55%

Systolic heart failure is 20%-40%

Question 5

The ejection fraction is an important measurement in determining how well the heart is pumping out blood and in diagnosing and tracking heart failure.

Answer 5

Patients will undergo an echocardiogram (ECG) to determine the ejection fraction.

Question 6

What is Ejection Fraction (EF):

Answer 6

A measurement of the amount of blood pumped out of the left ventricle with each heartbeat. In a normal person, the ejection fraction equals about 55% or more. If someone has systolic heart failure, the ejection fraction will be about 20% to 40%, or even less.

Question 7

Left-Sided Heart Failure

Answer 7

The heart’s pumping action moves oxygenated blood from the lungs to the left atrium and then on to the left ventricle, which pumps it to the rest of the body. The heart’s pumping power comes from the left ventricle; as a result, it is larger than the other chambers and essential for normal function. In left-sided or left ventricular (LV) heart failure, the left side of the heart must work harder to pump the same amount of blood.

There are two types of left-sided heart failure; drug treatments are different for the two types:

Systolic Heart Failure
and
Diastolic Heart Failure

Question 8

Systolic Failure -

Answer 8

The left ventricle loses its ability to contract normally. The heart can’t pump with enough force to push enough blood into circulation.

Question 9

Diastolic Failure -

Answer 9

(also called diastolic dysfunction) - The left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can’t properly fill with blood during the resting period between each beat.

Question 10

Right- Sided Heart Failure

Answer 10

The heart’s pumping action moves deoxygenated blood that returns to the heart through the veins through the right atrium into the right ventricle. The right ventricle then pumps the blood out of the heart and then into the lungs to be oxygenated.

Question 11

Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure.

Answer 11

When the left ventricle fails, increased fluid pressure is forced back through the lungs, ultimately damaging the heart’s right side. When the right side loses pumping power, blood backs up in the body’s veins. This usually causes swelling in the abdomen, legs and ankles.

Question 12

The majority of heart failure patients present with:

A. Right-sided heart failure
B. Left-sided heart failure
C. Aortic regurgitation
D. Cardiogenic shock

Answer 12

B. Left-sided heart failure

The majority of patients will experience left-sided heart failure. Right-sided heart failure is usually the result of left-sided heart failure.

Question 13

The structural changes that result from heart failure is generally known as cardiac remodeling.

Answer 13

The left ventricle is thick and stiff (hypertrophy), which will cause the valves to leak due to increased pressure.

The changes to the left ventricle prevent the heart from pumping oxygenated blood to the rest of the body adequately.

Question 14

Most heart failure occurs due to systolic dysfunction, which is a gradual decline in myocardial contractility; it is defined by left ventricular EF of less than 50%. Most cases are a result of:

Answer 14

End-stage coronary artery disease

History of myocardial infarction

Chronically under-perfused myocardium

Idiopathic dilated cardiomyopathy

Valvular heart disease

Hypertensive heart disease

Toxin-induced (chemo, alcohol)

Congenital heart disease

Question 15

When there is a decrease in the contractile force and there is complete ventricular ejection, the stroke volume and cardiac output also decreases. With the decrease in the ventricular ejection, the accumulation of blood will raise the volume and pressures in the ventricles; as a result, the EF will be reduced.

Answer 15

This systolic dysfunction commonly occurs due to myocardial infarction, myocarditis or cardiomyopathy. This will lead to left ventricular failure or right ventricular failure. Left ventricular failure usually occurs before right ventricular failure.

Question 16

At least half of the HF population has a normal or near-normal left ventricular ejection fraction (LVEF). Even more striking is the observation that the percentage of patients with heart failure with preserved ejection fraction appears to be increasing in relation to the percentage that have heart failure with reduced ejection fraction.

Answer 16

The reason for this shift in the ratio between preserved EF heart failure and reduced EF heart failure is related to differences in the causes of these conditions. Although the underlying causes of preserved EF heart failure have yet to be fully understood, changes in the diastolic properties of the heart that occur with aging are clearly involved.

Question 17

As the mean age of the population increases, preserved EF heart failure will become more common. Advancement in technology of therapeutic interventions that limit myocardial damage (particularly in the setting of an acute myocardial infarction) should reduce the rate of occurrence of reduced EF heart failure.

Answer 17

As a result, preserved EF heart failure will emerge as the primary form of HF throughout the world in the not too distant future.

Question 18

A patient presents with 3+ pitting edema, weak peripheral pulses, and cool, clammy skin. HR is 90 bpm; BP is 100/76 mmHg. Lung sounds are clear. Which of the following diagnoses would you consider?

Left-sided heart failure
Right-sided heart failure
Cardiogenic shock
Chronic renal failure

Answer 18

Right-sided heart failure

These are typical findings of patients with right-sided heart failure. Lower extremity edema is not common for left-sided heart failure patients. Patients in cardiogenic shock are extremely hypotensive and unstable.

Question 19

What is Pulmonary Edema and what causes it?

Answer 19

When the left ventricle fails, it causes blood to accumulate in the pulmonary veins of the lungs, producing a dangerous rise in blood pressure within these veins.

Sustained high pressure in the pulmonary veins eventually forces some fluid from the blood into the surrounding alveoli.

As the alveoli fill with fluid, they can no longer provide adequate amounts of oxygen to the body.