Adult Cardio 5 (Heart Failure) Flashcards
Approximately __ million patients in the US have heart failure
6
Over ____ patients are diagnosed with heart failure for the first time each year
550,000
Heart failure is the primary reason for __-__ million office visits and 6.5 million hospital days each year
12-15
Heart failure is the most common ____ diagnosis-related group
Medicare
In 2009, ____ patients died of heart failure as a primary/secondary cause
275,000
In incidence of heart failure approaches ___ per 1000 people after the age of 65
10
More dollars are spent for the diagnosis and treatment of heart failure than any other ___ by Medicare (2007: $33 billion)
Diagnosis
Before age 80, do males or females have a higher prevalence of heart failure?
Males
After age 80, ____ have a higher prevalence of heart failure
Females
Risk factors for heart failure:
-Hypertension
-Myocardial infarction
-Diabetes
-Obesity
-Idiopathic cardiomyopathy
-Infection (e.g., viral myocarditis)
-Old age/male sex/AA
-Abnormal conduction (Left bundle branch block)
-Heart valve disease
-Prolonged arrhythmias
-Toxins (alcohol, cytotoxic drugs, etc.)
Although heart failure is a major public health problem, there are no national ___ ___ to detect the disease at its earlier stages
Screening efforts
Heart failure is largely ____, primarily through the control of blood pressure and other vascular risk factors
Preventable
Until recently, however, the factors that render a patient at a high risk for heart failure has not been clearly ___ or ___
Defined/publicized
Staging of heart failure is necessary for targeting therapy and improving the ___ ___ ___
Quality of life
Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to ___ with (diastolic) or ___ blood (systolic)
Fill/eject
Since not all patients have ___ ___ at the time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive heart failure”
Volume overload
Heart failure is not a disease by itself, but rather a manifestations of various ___ ___
Cardiac diseases
The clinical syndrome is characterized by the reduced ability of the heart to…
-Fill with blood (diastole)
-Eject blood (systole)
What happens when the right side of the heart fails?
-More blood will back up to the body causing edema
-Less blood will be ejected to the lungs, causing deoxygenation
What happens when the left side of the heart fails?
-More blood will back up to the lungs, causing pulmonary edema and shortness of breath
-Less blood will be ejected to the body, causing activity intolerance and fatigue
-Vital organs (brain and kidney) will receive less blood
Heart failure can lead to pressure build-up, which causes symptoms like…
-Difficulty breathing
-Ascites
-Peripheral edema
Heart failure can also cause poor pumping which can lead to symptoms like…
-Neurological problems
-Reduced urine output
-Fatigue
Currently, a complex blend of structural, functional, and biologic alterations are evoked to account for the ____ nature of heart failure and to explain the efficacy or failure of therapies used in clinical trials
Progressive
The rationale for the use of ___-___ in a patient with a poorly contracting heart is based on a conceptual framework broader than that which suggests the treatment of congestion with diuretics or digoxin
Beta-blockers
The New York Heart Association (NYHA) classifies stages of heart failure based on…
Functional limitations
NYHA class I of heart failure characteristics:
-No limitation on physical activity
-No overt symptoms
NYHA class II of heart failure characteristics:
-Slight limitation on physical activities
-Comfortable at rest, but ordinary physical activity causes symptoms of heart failure
NYHA class III of heart failure:
-Marked limitations on physical activities
-Comfortable at rest, but less than ordinary activity causes symptoms of heart failure
NYHA class IV of heart failure:
-Inability to carry on any activity without symptoms
-Presence of symptoms even at rest
Stages A-D of heart failure classify heart failure based on ___ ___
Structural abnormalities
Stage A of heart failure:
At high risk for heart failure but without structural heart disease or symptoms of heart failure
Stage B of heart failure:
Structural heart disease but without signs or symptoms of heart failure
Stage C of heart failure:
Structural heart disease with prior or current symptoms
Stage D of heart failure:
Advanced heart failure
Treatment for those with Stage A HF:
-Risk-factor reductions
-Patient and family education
Treatment for stage B HF:
-ACE Inhibitors or ARBs in all patients
-Beta-blockers in selected patients
Treatment for stage C HF:
ACE inhibitors and beta-blockers in all patients
Treatment for stage D HF:
Inotrope drugs
What neurohormonal concepts can impact systolic heart failure?
-Renin-Angiotensin-Aldosterone System
-Sympathetic nervous system
What structural abnormalities can impact systolic heart failure?
-Myocardial remodeling
-Cardiomyopathy
-Mitral regurgitation
-Arrhythmia and BBB
What are the short-term effects of salt and water retention?
Augments preload
What are long-term effects of salt and water retention?
-Pulmonary congestion
-Anasarca
What are the short-term effects of vasoconstriction?
Maintains blood pressure for perfusion of vital organs
What are the long-term effects of vasoconstriction?
-Exacerbates pump dysfunction (excessive afterload)
-Increases cardiac energy expenditure
What are the short-term effects of sympathetic stimulation?
Increases heart rate and ejection
What are the long-term effects of sympathetic stimulation?
Increases energy expenditure
What are the negative effects of catecholamines?
-Directly toxic
-Induces myocyte apoptosis
-Myocardial remodeling
-Down-regulation of adrenergic receptors
-Facilitate arrythmias
-Potentiation of autoimmune effects
Negative effects of aldosterone:
-Myocardial fibrosis
-Autonomic dysfunction
-Dysrhythmias
Negative effects of angiotensin II:
-Directly toxic to myocardium
-Mediates remodeling of ventricular wall
-Loss of contractility
-Associated with increased mortality
Negative effects of vasopressin:
-Antidiuretic hormone
-Exacerbates hyponatremia and edema
Steps of heart failure progression:
-Increased peripheral vascular resistance
-Increased resistance to ventricular ejection (afterload)
-Increased workload for the left ventricle
-Neurohumoral changes (RAA and SNS)
-Hypertrophy
-Increased myocyte demand for oxygen (relative ischemia)
-Ventricular remodeling
-Decreased contractility (decreased cardiac output and underperfusion of vital tissues)
Increased levels of circulating ____ are only part of the response seen in heart failure
Neurohormones
Left ventricular ___ is the process by which mechanical, neurohormonal, and possibly genetic factors alter ventricular size, shape, and function
Remodeling
Hallmarks of remodeling include…
-Hypertrophy
-Loss of myocytes
-Increased interstitial fibrosis
After a myocardial infarction, the acute loss of myocardial cells results in abnormal loading conditions that involve not only the border zone of the infarction, but also the ___ ___
Remote myocardium
These abnormal loading conditions induce ____ and change the shape of the ventricle, rendering it more spherical, as well as causing hypertrophy
Dilation
Remodeling continues for ____ after the initial insult, and the eventual change in the shape of the ventricle becomes harmful to the overall function of the heart as a pump
Months
The primary problem that causes remodeling is __ ___, which leads to lowered stroke volume, increased left ventricular end-diastolic volume, cardiac dilation, and increased preload
Impaired contractility
Preload (LVEDV) increases with…
-Decreased contractility
-Increased plasma volume
Increased afterload causes…
-Low perfusion
-Increased peripheral vascular resistance
-Increased myocardial workload
-Increased Mv02 in the face of decreased myocardial oxygen delivery
Ventricular remodeling is when a chronic intracellular state of ____ results in progressive myocyte contractile dysfunction (cellular hypertrophy and collagen deposition between cells)
Hypoxia
Remodeling precedes symptoms, continues after symptoms, and worsens symptoms despite ____
Treatment
Several trials involving patients who were studied after a myocardial infarction or who had dilated cardiomyopathy found a benefit from…
-ACE inhibitors
-Beta-adrenergic antagonists
-Cardiac resynchronization
Such beneficial effects were associated with so-called ___ ___, in which the therapy promoted a return to a more normal ventricular size and shape
Reverse remodeling
The reverse-modeling process is a mechanism through which a variety of treatments palliate ___ ___
Heart failure
____ refers to diseases of the heart muscle where it becomes enlarged, thick, or rigid (in rare cases, the muscle tissue in the heart is replaced with scar tissue)
Cardiomyopathy
As cardiomyopathy worsens, the heart becomes ___ and is less able to pump blood through the body and maintain a normal electrical rhythm
Weaker
In cardiomyopathy, the process of progressive ___ ___ or ___ occurs without the initial apparent myocardial injury (e.g. MI)
Progressive ventricular dilation or hypertrophy
What are the three types of cardiomyopathy?
-Dilated
-Hypertrophic
-Restrictive
In dilated cardiomyopathy, the ventricles ____
Enlarge
In hypertrophic cardiomyopathy, the walls of the ventricles ___ and become ___
Thicken; stiff
In restrictive cardiomyopathy, the walls of the ventricles still become ___, but don’t necessarily thicken
Stiff
Dilated cardiomyopathy is responsible for ___ deaths and ____ hospitalizations
10,000; 46,000
Dilated cardiomyopathy is most common in ___ age
Middle
Is dilated cardiomyopathy more common in men wor women?
Men
Idiopathic dilated cardiomyopathy is a primary indication for ___ ___
Cardiac transplant
Etiology of dilated cardiomyopathy:
-Idiopathic
-Alcohol
-Myocarditis
-IHD, VHD
-Postpartum
-Radiation therapy
-Chemotherapy (doxorubicin, daunorubicin)
-Genetic
-Cocaine abuse
-Connective tissue diseases
-Neuromuscular diseases
-Sarcoidosis, hemochromatosis
-Pheochromocytoma
Pathophysiology of dilated cardiomyopathy:
-Injured myocytes replaced by connective tissue
-Myocardial fibers lengthen and ventricles dilate
-CO falls and left ventricle filling pressure rise
-Heart failure ensues
-Dilation of one or both ventricles
-Primary consequence-systolic dysfunction
-Progressive deterioration
-Poor prognosis
Consequences of dilated cardiomyopathy:
-Decreased ejection fraction
-Increased end-diastolic and residual volumes
-Decreased ventricular stroke work
-Biventricular heart failure
Signs and symptoms of dilated cardiomyopathy:
-Dyspnea due to pulmonary congestion
-Fatigue
-Palpitations
-Systemic and pulmonary emboli
-Chest pain
-Extra heart sounds and murmurs
Hypertrophic cardiomyopathy can be seen in ___-___% of people (1 in 350-624 people)
0.16-0.29%
Etiology of hypertrophic cardiomyopathy:
-Genetic disease of cardiac sarcomere (autosomal dominant patterns of inheritance)
-Myocardial hypertrophy (small or normal ventricular cavity, hyperdynamic ventricular function, diastolic dysfunction)
-Can be classified as either obstructive or nonobstructive
Pathophysiology of hypertrophic cardiomyopathy:
-Systolic function: hallmark is hypercontractility; normal cardiac output; ejection fraction is higher than normal
-Primary consequence is diastolic dysfunction (reduced distensibility and compliance)
Consequences of hypertrophic cardiomyopathy:
-Asymmetric thickening
-Disproportionate septal thickening
-Abnormalities of collagen deposition and altered contractile proteins in myocytes
-Hperdyanmic state (increased contractility and ejection fraction)
-Impaired diastolic relaxation- ventricles can’t fill
Signs and symptoms of hypertrophic cardiomyopathy:
-Sudden onset of VT or VF
-Angina
-Syncope
-Palpitations
-LV heart failure
-MI can occur if ventricular myocardium outgrows its blood supply
Restrictive cardiomyopathy has a greater incidence in the ___ population, especially in ___
Elderly; women
Etiology of restrictive cardiomyopathy:
-Idiopathic
-Familiar
-Amyloidosis
-Inborn metabolic errors
-Hemachromatosis
-Sarcoidosis
-Radiation
Pathophysiology of restrictive cardiomyopathy:
-Primary consequence: diastolic dysfunction
-Non-dilated ventricle with normal wall thickness
-Ventricular walls are rigid (severe diastolic dysfunction causing elevated filling pressures and dilate atria)
-Normal left ventricle systolic function
Consequences of restrictive cardiomyopathy:
-Myocardium becomes rigid and non-compliant
-Impedes ventricular filling (diastolic dysfunction)
-Impaired contractility (Systolic dysfunction)
Signs and symptoms of restrictive cardiomyopathy:
-Exercise intolerance
-Weakness
-Dyspnea
-Edema
-Heart failure
-Dysrhythmias
___ ___ is a deleterious outcome of remodeling
Mitral regurgitation
With mitral regurgitation, as the left ventricle dilates and the heart assumes a more globular shape, the geometric relationship between the papillary muscles and the mitral leaflets changes, causing ___ ___ and ___ ___ of the leaflets and distortion of the mitral apparatus
Restricted opening and increased tethering
Dilation of the annulus occurs as a result of increasing left ventricular or atrial size or as a result of regional abnormalities caused by ___ ___
Myocardial infarction
The presence of mitral regurgitation results in an increasing volume overload on the overburdened ___ ___ that further contributes to remodeling, the progression of the disease, and symptoms
Left ventricle
___ ___ (arrhythmia) is the primary precipitating event that happens before the onset of heart failure
Atrial fibrillation
Atrial fibrillation is a very rapid ___ ___ due to the chaotic and irregular contraction of the atria
Heart rate
The contraction of the atria is out of coordination with the hat of the ____, resulting in improper and inefficient cardiac cycle
Ventricles
Episodes of atrial fibrillation may be ___ or ____
Persistent or intermittent
With arrhythmias, elevated end-diastolic pressure in a patient with hypertension or abnormal myocardial function leads to ___ ___, which in turn incites electrical instability
Atrial stretch
Atrial fibrillation further compromises ___ ___, leading to aggravating neurohormonal compensatory mechanisms and subsequent cardiac compromise and remodeling
Cardiac output
A ___ ___ ___ (BBB) is a result of altered conduction properties observed in response to ischemia, inflammation, fibrosis, and aging
Bundle branch block
The presence of a BBB also affects the mechanical events of the cardiac cycle by causing…
-Abnormal ventricular activation and contraction
-Ventricular dyssynchrony
-Delayed opening and closure of the mitral and aortic valves
-Abnormal diastolic function
Pathophysiology of a BBB:
-Reduced ejection fraction
-Decreased cardiac output and atrial pressure
-Increased left ventricular volume
-Mitral regurgitation
-Inhomogenous activation
-Paradoxical septal motion
-Repetitive ventricular contractions
-Ventricular repolarization dispersion
-Ventricular arrhythmias
-Sudden cardiac death
It is estimated that 20-50% of patients with heart failure have preserved ___ function or a normal ___ ___ ___ ___
Systolic; left ventricular ejection fraction
Although such heart contracts normally, ____ is abnormal and it occurs singly or in combination with systolic heart failure
Relaxation (diastole)
With diastolic heart failure, ___ ___, especially during exercise, is limited by the abnormal filling characteristics of the ventricles
Cardiac output
The result of diastolic heart failure is elevated ___ ___ and subsequent ___ ___ despite normal stroke volume and cardiac output
Ventricular pressure, pulmonary congestion
Causes of diastolic heart failure:
-Hypertension (myocardial hypertrophy)
-Myocardial ischemia (ventricular remodeling)
-Diabetes
-Diseases of aortic valve, mitral valve, or pericardium
-Cardiomyopathies
With diastolic heart failure, there is decreased compliance, and abnormal ___ ___
Diastolic relaxation
With diastolic heart failure, normal left ventricular end-diastolic volume causes increased…
Left ventricular end-diastolic pressure
Diastolic heart failure is manifested as…
-Dyspnea on exertion
-Fatigue
-Pulmonary edema
-Pleural effusions
Systolic heart failure affects people of all ages (typically age 50-70), while diastolic heart failure frequently affects ____ people
Elderly
Diastolic HF is more common in ___ while systolic HF is more common in ___
Female; Male
Left ventricular ejection fraction is ___ or ___ with diastolic heart failure, but depressed with systolic HF
Preserved or normal
Left ventricular cavity size is usually ____ with diastolic HF but ___ with systolic HF
Normal; dilated
Since no one single pathophysiological model can account for the host of clinical expressions of heart failure, current therapy often targets more than one ___ ___
Organ system
