Cardio Block 2 Flashcards
What is the most important and weakest part of the visit when assessing heart valves?
PE- weakest
Hx/Diagnostic study- strongest
What are the common causes of aortic valve diseases?
Congenital bi/unicuspid- most common congenital heart Dz, seen in PTs <70y/o
Degenerative Ca+- wear/tear from atherosclerosis/CAD, seen in PTs +65/yo
Worldwide- RF, usually mitral valve involvement then aortic valve
How much of an AS occlusion is needed for Sxs?
What is the bodies remodeling response to AS/inc AL and what other issue can be forced to develop?
90% for Sxs to appear
Concentric hypertrophy, can lead to MR
What is the sequence of pathophysiologic changes seen in AS?
AS, Outflow obstruction, Inc EDP, Concentric* LVH, LVF, CHF, Subendocardial ischemia
Why does exertion syncope occur with AS during exercise?
Why does CHF occur?
LV can’t increase CO, dilation causes decreased cerebral perfusion pressure
Inc AL causes contractile dysfunction and inc LV diastolic volume/press, pressure backs into pulmonary vessels, inc alveoli congestion
What are the S/Sxs of AS
How are AS seen on PE?
Prolonged ASx period:
Exertion induced dyspnea, angina, dizziness
Harsh Cresc/Decresc at RUSB w/ bell/diaphragm, radiates to carotid
Narrow pulse pressure
Displaces PMI
Define Pulsus Parvus et Tardus
How does AS cause angina?
Weak and late/slow rising best appreciated at carotid/PMI and carotid at same time
Imbalance between supply/demand
Inc LVDP reduces coronary perfusion pressure gradient
How does AS present on ECG?
What Sx is seen in PTs w/ severe form?
LVH, LAE, possible A-Fib
A-Fib leading to HF/Stroke
Where is A-Fib seen on an EKG?
How does AS appear on CXR?
Bi-phasic in V1 or Lead 2
LVH, Calcified leaflets, CHF if advanced
How does Echo appear on Echo?
Bicuspid aortic valves are associated w/ increased risks for ?
TTE shows inc wall thickness and determines severity
Aneurysm and Dissections
If AS can’t be seen w/ Echo, what test is ordered?
Who else receives this test?
CT or MRI
Candidates for Transcatheter Aortic Valve Replacement (TAVR)
When do AS PTs get an Exercise Test?
How are AS PTs treated?
Asx severe AS to confirm absence of Sxs
Limit activity
No optimal pharm Tx
Caution w/ anti-hypertensive meds
NO diuretics
How often do AS PTs receive Echos?
At Dx Mild= Q3-5yrs Mod= Q1-2yrs Sev= Q6-12mon Any time Sxs change
What is the only true effective Tx for PTs w/ severe AS?
What is the alternate procedure for kids and young adults w/ congenital AS?
Valve replacement- preferred method is transcatheter aortic valve replacement
Balloon aortic valvuloplasty
What type of PT gets a mechanical valve and what prophylaxis do they get?
Who gets a bioprosthetic valves?
Younger PTs, Coumadin
PTs that won’t live more than 10yrs, no coumadin
What is the prognosis of AS?
What AS PTs do we screen for unnoticed Sxs?
ASx- near normal survival Angina= <5yrs Syncope= <3yrs Dyspnea= <2yrs A-Fib precipitates overt HF and increases mortality rates
ASx PTs
What is the normal cross sectional area of the aortic valve?
What is the most common etiology of AI in developed countries?
3-4cm^2
Congential bicuspid
Dilation of aortic root- Marfans/Ehlers-Danlos
Acute AI is a medical emergency if it appears in ? situations?
Native valve Endocarditis Aortic dissection Traumatic rupture of leaflets Iatrogenic- failed valvotomy/valve repair
What is the sequence of pathophysiology events that occur in AI?
Acute AR is usually associated with rapid decompensation due to ?
AR, Vol overload, LV dilation, Wide Pulse Pressure, Inc wall tension, Pressure overlaod, LVH
Inability to accomodate inc end DBP
How is Chronic AR different than Acute?
How does this compensation cause a widened pulse pressure and what is unique about this change?
Dilation w/ less hypertrophy
Drop in aortic diastolic pressure
High LVSV, reduced DBP= Wide pulse pressure, HALLMARK of AR**
How does acute AI present?
How does chronic AI present?
Acute Pulmonary Edema
Wide pulse pressure, CHF Sxs, Angina, Atypical chest pain
What are 5 Signs associated w/ AI and what are they all indicative of an increased risk for?
De Musset- head bobbing w/ systole Corrigans- water hammer Quincke- nail bed pulsations Traube- pistol shot heard over radial/femoral Duroziez- to and fro heard over femoral
Inc stroke volume and widened pulse pressure
What type of murmur is AI?
AI valve etiology is best hear at ? while root etiology is best hear at ?
High pitched, blowing diastolic murmur at Erb’s point w/ PT leaning fwd and exhaling
Valve= LSB 2/4ICS Root= RSB and apex
Define Austin Flint murmur
Low rumble during mid systolic sound from normal diastolic flow from LA hitting anterior leaflet of MV, which is partially closed due to inc force of AR
AR + physiological MS w/out opening snap
How does AI look on EKG?
How does it look on CXR?
LVH, LAE, LAD
Strain pattern
LBBB
A-Fib
Acute= pulmonary edema/congestion Chronic= cardiomegaly, dilated ascending aorta
Why do PTs w/ AI get a radionuclide angiography/MRI?
What two tests can be ordered as follow up tests?
Initial and Serila assessment of LV volume and function at rest
Root angiography- hymodynamic measurements
Cardiac cath- when non-invasive tests are inconclusive/discrepant results
How are AI PTs managed with pharmaceuticals?
Nothing in ASx
ACEI, D-CCB or Hydralazine in severe cases w/ preserved LV function
BBs in PTs w/ Sxs or reduced LV function who are not surgical candidates
When do AI PTs get surgery?
Sxs and NYHA >2
EF <50%
ASx severe AI while undergoing CABG or surgery
What are the 3 ways to classify infective endocarditis?
What heart valve d/o is commonly affected by infective endocarditis?
Clinical- sub/acute
Host substrate- native, prosthetic, IVDA
Microbe- Staph, Strep
AS
Majority of US infective endocarditis PT are ? old and w/ ? issues
What valves are usually infected?
+60
Pre-existing structural heart Dz
AV > TV > PV
Drug abuse= TV
?? is the most common underlying cardiac condition in PTs w/ infective endocarditis
What PT population is at an increased risk of infective endocarditis?
MVP
Hypertrophic cardiomyopathy, especially w/ outflow obstructions
What risk factor is among the highest risk factors for subsequent infective endocarditis cases?
Nonbacterial thrombotic endocarditis can occur spontaneously in PTs w/ ? systemic illnesses?
Previous endocarditis
Marantic endocarditis of malignancy
Libman-Sacks endocarditis in Lupus Eryth.
What are the most common microbes in endocarditis on native valves?
What microbes are most common in IVDU PTs?
Strep, mainly Viridans
Staph A
Staph A
Strep
What are the most common microbes in prosthetic valve endocarditis when PT has had surgery within the past year?
What two microbes are the most common in PTs w/ prosthetic valves and surgery was more than 1yr ago?
Staph Epidermis
Staph A
Strep
Staph A
What are the risk factors for endocarditis
Age >60 Male Structural heart Dz Prosthetic valves Congenital heart Dz
Define Pentology of Fallot
VSD PS Misplaced aorta Thickened RV wall ASD
What are the non-heart Dz risk factors for endocarditis
Indwelling catheter (chronic hemodyalisis) IV drugs Hx of endocarditis infection Poor dental hygiene HIV
What conditions are needed inside of the body for endocarditis to start an infection process?
What is the most common cause of endocarditis adherence?
Endocardial surface injury
Platelet/fibrin thrombus formation
Bacteria enters circulation
Bacteria adherence to injured sites
Turbulent blood flow
Sterile vegetation is able to adhere to surfaces due to ?
What additional issue does this adherence material offer than promotes infections?
Fibrin deposits
Covers and protects vegetation from host defenses
Acute endocarditis usually presents with ? 2 Sxs and is due to ? microbe
Subacute endocarditis is usually due to ?
Rapid/high fever, New murmur
Staph
Low fever, non constitutional Sxs
50% of endocarditis PTs complain of ? issue
In 5-10% of cases, what is the chief complaint?
MSK Sxs- flank arthritis to diffuse myalgias
Low back pain/low grade fever w/ no osteomyeltitis or epidural abscess
What are the primary cardiac Dzs of endocarditis?
What are the secondary phenomena?
CHF signs from valve insufficiency
Focal neural from embolic stroke
Back pain w/ vertebral osteomyelitis
What are the common complaints of endocarditis PTs who abuse IV drugs?
How are acute and subacute infectious endocarditis Dxs differentiated?
Dyspnea, Cough, Angina
Due to TV involvement and secondary embolus in pulmonary vasculature
Subacute (Strep)= fever, fatigue, anorexia, back pain and weight loss
Less common Sxs= CVA or CHF
What are the 4 symptoms and 4 signs that appear in high frequency (>40%) of endocarditis?
S= Fever, Chills, Weakness, Dyspnea Sxs= Fever, Murmur, Skin lesion/emboli, Petechia
What are the S/Sxs of moderate frequency (10-40%) of endocarditis?
S: Olser nodes(painful)/Janeway lesion (painless), Splinter hemorrhages, Splenomegaly, Stroke, HF, Pneumonia, Meningitis
Sxs= Sweat, Anorexia, Cough, Stroke, Rash, N/V, HA, Myalgias/Arthralgias
What are the low frequency (<10%) S/Sxs of endocarditis?
How is steps are taken and labs ordered to help Dx endocarditis?
S: New murmur, Retinal lesion, RF
Sx: Ab pain, Delerium/coma, Hemoptysis, Back pain
Hx, PT, Blood culture, Echo, EKG, CXR
What murmur presents w/ hemoptysis?
What criteria is used to diagnose definite or possible endocarditis?
MS
Modified Duke criteria
Definitive= 2 major, 1 major 3 minor, 5 minor
Possible= 1 major 1 minor, 3 minor
What is unique about the presence of Strep Bovis/Strep Gallolyticus
Major criteria for Duke criteria include ?
Colorectal cancer
1) Typical microbes= Two +Blood cultures drawn 12hrs apart
2) Skin microbes= 3 or 4 or more blood cultures w/ first and last drawn at least 1hr apart
3) Single +Blood culture for Cox Burnetii (Q Fever) or Phase 1 IgG Ab titer >1:800
What are the 5 minor criteria of Duke Criteria?
IV drug use/Prosthetic heart valve Fever + 100.4/38*C or higher Vascular phenomenon Immunologic phenomenon Microbe evidence- only one positive
What labs are ordered for PTs w/ suspected endocarditis?
What are the major criteria for Echo?
Chem 7, CBC, UA, Blood cultures
Vegetation, New regurgitation, Abscess, TTE- initial TOC (large vegetations, quantifies dysfunction, non-invasive and easy)
TEE- >90% specific and more sensitive (small vegetation, prosthetic valves, prior valve abnormality, bad windows/deformity)
What type of EKG changes can indicate endocarditis?
What is the most common risk factor for enteric gram-negative endocarditis?
Conduction d/o, blocks- indicate peri-valvular involvement
Health care contact, not IV drug use
What is the diagnostic procedure of choice for suspected atrial myxomas?
If the search continues to be negative, what two microbes are considered last?
2D echo
Marantic/Libman-Sacks (Lupus and Myxoma)
HACEK spp microbes are mostly ?
Coxiella Burnetti
Oral flora, often w/ Hx of peridontal Dz
Exposure to raw milk, farms or rural areas
Brucella spp
Bartonella spp
Ingestion of contaminated milk/milk products
Henslae- Cat
Quintana- human body lice; homeless, alcohol abuse
Chlamydia psittaci
Nutritionally variant streptococci
Bird exposure
Slow/indolent course, MOST common
Legionella spp
Aspergillus and non-candidal fungus
Contaminated water, often nosocomial outbreaks, usually prosthetic valves
Prosthetic valves
Initial labs for endocarditis include ? and usually reveal ? results
CBC w/ Diff, Serum E+, Renal function, UA
Subacute= Fe like anemia, WBC normal
Acute= Inc WBC especially if Staph A is the cause
Proteinuria and hematuria are common
What test is King for endocarditis?
What if this initial test is negative?
TEE
Repeat Q3-5 days
If PT is unstable and must be given ABX prior to culture draw, when is the preferred time to draw blood?
How long does ABX Tx last?
Give ABX after all 3 cultures are drawn, minimum of 2
4-6wks
What ABX is used for empiric Tx of endocarditis?
What is used for Strep, Staph or PCN allergy?
IV vancomycin- covers Staph (methicillin susceptible and resistant), Strep and Enterococci
Strep- IV Penicillin G 12-18M units
Staph (Oxacillin susceptible)- IV Nafcillin + Gentamicin or Cefazolin + Gentamicin
Staph (Oxacillin resistant)- IV vancomycin
PCN allergy- Ceftriaxone + Gentamycin or Vancomycin
(Dont give Gentamycin alone)
What are the potential complications of endocarditis Tx?
Emboli CHF Abscess- seen w/ TEE Intracranial hemorrhage Immune complex glomerulonephritis
What endocarditis PTs get surgery?
Refractory pulmonary edema Severe valve regurgitation Obstruction w/ cardiogenic shock HF of any degree Local infection complications Relapsing/refractory bacteremia despite ABX therapy
What is the Tx step for infective endocarditis that has no available effective anti-microbial therapy
What are the relapse chances?
Fungi, Brucella, Pseudomonas aerugiosa (DM), L sided Staph
Usually w/in 2mon
Inc w/ prosthetic valves
Continued IV drug use
What are the mortality chances of infective endocarditis?
When is it recommended to give PTs prophylaxis?
In hospital- 23% or less
6mon- 27% or less
50% if infected w/ fungus or P. aeruginosa
Prostetic valves/materials
Prior Hx of IE
Unrepaired cyanotic congenital heart Dz
What PTs are at highest risk for IE and need prophylaxis?
Repaired congenital heart dz w/ residual shunts/regurgitation at/near site of repair
First 6mon after congenital dz repair w/ catheter/occlusion device
Valve regurgitation due to structurally abnormal valve in transplanted heart
What PTs are NOT given prophylaxis for IE?
Congenital bicuspid valve
Acquired native aortic/mitral valve dz
MVP w/ regurgitation
HCM w/ latent/resting obstruction
What is the DOC for IE prophylaxis?
What ABX are used for PTs that are allergic to this prophylaxis?
2g Amoxicillin
Post-procedure ABX are not required
Allergic to PCN=
Cephalexin
Clindamycin
Azithromyin/Clarithromycin
What are the murmurs associated w/ MS, MR and MVP?
What PT population tends to get it?
MS= opening snap MR= blowing holosystolic MVP= mid-systolic click
Young females w/ 2:1 W/M, younger ages in 3rd world countries, 2-3 decades post-infection
What is the pathophysiology of MS?
How does PHTN look on EKG?
MS, Fixed CO, Inc LA Press, Inc pulm press, Inc hydrostatic press, Plasma in lungs, CHF dyspnea
P wave >2.5mm in Lead 2
What are the two types of PHTN that develop due to MS?
How do they form?
Passive- inc pressure due to backward flow from LA press (most common)
Reactive- hypertrophy of pulmonary artery
What is the end result of MS?
What are the main S/Sxs of MS?
R sided HF due to RVH, and TR
Progressive dyspnea w/ exertion
Hemoptysis
How does a MS murmur sound?
What PE finding indicates the severity of MS?
Low rumbling decrescendo diastolic rumble
heard w/ bell @ LLD
Duration
How does MS look on EKG?
How does it look on CXR?
LAE (P-mitrale)
RVH
RAD
Possible A-fib
LAE, Pulmonary congestion, Kerley B lines, Prominent pulmonary arteries
What Dx test is done for suspected MS and can confirm Dx?
What can be seen on this test?
TTE
Thick MV leaflets (fish mouth)
Severity of mean gradient
Potential LA thrombus
TEEs should always be performed for ? 2 reasons?
How is MS treated?
ID LA thrombus
Eval MV morphology and hemodynamics in PTs w/ sub-optimal TTE
Na restriction/Diuretics BB Non-DHP CCB Digoxin- rate control A-fib Anti-coagulants- A-fib or thrombus ACEIs can be used but have delayed benefit
Since sudden death from MS is rare, all PTs need to ?
What is the best/definitive Tx for MS?
Exercise
Valvotomy/replacement
Percutaneous mitral balloon valvotomy is PREFERRED unless congenital MS
What is the f/u schedule for MS PTs after Tx?
What is the normal MV size?
Known MS and changing Sxs Serial echo for ASx Routine TTE: Q3-5yrs MVA >1.5cm (mild) Q1-2yrs MVA 1-1.5cm (mod) Annually MVA <1cm (sev)
4-6cm^2
MR usually effects ? PTs and involves ? leaflet?
What is the most common cause of degenerative MR in the US?
F>M
Posterior leaflet
MVP
What are the etiology causes of Primary MR?
What are the secondary causes?
Congenital, RH, IE, MVP, Trauma
HOCM, Acute MI, Ischemic Dz, LV dysfunction, RF
Define Acute MR
Sudden usually from damage to valve: Post-MI Ruptured chordae from IE Blunt trauma to chest Deteriorated chordae from CT Dz (Marfans, Ehlers-Danlos)
Define Chronic MR
Myxomatous degeneration of valve
Rheumatic deformity
Congenital defect
Calcification of annulus
Severity of MR is based on what 5 things?
Opening size during regurg Systolic gradient between LA/LV Systemic resistance on LV LA compliance Duration of regurg
What are the 3 direct consequences of MR
One of these consequences is different than MS how?
Elevated LA volume/press
Reduction of Fwd CO
Diastolic volume stress on LV
MS= fixed forward CO
What is the difference in pathophysiology between Acute and Chronic MR
Acute=
Normal LA, High LA pressure, High Pulmonary venous press, Dec CO
Chronic=
Inc LA size, normal LA/pulmonary press, low fwd CO
What is the difference in Tx of Acute and Chronic MR?
What are the primary Sxs of each?
Acute= no fluids Chronic= fluids
Acute= pulmonary edema, needs emergent surgery Chronic= low CO
How does acute MR present on PE?
Apical thrill if severe Soft S1 w/ wide split S2 Loud P2 (PHTN always) Enlarged LV L displacement of PMI
How does chronic MR present on PE?
Why is one of these Sxs unique and differentiating from acute?
Loud, high pitched holosystolic at apex and radiates to axilla best heard at axilla in LLD w/ diaphragm
Loud S2
Intensifies w/ hand grips
May radiate to back
Chronic doesn’t have PHTN, quiet P2
How does MR look on EKGs?
How does it look on CXR?
A-fib, LAE, LVH
Cardiomegaly
LAE, LVH
Annular calcification
What’s the difference between acute/chronic MR on CXR?
What Dx test can be done?
Acute= pulmonary edema
TTE
Echo
Exercise Doppler Echo- for ASx PTs w/ severe MR
How is acute MR Tx?
How is Chronic MR Tx?
Acute= dec preload w/ diuretics, vasodilators
Chronic= no benefit from meds Vasodilators (ACEI) to dec AL Goal is surgery Tx HTN Anti-arrhythmics MVP/Afib= anticoagulation
If MR is acute and secondary to papillary rupture, what is the Tx of choice?
Valve replacement
If HOTN/cardiogenic shock is present, aortic balloon pump can be used to increase organ perfusion and decrease MR
Normotensive PTs- vasodilators decrease AL
What is the prognosis for mild/mod/sev MR?
How is MVP defined on Echo?
Mild= stable for yrs Mod-Sev= surgery within 10yrs or death
Billowing of mitral leaflets 2mm or more above annual plane
MR is associated w/ ? CT D/ox?
Marfann- ectopia lentis, pectus excavatum, pes planus, wrist/thumb sign
Ehlers-Danlos Syndrome
Osteogenesis imperfecta
Define Ebstein’s Abnormality
Congenital malformation of TV and RV due to improper development of TV in first 8wks of gestation
Define MVP Syndrome
DEFAMED MP Dyspnea Exercise intolerance Fatigue Anxiety Mild to Stabbing chest pain Emoblic phenomena Dizziness S/Sxs of MR Palpitation
What type of murmur is MVP?
What causes one of the identifying features?
Mid systolic click w/ late systolic click
Snapping of chordae during systole when valve bows into atria
What bedside maneuver accentuates MVP?
What diagnostic imaging is used?
asd
Echo
What test is ordered for PTs w/ suspected MVP or ASx w/ MVP?
How often are they followed up on to track progression?
Echo
Only w/ change of Sxs
How is MVP managed?
How is MVP syndrome managed?
ASA
A-Fib= anti-coag therapy or TIA while on ASA
No prophylaxis
Reassurance/life style changes
Avoid caffeine/ETOH
Avoid stress/fatigue
PT w/ late systolic murmur and mids-ystolic click can move the click later into systole by ? maneuver?
TS usually found with other valve lesions, especially ? but rarely ?
Squatting
Common- MS from RH
Rarely- congenital, carcinoid syndrome, RA/metastatic tumors
S/Sxs of TS?
What type of murmur is it?
Abd distension
Hepatomegaly
JVP w/ A-waves
Low pitch tumble hear on LLSB w/ bell w/ possible opening snap
What maneuvers make TS louder?
How does it appear on EKG and CXR?
Inspire
Leg raise
Squat
RAE w/ absence of RVH
RAE
How is TS Dx?
How is it Tx?
Echo
Reduce preload w/ diuretics
Surgery for other valve repair
Percutaneous balloon dilation
What can cause/lead to TR?
RDz on MS to TR from PHTN w/ RV enlargement
IE
Ebstein- most common
Carcinoid syndrome from Lungs or GI- rare
How does TR present on PE?
What findings will be found on PE?
Palpitations w/ A-Fib
Abd fullness
Prominent V-waves
RV heave
Ascites
Pulsatile liver edge
What type of murmur is TR?
What makes it louder or quieter?
Blowing holosystolic heart at LLSB w/ diaphragm
Iinc w/ inspiration
Dec w/ valsalva/standing
What EKG changes are seen w/ TR?
What will be seen on CXR?
RAE, RVH, A-Fib
RAE, RVH
How is TR treated?
What usually causes PS?
Diuretics for volume/congestion
Severely Sxs= surgery
Congenital- most common
Carcinoid syndrome from Gi tumor metastasizing to liver and releasing serotonin metabolites into blood forming plaques
What are the S/Sxs of PS?
What is seen on PE?
ASx to exertional dyspnea
Exercise induced fatigue/syncope
Sxs of R HF
RV impulse w/ left parasternal lift
S2 split and S4
How does PS sound?
How often are these PTs f/u on?
Crescendo-decrescendo systolic murmur heard w/ bell or diaphragm at LUSB and accompanied w/ early ejection click
ECG for baseline and Q5-10yrs
RVH present
When/why would cardiac cath be done on PS PT?
R sided Swan Ganz cath to w/ Doppler
PTs w/ peak gradient greater than 36mm
Balloon valvotomy candidates
How is PS treated?
How does PHTN look on EKG?
Severe w/ surgery
Balloon valvotomy via cath is usually effective
Peaked P-wave 4-6mm tall in Lead 2
What causes PR?
What PTs usually get this?
PHTN
Tetrology of Fallot
What heart dz is associated w/ rheumatic d/os?
What are the S/Sxs of PR?
PI
Exertional dyspnea, chest pain, syncope
Fatigue
Anorexia/abd pain
Ortner’s Syndrome- cough, hemoptysis, hoarsness (2nd one, MS)
What doe PR sound like?
Define the Graham-Steele murmur
Early diastolic murmur w/ ejection click
Result of PHTN- high pitched decrescendo diastolic murmur hear at LSB
How is PR treated?
What is the difference between ASD murmur and PR murmur?
Diuretic, O2, HTN treatments
ASD- Fixed split S2, no inc w/ inspiration
PR- wide split
What type of murmur does HOCM create?
Which holosystolic murmur inc w/ inspiration?
High pitched cresc/decresc mid-systolic murmur heard on LLSB
TR
What is the relation between a VSD size and its sound?
HF is considered the final/most severe form of heart Dz including ? 6
Smaller= louder
Coronary artherosclerosis HTN MI Valve Dz Congenital HDz Cardiomyopathies
What are the 3 things that cause HF?
Inc Preload
Inc Afterload
Dec contractility
Low CO and inc AL causes decreased ? which causes what chain reaction?
What is the sequence of pahtologial events leading to CHF?
RAAS, causes fluid overload
LV dysfuntion Dec contractility/CO Catecholamine produciton- Epi, NorEpi Inc Afterload/BP Inc wall tension
What are two meds given to reduce catecholamine production during HF?
Which drug is best for HF?
BBs, ACEIs- dec PL, AL and contractility
BBs
What is the number one Dz that increases Afterload?
HF is a ? problem
HTN
Diastolic
What are the 5 Tx goals of HF?
What med can be used to decrease Preload?
Manage oxygenation/ventilation
Treat unstable arrhythmia
Dec PL/AL
Improve contractility
Nitro, BB, Loops/Thiazide
What meds can be used to decrease after load?
What drugs can be used to inc contractility?
ACEI, BB, Hydrochlorothiazide, Chlorthaladone
Dobutamine, Digoxin, NorEpi, Epi
What 2 meds are used last for HF and affects the pump?
Pulmonary edema occurs as a secondary result to ? HF
CCB, Digoxin
Only used if dec PL/AL isn’t successful
Backwards
What is the difference between Diastolic Dysfunction and Systolic Dysfunction?
What is the difference between forward and backward HF?
Dys- ineffective ventricle filling (hypertrophy)
Sys- ineffective ventricle emptying
Fwd- can’t maintain CO to meet demand
Rvs- can’t accommodate venous return causing congestion
What’s the difference between Low and High output failure?
What causes 70% of HFrEF?
Low- poor CO
High- inc metabolic demand
CAD
Reduced ejection fraction is anything below ?
What is the cellular response to the first sign of ischemia?
40%
40-50= gray area
Hibernation
What are the 3 things that cause constrictive cardiomyopathy?
What causes transient and permanent Diastolic Dysfunction?
Amylodosis, Sarcoidosis, Hemachromatosis
Transient- ischemia
Permanent- Hypertrophy, restrictive cardiomyopathy, MIs
Inc LV filling pressure produces ?
What is the cause of R sided HF when not caused by L sided HF?
Venous congestion upstream
Issue in the lungs
What processes can cause impaired contractility?
What can cause increased after load?
What can cause impaired diastolic filling?
CAD (MI, transient ischemia)
Chronic volume overload (MR, AR)
Dilated cardiomyopathy
Severe AS
Uncontrolled/severe HTN
LVH Restrictive cardiomyopathy Myocardial fibrosis Transient ischemia Tamponade/constriction of pericardium
What is the CO equation
CO= SV x HR
What is the Preload equation
What happens if AL and Contractility are the same?
Wall tension at end of diastole
EDV/EDP
Inc Pre-Load, Frank Starling adjusts
What is the Afterload equation
How does inc Afterload result in a dec SV?
Wall tension during contraction
SBP
LV pressure increases
Inc SBP
Less shortening of myocardial fibers
Dec SV
What is Contractility?
What does this measurement reflect?
Strength of contraction
Independent of AL or PL
Chemical/Hormone influence of contraction
Consistent AL and PL, but inc of Contractility= efficient emptying of ventricles
S/Sxs of HFrEF?
What type of dysfunction is this?
Paradoxysmal dyspnea and fatigue
Primary systolic dysfunction
Once we have cardiac remodeling, what 3 neuro-hormonal mechanisms are activated?
RAAS
Adrenergic
Hypothalamic Neuro Hypophyseal system
With over stimulation of RAAS, what type of renal consequence is seen?
Renal free water absorption
Dilutional hypnatremia
