CC 5 - Congestive Heart Failure Flashcards
1
Q
What are the 4 types of shock?
A
- Hypovolumic
- Cardiogenic
- Distributive
- Obstructive
2
Q
3 types of distributive shock?
A
- Anaphylactic
- Septic
- Neurogenic
3
Q
2 types of cardiogenic shock?
A
- Inotropic
2. Chronotropic
4
Q
2 types of hypovolumic shock?
A
- Hemorrhagic
2. Dehydration
5
Q
What is shock?
A
Circulatory failure (i.e. hypoperfusion) resulting in inadequate perfusion of vital tissues
6
Q
Other name for distributive shock?
A
Vasodilatory shock
7
Q
What 3 subgroups of patients are more prone to distributive shock?
A
- Pregnant women
- Patients with liver failure
- Patients with renal failure
8
Q
What are 4 examples of obstructive shock?
A
- Pulmonary embolism
- Pulmonary HT
- Cardiac tamponade
- Stenotic heart valves
9
Q
Simplest vein to insert the Swan-Ganz catheter?
A
Right internal jugular vein
10
Q
When using a Swan Ganz catheter, how do you know you just went from the RV to the PA?
A
Systolic P stayed the same around 25 mmHg and diastolic P just got raised to 10 mmHg from 0
11
Q
What is the normal pulmonary wedge pressure?
A
10 mmHg with the normal a, c, and v waves of the atrium pressure curve
12
Q
When using a Swan Ganz catheter, how do you know when you are in the RA from the IVC?
A
Pressure is around 5 mmHg with the normal a, c, and v waves of the atrium pressure curve
13
Q
What is the Starling curve?
A
Preload vs measure of cardiac performance aka ventricular output (systolic pressure/stroke volume/stroke work)
14
Q
What could cause a decrease in preload?
A
Diuresis
15
Q
What could cause a decrease in afterload?
A
Arterial vasodilation
16
Q
What are the 3 measures of vascular performance?
A
- Preload
- Afterload
- Contractility
17
Q
Describe the Frank-Starling curve presented during this lecture.
A
X-axis = systolic pulmonary capillary wedge pressure = LAP when full during systole = LV EDP = preload
Y-axis = cardiac index (cardiac output adjusted for body surface area)
18
Q
If we use pulmonary capillary wedge pressure as a measure of preload, what will happen if we increase pressure past the optimal filling point?
A
Pulmonary edema
19
Q
What is another name for pulmonary edema?
A
Congestive heart failure
20
Q
What factors decrease heart contractility/inotropy?
A
- Infarction
- Ischemia
- Heart failure
21
Q
How would heart failure be represented on a Frank-Starling curve?
A
Shift down and to the right
22
Q
How many patients with heart failure in the US in 2002?
A
5 million
23
Q
How many patients predicted with heart failure in 2030?
A
8 million
24
Q
Direct + indirect costs of treatment heart failure in 2012 in the US?
A
Close to $31 billion
25
How many hospitalizations due to heart failure in the US in 2010?
1 million
26
What % of hospital admissions among peeps over 65 are due to heart failure?
20%
27
How do deaths due to cardiovascular diseases compare to deaths due to cancer in the US?
Cardiovascular disease cause almost twice as many deaths as all types of cancers combined
28
How many deaths caused by heart failure each year in the US?
300,000
29
How many new cases of heart failure each year in the US?
550,000
30
Why are blacks more at risk for heart failure?
Modifiable cardiac risk factors:
1. Elevated systolic BP
2. Elevated fasting glucose level
3. Coronary heart disease
4. LV hypertrophy
5. Smoking
31
4 most common causes of heart failure in order of incidence? Others?
1. Coronary artery disease
2. Dilated cardiomyopathy
3. HT
4. Valvular heart disease
Others: infection, drug induced, infiltrative cardiac disease, obstructive cardiomyopathy, toxins (alcohol), nutritional
32
Why does coronary artery disease cause heart failure? Other name for this?
The narrowing of the coronary arteries due to plaques causes ischemia leading to cell death = ischemia cardiomyopathy
33
What is dilated cardiomyopathy?
Myocardium weakens and swells
34
What could cause an increase in afterload?
1. HT
| 2. Blood clot in arterial system
35
Why do we not see heart failure due to valvular heart disease anymore?
Decreased occurrence of rheumatic heart disease
36
How can we classify the severity of heart disease?
New York functional classification:
1. Class I: no limitation (max VO2 > 20 mL/kg/min)
2. Class II: slight limitation of physical activity (max VO2 = 16-20 mL/kg/min)
3. Class III: marked limitation of physical activity (max VO2 = 10-15 mL/kg/min)
4. Class IV: inability to conduct any physical activity without discomfort (max VO2 < 10 mL/kg/min)
37
What is max VO2?
The total maximum volume of oxygen consumed related to body weight and allows comparison of aerobic fitness among individuals of various body size
Expressed as mL/kg/min
38
How can we determine which side of the heart is failing?
When a ventricle fails we see a build up of fluid before the ventricle resulting in increased pressure in the system preceding the failing ventricle
39
What is the most common cause of right sided heart failure? Other causes?
Left sided heart failure
Other causes: RV infarcts, pulmonary HT, pulmonary embolism, pulmonic valve disease
40
What is the hemodynamic profile of PURE right ventricle heart failure?
CVP/RAP > 10 mmHg and CVP >/= LV EDP BUT RVP, PAP, PAOP/PCWP, and CO are all decreased
41
What is the hemodynamic profile of left ventricle heart failure?
CVP/RAP, RVP, PAP, PAOP/PCWP are all elevated but CO is diminished
42
2 names for wedge pressure?
1. Pulmonary capillary wedge pressure
| 2. Pulmonary capillary occlusion pressure
43
Symptoms of right heart failure?
FLUID OVERLOAD:
1. Peripheral edema
2. JVD = jugular venous distention when patient is laying down at 45 degree angle
3. Hepatojugular reflux (HJR) when patient is laying down at 45 degree angle
4. Without pulmonary edema
44
Symptoms of left heart failure?
1. Pulmonary edema
2. Dyspnea
3. Fatigue weak cough
4. Paroxysmal norturnal dyspnea (PND)
5. Orthopnea
6. W/o peripheral edema
7. Left sided S3
8. Inspiratory crackles on lung exam = rales
9. Often concurrent signs of right sided failure
10. Hypoxia of tissues
45
What does hypoxia mean?
Deficiency in the amount of oxygen reaching the tissues
46
What is hepatojugular reflux?
If you push on the liver you will see blood distention of the jugular veins because the RA/RV are full and cannot receive it
47
What can jugular venous distention tell you?
Patient laying down at 45 degrees: measure parallel distance between height of observed venous distention to the height of the sternal angle = indication or not of fluid overload in right heart
48
What is orthpnea?
Dyspnea that occurs when lying flat
49
What is paroxysmal norturnal dyspnea (PND)?
Attacks of severe shortness of breath and coughing that generally occur at night (because laying down and blood is accumulating in the lungs)
50
How can we know that left side failure has progressed to the right side as well?
Less shortness of breath is experienced because the blood is now backing up further
51
What are the two types of left ventricular heart failure? Which one is the classic one?
1. Systolic***
| 2. Diastolic
52
Describe systolic left ventricular heart failure.
Deficit in blood expulsion:
1. Ejection fraction is below 40%
2. Impaired contractility of LV
3. Increased EDV and EDP
4. Heart is very sensitive to increased afterload
5. Inadequate CO
6. Dyspnea when preload is increased
7. Systemic and pulmonary vascular congestion
53
Describe diastolic left ventricular heart failure.
Deficit in ventricular filling (because the ventricle does not completely relax):
1. Preserved contractility
2. Ejection fraction is above 40%
3. Increase in pulmonary venous pressures and pulmonary congestion
4. Dyspnea on exertion
5. Normal stroke volume
6. Decrease in EDV/Increase in EDP
54
In what cases is diastolic left ventricular failure common?
1. Post myocardial infarction
2. HT
3. LV hypertrophy
55
Effect of systolic left ventricular heart failure on compliance curve?
1. Loop is thinner: decrease in SV (because of decrease in ejection fraction)
2. Portion of the bottom of the loop is cut off: EDP is higher
3. Loop is shifted to the right: higher volume in LV
56
Effect of diastolic left ventricular heart failure on compliance curve?
1. Normal width: normal SV (because of normal ejection fraction)
2. Shift to the left and up: higher pressure in the ventricle because of the stiffness of the muscle and slightly less volume of blood in it for same reason
57
What will the chest X-ray look like when the LV EDP is below 12 mmHg?
Normal
58
What will the chest X-ray look like when the LV EDP is 15-20 mmHg?
Cephalization = increased pressure in the lungs causing arteries and veins in the upper lungs to dilate and look like those in the lower lungs (these are usually underfilled compared to the lower lungs)
59
What will the chest X-ray look like when the LV EDP is 20-25 mmHg?
1. Pulmonary interstitial edema
| 2. Kerley B lines = swollen linear pulmonary lymphatics
60
What will the chest X-ray look like when the LV EDP is above 25 mmHg?
1. Alveolar edema
| 2. Opacified airspaces due to pleural effusion
61
What are the 4 quadrants of the Frank-Starling curve? What happens in each? Which is the worst case situation?
4 quadrants are formed by 2 lines:
1. Vertical = past which preload is too high = pulmonary edema
2. Horizontal = past which CO is too low = cardiogenic shock
- Upper left quadrant: warm/dry = normal
- Upper right quadrant: warm/wet
- Lower right: cold/wet = WORST = cardiogenic shock
- Lower left: cold/dry
62
How to treat a warm/wet patient?
Diuretics
63
In which quadrant of the Frank-Starling curve do we find the diastolic left ventricular heart failure patient?
Warm-wet
64
In which quadrant of the Frank-Starling curve do we find the distributive shock patient?
Cold-dry
65
In which quadrant of the Frank-Starling curve do we find the hypovolumic shock patient?
Cold-dry
66
Effect of distributive shock on the Frank-Starling curve?
Decreased afterload => shift to the left
67
In which quadrant of the Frank-Starling curve do we find the obstructive shock patient?
1. If obstruction is in venous system or pulmonary arteries: cold-dry
2. If obstruction is it arterial system: cold-wet
68
Treatment for people in cold-dry quadrant of the Frank-Starling curve?
1. Step 1: IV fluid
2. Step 2: positive inotropic agent
3. Step 3: afterload reducer if necessary
69
Treatment for people in cardiogenic shock?
1. Step 1: diuretic
2. Step 2: positive inotrope
3. Step 3: afterload reducer
70
Class I: disease? treatment?
Disease: mild LV systolic dysfunction (usually asymptomatic)
Treatment: beta blockers to slow the heart down and ACE inhibitors to reduce afterload
71
Class II and III: disease? treatment?
Disease: ejection fraction below 35%
Treatment: inotropic support, ACE inhibitors, diuresis (decrease preload) + if EF is below 30% give automatic implantable cardioverter defibrillator (AICD)
72
Class IV: disease? treatment?
Disease: very advanced and at risk of sudden death
Treatment: inotropic support, ACE inhibitors, diuresis, supplemental O2
73
Procedure treatment for cardiogenic shock?
Catheter in descending aorta from the femoral artery = intra-aortic balloon pump:
- Expansion during diastole to increase pressure and to increase coronary and cerebral perfusion
- Collapse during systole to decrease the afterload because causes a vacuum in the aorta and sucks the blood out of the ventricle
74
Usual inotropic drug?
Digoxin or Dobutamine
75
Usual diuresis drug?
Lasix
76
During what portion of the cardiac cycle does the heart get perfused?
Diastole
77
What is a heart attack?
Popular term used to refer to myocardial infarction
78
What is a stroke? 2 types?
Ischemia in the brain leading to infarction
Thrombotic or hemorrhagic
79
What is heart failure?
Circulatory failure due to the heart's reduced ability to pump (eventually leading to cardiogenic shock)
80
What is angina?
Chest pain associated with myocardial ischemia
81
Can you have myocardial infarction without total occlusion of a coronary artery?
Yes, but not as likely
82
What is diaphoresis?
Excessive sweating
83
If a patient has chest pain, excessive sweating, and nausea: what does this tell us about the location of the infarction?
Inferior infarction because signs of major vagal activation
84
Other name for warm and dry?
Compensated
85
Other name for warm and wet?
Congested
86
Other name for cold and wet?
Decompensated
87
Other name for cold and dry?
Low flow state
88
What are signs of insufficient CO (aka being cold)?
1. Cold extremities
2. Abnormal mental status
3. Decreased kidney function
4. High lactate levels
89
What is the hemodynamic profile of cardiac tamponade?
All of the diastolic pressures of all of the heart chambers will equilibrate because the diastolic pressures are no longer dependent on the compliance of the chamber - they depend on the pressure due to the filled pericardial cavity
90
3 cardinal signs of aortic stenosis during exercise?
1. Angina
2. Syncope
3. Heart failure
91
What is hemoptysis?
Coughing up of blood
92
How does pregnancy affect the heart?
Huge stress on the heart, especially in late 2nd and early 3rd trimester
93
Medical management of mitral valve stenosis?
1. HR control to increase time in diastole
2. Keep out of afib
3. BV control
