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Pathophysiology II class notes > Ch. 20 Heart Failure and Circulatory Shock > Flashcards

Ch. 20 Heart Failure and Circulatory Shock Flashcards

1
Q

What is heart failure?

A

Heart Failure is a clinical syndrome that occurs when the heart is unable to pump adequate blood to meet the metabolic demands of the body

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2
Q

What is the cardio-renal model of heart failure?

A

It views heart failure as a disorder of excessive sodium and water retention (outdated model).

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3
Q

What is the view of heart failure as a hemodynamic disorder?

A

It looks at the reduced cardiac output or afterload.

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4
Q

What is the current understanding of heart failure?

A

heart failure as a neurohormonal model

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5
Q

What is “preload”?

A

“End diastolic volume”

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6
Q

What is “afterload”?

A

Amount of force needed to eject filled heart.

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7
Q

What determines afterload?

A

Determined by SVR and ventricular wall tension.

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8
Q

What determines preload?

A

Determined by venous return to the heart.

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9
Q

What is “contractility”?

A

Performance of cardiac muscle.

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10
Q

What are four general types of heart failure?

A

Systolic vs. diastolic
Dilated vs. hypertrophic
Left vs. right
High-output vs Low-output

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11
Q

What is systolic heart failure?

A

Impaired ejection of blood. Presence of signs and symptoms of heart failure with an ejection fraction of

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12
Q

What are the causes of systolic heart failure?

A

Muscle issues
Volume overload
Pressure overload

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13
Q

What are some of the muscle problems that can cause heart failure?

A

CAD, myocarditis, cardiomyopathy, conduction issues

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14
Q

What are some volume overload problems that can cause heart failure?

A

Valvular insufficiency, kidney disease

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15
Q

What are some pressure overload problems that can cause heart failure?

A

HTN
valvular stenosis
Pulmonary disease

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16
Q

What is diastolic heart failure?

A

Impaired filling during diastole
Presence of signs and symptoms of HF in the absence of systolic dysfunction (LVEF > 40%)
Myocardium is “stiff” (and often hypertrophied) and does not relax normally after contraction

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17
Q

What are the causes of diastolic heart failure?

A

Impaired ventricular stretch
Increased wall thickness
Delayed diastolic relaxation

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18
Q

What are some disorders that cause impaired ventricular stretch, that can cause diastolic heart failure?

A

pericardial effusion, pericarditis, amyloidosis

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19
Q

What are some disorders that cause increased heart wall thickness, that can lead to diastolic heart failure?

A

hypertrophy, myopathy

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20
Q

What are some factors that cause delayed diastolic relaxation, that can lead to diastolic heart failure?

A

Aging, CAD

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21
Q

Why is diastolic heart failure aggravated by tachycardia?

A

The heart already has a hard time filling properly, and in tachycardia there is even less time for the heart to fill between pumping

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22
Q

What are the risk factors for diastolic heart failure?

A

Women, obesity, HTN, diabetes mellitus

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23
Q

What is the main difference between systolic heart failure and diastolic heart failure?

A 
Systolic = an ejection problem
Diastolic = a filling problem
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24
Q

What do systolic and diastolic heart failure have in common?

A

A decreased cardiac output.

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25
Q

What are the CNS symptoms of left ventricular dysfunction (left-sided heart failure)?

A

Fatigue, weakness, confusion, dizziness (worsens over day)

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26
Q

What are the cardio-vascular manifestations of left ventricular dysfunction (left-sided heart failure)?

A

Hypotension, angina, tachycardia, palpitations, pallor, weak peripheral pulses, cool extremities, S3/S4

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27
Q

What are the renal complications of left ventricular dysfunction (left-sided heart failure)?

A

Oliguria (less urine) during the day

Night time = frequent urination

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28
Q

What are the manifestations of left ventricular dysfunction (left-sided heart failure)?

A 
SOB (initially during exertion/orthopnea/PND)
Cough, “cardiac asthma” (worse at night)
Inspiratory crackles/expiratory wheezes
Tachypnea
Frothy/pink sputum (pulmonary edema)
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29
Q

What are the manifestations of right ventricular dysfunction (right-sided heart failure)?

A 
Jugular vein distention/elevated central venous pressure
Enlarged liver and spleen
Dependent edema
Ascites
Polyuria at night
Weight gain
Hepatojugular reflux (HJR)
BP changes
     Elevated BP (excess volume)
     Decreased BP (decreased cardiac output)
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30
Q

What is high-output heart failure?

A

Caused for excessive need for cardiac output. The heart compensates, and then fails from too much compensation.

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31
Q

What are the causes of high-output heart failure?

A

Severe anemia

Thyrotoxicosis/thyroid storm

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32
Q

What is low-output heart failure?

A

Caused by conditions decreasing pumping ability

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33
Q

What are the causes of low-output heart failure?

A

Coronary artery disease

Cardiomyopathy

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34
Q

What is the Frank-Starling mechanism of compensating for heart failure?

A

+Increased preload (end diastolic volume) will increase stroke volume.
-Stretch increases wall tension, increasing oxygen requirements

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35
Q

What is the sympathetic nervous system mechanism of compensating for heart failure?

A

+Increase in circulating catecholamines increase HR, contractility, peripheral vascular resistance, stroke volume, cardiac output.

-Increased workload

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36
Q

What is the renin-angiotensin-aldosterone system of compensating for heart failure?

A

+Increased concentration of renin, angiotensin II & aldosterone d/t decreased renal perfusion
-Increased preload, increased workload

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37
Q

What is the natriuretic peptide (ANP&BNP) mechanism of compensating for heart failure?

A

+Released in response to stretch, pressure, fluid overload (promote diuresis)
-Decreases preload, decreases cardiac output

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38
Q

What is the endothelins method of compensating for heart failure?

A

+ Responds to pressure changes (v/c, myocyte hypertrophy, ANP & catecholamine release)
- Increased workload

39
Q

What is ventricular remodeling? (Pros and cons)

A

Pros:
Symmetric hypertrophy

Cons:
Pressure overload (hypertension)
Volume overload (dilated cardiomyopathy)
40
Q

What is symmetric hypertrophy in ventricular remodeling?

A

Proportionate increase in muscle length and width (athletes)

41
Q

What is pressure overload (hypertension) in ventricular remodeling?

A

Concentric hypertrophy d/t replication of myofibrils, thickening of myocytes
Increase in wall thickness (hypertension)

42
Q

What is volume overload (dilated cardiomyopathy) in ventricular remodeling?

A

Concentric hypertrophy d/t replication of myofibrils, disproportionate elongation of muscle cells

43
Q

What are the late manifestations of heart failure?

A

Cyanosis

Clubbing of fingers

Cachexia/Malnutrition

Arrhythmias/Sudden Cardiac Death

44
Q

Why does late stage heart failure cause cyanosis?

A

Due to pulmonary edema, vasoconstriction, decreased oxygen availability

45
Q

Why does late stage heart failure cause cachexia/malnutrition?

A 
CNS factors (not getting enough oxygen to the brain, supresses apetite)
Liver and GI congestion
46
Q

Why does atrial fibrillation occur?

A

Myocardial infarction
Heart failure
Valvular damage

47
Q

What is happening in the heart during atrial fibrillation?

A

Quivering muscle (atria)
Poor emptying of atria
Poor filling of ventricle resulting in decreased cardiac output

48
Q

How does a patient in atrial fibrillation present?

A 
Irregulary irregular HR
Pulses will be irregular with varying strenghts
Low BP
Possibility of angina
Possibility of thrombi
49
Q

What is acute pulmonary edema?

A

Accumulation of capillary fluid in alveoli that impairs gas exchange and limits lung expansion.

50
Q

What are the manifestations of acute pulmonary edema?

A 
Short of breath, dyspnea, tachycardia
Tachycardia, moist/cool skin
Fine to coarse crackles
Frothy, blood-tinged sputum
Cyanotic lips, nailbeds
CNS: confusion, stupor
51
Q

What are the diagnostic methods for heart failure?

A 
History, physical assessment
     Signs and symptoms
ECG
CXR
Echocardiography
     Ejection fraction
     Wall motion, thickness
     Chamber size
     Structural defects (valves, tumors, etc.)
Blood tests: BNP, CBC
Central venous pressure/jugular vein distension
Pulmonary artery catheter pressures/volumes
52
Q

What are the non-pharmacological treatments for heart failure?

A

Exercise program, fluid/Na restriction, weight control, dietary counseling
Non-surgical and surgical medical management

53
Q

What are the pharmacological treatments for heart failure?

A

Diuretics, ACE inhibitors, cardiac glycoside (digoxin), ARBs, B-blockers

Oxygen therapy

54
Q

What is circulatory failure/shock?

A

Acute failure of the circulatory system to supply tissues and organs with an adequate blood supply resulting in hypoxia.

55
Q

What is the cellular response to shock affecting anaerobic energy production?

A

Cytoplasm uses glucose to create ATP and pyruvate

Less efficient

56
Q

What is the cellular response to shock affecting aerobic energy production?

A

Oxygen and pyruvate create ATP in mitochondria

If no oxygen, pyruvate converts to lactic acid

57
Q

What is cardiogenic shock?

A

Heart failure, uncompensated (can be due to other shock situations)

58
Q

What are causes of cardiogenic shock?

A 
Myocardial Infarction
Myocardial contusion
Acute mitral valve regurgitation - d/t pappilary muscle rupture
Arrhythmias
Severe dilated cardiomyopathy
Cardiac surgery
59
Q

What are the cardiovascular manifestations of cardiogenic shock?

A

Decreased stroke volume, mean arterial pressure, systolic blood pressure
Narrow pulse pressure
Normal diastolic blood pressure
Cyanosis (lipds, nailbeds, skin)
Elevated central venous pressure/pulmonary capillary wedge pressure
Dysrhythmias

60
Q

What are the renal manigestations of cardiogenic shock?

A

Oliguria, anuria

61
Q

What are the CNS manifestations of cardiogenic shock?

A

Altered mentation (GNS 15-0)

62
Q

What is the treatment for cardiogenic shock?

A

Fluid volume management
Treat cause and symptoms
Improve cardiac output, avoid increasing workload of heart

63
Q

What is hypovolemic shock?

A

Any condition which decreases blood volume >15%

64
Q

What are external ways to lose blood volume?

A

Hemorrhage, burns, severe dehydration/vomiting/diarrhea

65
Q

What are internal ways to lose blood volume?

A

3rd spacing, hemorrhage

66
Q

What are the immediate compensation methods for hypovolemic shock?

A

SNS, RAAS, hypothalamus, fluid shift

67
Q

What are the cardiovascular manifestations of hypovolemic shock?

A

Tachycardia, weak/thready pulses
Skin cool/clammy/mottled
Hypotension
Decreased CVP

68
Q

What are the CNS manifestations of hypovolemic shock?

A 
ADH release, thirst
Altered mentation (CGS 15-0)
69
Q

What are the respiratory manifestations of hypovolemic shock?

A

Tachypnea, deep resps

70
Q

What are the renal manifestations of hypovolemic shock?

A

Oliguria, anuria

71
Q

How do we treat hypovolemic shock?

A

Treat the cause

Increase oxygen delivery by maintaining adequate vascular volume

72
Q

What are three ways to increase oxygen delivery by maintaining adequate vascular volume?

A 
IV crystalloids
IV colloids (rbc’s, plasma volume expanders)
Vasoactive pharmacology (not usually recommended)
73
Q

What is obstructive shock?

A

Mechanical obstruction of blood to or through great veins, heart, lungs

74
Q

What are some causes of obstructive shock?

A

Pulmonary embolus
Dissecting Aortic aneurism
Tamponade
Pneumothorax
Atrial myxoma (benign tumour of the heart)
Abdominal evisceration (your guts come out)

75
Q

What is neurogenic shock?

A

Rare, often transitory depending on the cause

Decreased SNS control of vessel tone

76
Q

What are the causes of neurogenic shock?

A 
Brain stem defect
Spinal cord injury
Drugs
General anesthesia
Hypoxia
Insulin reaction
77
Q

What is anaphylactic shock?

A

Immunological mediated reaction of histamine release causing
v/d of arterioles and venuoles, and
Increased capillary permeability

78
Q

What are the manfestations of anaphylactic shock?

A

Manifestations dependent on: Level of sensitivity, Rate/quantity of antigen exposure

Pruritis, urticarial
Angioedema
Laryngeal edema/bronchospasm
Rapid hypotension; circulatory collapse

79
Q

What are the treatments of anaphylactic shock?

A

Remove cause

Epinephrine, oxygen, antihistamines, corticosteroids

80
Q

What is septic shock?

A

Systemic inflammatory response to a severe infection

81
Q

How does septic shock happen?

A

Neutrophils increase capillary permeability & damage to endothelial cells result
Cytokines, nitric oxide, & coagulation products are released, damaging cells/tissues and causing massive vasodilation

82
Q

What are the cardiovascular manifestations of septic shock?

A

Vasodilation (decreased SVR), hypovolemia, hypotension, tachycardia, skin flushed, edema

83
Q

What are the CNS manifestations of septic shock?

A

Pyrexia, abrupt change in mentation

84
Q

What are the renal manifestations of septic shock?

A

Oliguria, anuria

85
Q

What are the hematological manifestations of septic shock?

A

Leukocytes, metabolic acidosis, thrombocytopenia

86
Q

What are the treatments for septic shock?

A 
Treat cause
Support circulation
Oxygen
Aggressive fluids 
Aggressive management of fluids
Inotropes
Recombinant human activated protein C (rhAPC), a naturally occurring factor that 
Inactivates clotting factors
Inhibits cytokine production
87
Q

What are the complications of shock?

A 
Acute respiratory distress syndrome
Acute renal failure
GI tissue damage d/t hypoxia
Disseminated intravascular coagulation
Multi-organ dysfunction syndrome
88
Q

What is acute respiratory distress syndrome?

A

Rapid onset of hypoxemia unrelieved by supplemental oxygen
Ventilation-perfusion mismatch
Atelactasis, impaired gas exchange, fluid limits inflation

89
Q

What is the treatment for acute respiratory distress syndrome?

A

Mechanical ventilation, oxygen

90
Q

How does shock cause acute renal failure?

A

Ischemia/injury of renal tubules >20 minutes

91
Q

How do we treat GI tissue damage due to hypoxia that occurs as a result of shock?

A

Proton pump inhibitors, histamine-2 receptor agonists

92
Q

What is disseminated intravascular coagulation?

A

Widespread activation of coagulation cascade (not the primary disease)

93
Q

How is disseminated intravascular coagulation treated?

A

anticoagulation, platelets, plasma

94
Q

What is multi-organ dysfunction syndrome?

A

Failure of multiple organs such that homeostasis cannot be achieved.

Pathophysiology II class notes (15 decks)

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