CHF 1 Flashcards
What increases your risk of Heart failure?
increase with age coronary heart disease cigarette smoking HTN Obesity Diabetes Valvular heart disease Race African Amer.> Caucasian
What is the most common causes of heart failure according to an italian registry of 6,200 patients?
Ischemic heart disease 40%
Dilated cardiomyopathy 32%
Primary Valvular Dz-12%
HTN-11%
what is the most common causes of heart failure in developing countries?
HTN-33%
Idiopathic Cardiomypoathy-28%
Ischemic Heart Dz-9%
Rheumatic Fever 8%
In In 2007 the AHA estimated how many people in the US and world wide have heart failure
5.7 million people in the US and 23 million world wide have heart failure.
What happens with calcium during Heart failure?
Calcium influx results in decreased efflux from the SR, resulting in decreased contractile strength and poor relaxation
Note: low pH decreases the ability for calcium to bind to troponin C resulting in decreased contractions
what determines stroke volume?
preload, contractility and after load
What does end diastolic volume (preload) vs SV(CO+HR) tell us
it tells us that if you improve the preload then you will improve the stroke volume to a point. This helps to determine fluid resuscitation
What happens to afterload in heart failure
these changes are enhanced where the resistance that ventricle meets during systole increase
Describe how contractility, afterload and preload can exacerbate or ameliorate symptoms.
When these are not function correctly fluid gets backed up into the Lymphatics and into the lungs. It makes blood vessels plumper and will thicken interstitial space and make lungs thicker. You will see pleural effusion because it can not handle the volume
what is heart failure
Clinical syndrome of the inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency
what are the two types of heart failure
Two types of HF that can effect both the left side and the right side
Systolic- it cant squeeze it forward
Diastolic- can fill it
what is systolic dysfunction?
Decreased myocardial contractility.
Think of the spring where the coils are too far pulled apart and they lost there “springiness.”
What is the result in systolic dysfunction when there is decreased myocardial contractility?
results in decreased SV which results in decreased CO.
What is the bodies response to systolic dysfunction?
Neurohormone response to increase contractility and HR to maintain homeostasis. (work to keep alive but your limping on, the backup systems are just ok at functioning)
Angiotensin, Cathecholimines, antidiuretics pathways to regulate BP
Kidneys hold onto sodium resulting on water retention and volume expansion to maintain preload
Calcium looses its affinity of troponin C in vitro possibly from muscle stretch at the sarcomere level.
Cardiac myocyte is nml diameter and increased in length. (no change in LV wall thickness and increased in LV volume)
what is dyastolic dysfunction?
Diastolic Heart Failure is when the pt has clinical signs of heart failure in the setting of normal ejection fraction.
what happens with diastolic dysfunction in term of their Stroke volume?
SV is preserved but an increase in end diastolic pressure, resulting from decreased compliance to receive a certain amount of volume.
Generally a concentric pattern of LV remolding and a hypertrophic process characterized by
A normal or near nml EDV
Increased Wall Thickness
An increased ratio of myocardial mass to cavity volume
An increased ratio of wall thickness to chamber radius
What is the role of neurohumoral response?
Body compensates for decreased CO in order to maintain homeostasis by:
Maintain systemic vasoconstriction
Increase contractility and HR by improving volume expansion.
what are the 6 types of neurohumoral responses by the body for decreased CO
RAAS ADH (volume expansion) ANP (vasodilator) Nitric oxide (vasodilator) Endothelin (vasoconstrictor) Sympathetic nervous system (improves contractility, vasoconstrictive, and HR)
What are complications of neurohumoral response?
- Elevated Diastolic pressure to the atria and pulmonary/systemic venous circulations resulting in pulmonary congestion and edema
- Increased afterload in an attempt to vasocontsrict the peripheral systemic system.
- Catecholamines used to increase contractility and HR increase risk for coronary ischemia.
- Catecholamines and Angiotensin II promote apoptosis of myocytes.
What are symptoms of right sided heart failure?
DOE Fatigue Syncope Exertional angina Anorexia Hepatomegaly JVD Split S2
What is the Tx for Right sided HF
Treat the underlying cause Pulmonary HTN PE COPD OSA L sided failure No Digoxin as it has no evidence that it helps and may have deleterious effects If in cardiogenic shock attempt IV inotropic agents (dobutamine and milrione)
what are the 5 classes of cardiomyopathy?
Dilated Hypertrophic Restrictive Arrhythmogenic Right Ventricular Unclassified
Cardiomyopathy is based on specific cardiac disorders or systemic disorders such as?
Ischemic Valvular HTN Inflammatory Metabolic Toxic Genetic Two types Primary -Genetic or acquired Secondary -When other organ systems are involved
what is dilated cardiomyopathy?
Dilation and decreased contractility of one or both ventricles (i.e. decreased systolic function)
Associated with Hypertrophy in severe disease
how will a dilated cardiomyopathy show up on echo?
Echo shows dilated LV, becomes more round than the nml ovoid, nml or decreased wall thickness, poor wall thickening and/or reduced inward endocardial systolic motion. LA enlargement, RV enlargement and dysfunction
what are the causes of dilated cardiomyopathy?
Idiopathic 50% Myocarditis 9% Ischemic 7% Infiltrative 5% Peripartum 4% HTN 4% HIV 4% Connective Tissue Disease 3% Substance Abuse 3% Doxorubicin 1% (shows up on boards)
what is hypertrophic cardiomyopathy?
Hypertrophied LV, and occasionally the RV
Usually the intraventricular septum compared to the LV free wall
Concentric hypertrophy involves both
Apical Hypertrophy
LV volume is nml or reduced and associated with with diastolic dysfunction
Increased risk of sudden cardiac death(specifically when it’s the left ventriclular wall septum
Characterized by a mid systolic harsh murmur that worsens with valvsalva (bearing down)
What is the cause of hypertrophic cardiomyopathy?
Hypertrophic
60-70% is genetic mutation of sarcomere proteins
Autosomonal dominant
Check routine ECHOs in 1st degree relatives
Acquired causes
HTN and Aortic stenosis
Heart needs to push against a high pressure
Arrhythmias are common
how is hypertrophic cardiomyopathy treated?
Avoid stress activities
TX Beta blockers (1st line) dihydro CCB (2nd line)
Diuretics, ICD, rate control, surgery, ETOH septal ablaation
what is restrictive cardiomyopathy?
Non-dilated, non-hypertrophied ventricles with impaired filling. Biatrial enlargement (secondary to elevated pressures)
Systolic function is nml in the early stages
RV failure more common than LV
how are restrictive cardiomyopathies classified?
Infiltrative (amyloid (most common), sarcoid, hematochromotosis)
Noninfiltrative (scleroderma, idiopathic, genetic)
Storage Diseases (hematochromotosis, Fabry Disease (alpha glaactosidase A))
Endomyocardial Diseases (endomyocardial fibrosis, hypereosinophillic syndrome, anthracycline fibrosis, radiation)
what are the treatments for restrictive cardiomyopathies?
- Amyloid Tx is transplant vs chemo vs stem cell transplant
- Sarcoid Tx is steriods, chloroquine, cyclosporine, methotrexate
- Hematochromotosis Tx is phelbotomy and iron chelation ? Heart transplant
- Endomycoardial diesase tx is warfarin
- Hypereosinophillia tx is steriods, interferion, cyclosporine and warfarin
- Fabry’s tx is alpha galactosidase A replacement
what is arrythmogenic right ventricular?
Genetic disease with ventricular arrhythmias and RV free wall fibrosis and/or fibro-fatty tissue with scattered residual myocardial cells.
Regional or global akinesis or dyskinesis of the RV
what is athletes heart?
Intensive endurance training results in increase in LV wall thickness, cavity size, and mass
Associated with benign arrhythmias but some can be lethal
Need to rule out other underlying causes of hypertrophy, LVH is generally symmetric and ≤ 12 mm
what are types of unclassified cardiomyopathies?
Endocardial Fibroelastosis
Fibrosis and elastic tissue involvement of the LV
Occurs in infants within the first two years of life
Left Ventricular Noncompaction
Rare
What is takotsubo cardiomyopathy?
(stress-induced) “Broken Heart Syndrome” Apical ballooning of the LV in systole More common in women Clinically can present as an MI Uncertain etiology Catecholamine surge, coronary artery spasm, mirovascular dysfunction Mortality of 0-8 %, typically recover function within 1-4 wks
what are the 4 criteria needed to classify something as peripartum cardiomyopathy?
4 criteria needed
- Development of cardiac failure in last month of pregnancy or within 5 months of delivery
- Absence of an identifiable cause of HF
- Absence of recognizable heart disease prior to last month of pregnancy
- LV systolic dysfunction
what are the risk factors for peripartum cardiomyopathy?
> 30 yo, Multiparity, African descent, multiple fetuses, Hx pre-/eclampsia, postpartum HTN, maternal cocaine abuse, > 4 wks use of tocolytic (to prevent contraction) use.
Alcoholic cardiomyopathy
- Large amounts of alcohol is associated with cardiomyopathy
- Pronounced LV dilation, increased LV mass, thin/nml LV walls, diastolic dysfunction (asymptomatic) and systolic dysfunction (symptomatic)
- Uncertain etiology
- ETOH induces apoptosis
- Acute and transient toxic effect on cardiac performance
- Nutritional Deficiency, esp thiamine(B1) which can lead to Beriberi
- Additives in alcoholic beverages, i.e. cobalt, can rarely have toxic effects on the heart
- Need to stop drinking
mitral stenosis causes
Often the result of rheumatic fever(caused by strep)
Other causes are:
Calcification of the valve
Abnormal papillary muscles
what happens with mitral valve stenosis?
- Decreased flow out of the atria results in high atrial pressures resulting in back flow into the pulmonary vasculature.
- Usually a gradual progression of increased pressures and in mild-moderate disease the lymphatic system can drain the extra fluid.
- In the setting of increase HR and decreased diastolic filling time fluid backs up more and the lymph system cannot drain that extra fluid
characteristics of mitral stenosis on exam
Opening snap following S2
Diastolic murmur loudest in mitral area
Mitral valve stenosis treatment?
-Rate control heat rate Warfarin if in afib -Surgery (in severe disease) Percutanteous valvuloplasty Open replacement (usually if there is both stenosis and regurg)
what is mitral regurgitation?
Fluid is shot back up into the LA during systole due to an incompetent valve. This results in an enlarged LA
-Characterized by
Pansystolic murmur at the apex radiating to the axilla
Systolic murmur heard over the mitral area
what causes mitral valve reguritation?
Papillary muscle failure/dysfunction
Enlarged mitral annulus
Dilated cardiomyopathies
Ischemic heart disease
what is a result of mitral valve regurgitation?
Can cause LV failure due to a decreased CO leaving the heart into the aorta.
mitral valve Tx
Asymptomatic failure has no treatment
Most symptomatic failure requires symptom management
Decreased CO from MR may result in the need for valve repair.
what is the most common cause of acute mitral regurg
Chordal rupture
what are other causes of mitral regurg
Also by MI, Endocarditis, Prosthetic Valve Dysfunction.
what is a result with mitral regurg
LA is not compliant and does not tolerate regurgitant flow well resulting in increased flow into the pulmonary circulation
what is mitral valve prolapse and who is it most common in?
Floppy” Valve
Most are female
what causes mitral valve prolapse?
Hyperadrenergic state Connective tissue diseases Ehlers-Danlos Marfan Chordae rupture
How is mitral valve prolapse characterized?
mid systolic clicks
how do you treat mitral valve prolapse?
Beta blockers for hyperadrenergic state
surgical repair
what are causes of aortic stenosis?
-Congenital Uni-cuspid valve Bi-cuspid valve -Degenerative or calcific 25% over age 65 and 35% over age 70
aortic stenosis is characterized by?
systolic murmur in aortic area
what are symptoms of aortic stenosis?
Angina (decrease flow to endocardium)
Syncope
Hypotension
what is the tx for aortic stenosis?
surgery
left ventricular outflow tract obstruction is causes by
Caused by Aortic Stenosis Supravalvular Stenosis Subvalvular Stenosis Hypertrophic Cardiomyopathy Genetic Disorder Severe Systemic HTN
what is the number one cause of aortic regurgitation?
rheumatic heart disease
now its congenital (bicuspid valve), endocarditits, HTN, marfans, aortic dissection
what are characteristic of aortic regurgitation?
diastolic murmur over aortic area
most patients are asymptotic
how do you treat aortic regurgitation?
Treatment is usually the underlying disease Severe AR (or infectious endocarditits) may need surgical repair Decreased afterload will help reduce amount of blood back into the LV
what is acute aortic regurgitation?
The LV cannot compensate for the rapid filling during diastole which is caused by regurgitant blood.
right sided valve disease notes
- Same things that happen on the Left can happen on the Right.
- However due to the lower pressures the severity of the disease is not as evident
tricuspid stenosis is causes by?
Usually as a result of valve repair, replacement or to carcinoid.
Not very common now that rheumatic heart dz is rare
what type of murmur would you hear with tricuspid stenosis
Diastolic “rumble” that worsens with inspiration
how to treat tricuspid stenosis
reduce fluid congestion
valve replacement
tricuspid regurgitation
- Very common
- Usually asymptomatic
- Common in pts with pulmonary disease
- Treat with diuretics for fluid congestion
- If surgical repair planned for mitral valve will repair tricuspid at same time
pulmonic regurgitation
Usually from pulmonary hypertension
Can be due to dilated annulus
Symptom management
acute heart failure physiology
- Heart failure either acute on chronic or new onset resulting in pulmonary capillary congestion causing shortness of breath and possibly respiratory failure.
- Decreased CO results in rapidly increasing LV filling pressures, LA pressure and filling of the pulmonary capillary bed.
- The increase in fluid overwhelms the lymphatic drainage system
what does stage 1 of congestive heart failure look like on a CXR
redistribution of pulmonary vessels
Cardiomegaly
what does stage 2 of congestive heart failure look like on a CXR
Kerley lines
Peribronchial cuffing
thickened interlobar fissures
what does stage 3 of congestive heart failure look like on a CXR
consolidation
air bronchogram
cottolwool appearance
plueral effusion
what are the 2 ways to classify causes of acute heart failure?
- chronic cardiac conditions that predispose decompensation
- triggers that precipitate decompensation
what are Chronic cardiac conditions that predispose decompensation.
Systolic Dysfunction
Diastolic Dysfunction
Left Ventricular Outflow Tract Obstruction
Mitral Stenosis
what are Triggers that precipitate decompensation
Myocardial ischemia/infection Acute Aortic Regurgitation Acute Mitral Regurgitation Reno-vascular HTN LA outflow impairment Volume Overload
ischemic heart disease
- HF can occur in the setting of CAD without acute coronary syndrome.
- Decreased flow to the myocardium can result in systolic and/or diastolic HF
- Can cause/worsen valvular disease
