CHF Flashcards
heart failure mostly caused by
fluid backing up into lungs–>pulmonary edema/congestion
LV failure: systolic or diastolic
symptoms due to ??
management ??
what is the EF? (not CO, can have EF of 10% or 70% in HF)
Symptoms due to low CO and congestion, including dyspnea
Optimal management includes: ACE-I/ARB, BB, aldosterone inhibitors
RV failure
most likely due to LV failure
primary RV failure: cor pulmonale
Peripheral congestion, acites, edema
Hi-output failure
beri beri: vit def (thiamine)
hyperthyroid
Causes of systolic CHF
Ischemic cardiomyopathy (HA caused dead heart muscle) HTN (stiffness inc. as afterload inc.) hypo/hyperthyroid HIV ETOH viral dilated cardiotoxins (herceptin, adriamycin?, doxirubicin) infectious (Chagas) hemochromatosis sarcoid (both) amyloid (both) valvular tachycardia-mediated peri-partum
*important to know bc some causes are reversible
Systolic/Diastolic CHF
50/50
originally though HF was just systolic
Causes of diastolic CHF
*HTN*-hypertrophic (dilated and burned out) restrictive (amyloidosis) DM pericardial disease aging
Neurohormonal activation
Partially responsible for the mechanical changes in HF
Vasopressin (ADH) secretion – promotes water absorption by the kidney
(RAAA): Renin-angiotensin-aldosterone axis: maintains cardiac output (CO) and tissue perfusion
*now use B-blockers, used to be contraindicated
RAAA does what ??
stimulates arterial vasoconstriction with angII
expands intravascular volume with Na+ and water retention
important pressure to know
LVEDP: left ventr. end diastolic pressure
(preload)
dry or wet?
use surrogate endpoints
if too high will have backup into lungs
about equal to LA pressure (and wedge pressure, same as pulmonary artery diastolic pressure), and further back….jugular pulsations (JVP)
dec. CO
inc. SNS–>inc HR, contractility, vasoconstriction–>raise BP–>inc. CO
inc. RAAS–>vasoconstr, inc. circ volume–>inc. venous return (preload)–>inc. CO
inc. ADH–>inc. circ volume–>inc. venous return (preload)–>inc. CO
CHF classification
Stages A-D (Duke staging)
A: predisposed (poorly controlled HTN)
B: have LVEDP elev. (EF (more in recording)
Signs/Symptoms/Physical Exam/labs
Palpation: diffuse PMI may imply cardiomyopathy
S3/S4: (S3 systolic dysfunction, S4 diastolic dysfunction)
murmurs: mitral regurg-functional MR
HJR: press on liver area, see inc. in JP (hep jug reflex)
JVP
edema
BNP: heart damage from inc. LV wall stress, release naturitic peptide (NP) from atrium helps with diuresis
Assessment of LV function
Echo easiest, no radiation
MUGA (chemo pts) best way to grade EF, but don’t do much
angiogram
Pressure-Volume Loops
Frank-Starling curve
preload vs. CO
*lasix will reduce preload
Treatment options
Target any potentially reversible causes (CAD, tachycardia, ETOH, etc..)
When to biopsy
acute fulminant myocarditis:
Acute presentation
hemodynamic compromise at initial presentation
new AVB, VT
don’t biopsy 95%, benign
worst myocarditis
giant cell myocarditis
treatable with chemo
needs to be biopsied
px CHF: 5-year mortality
50%
s/s
tachycardia
venous congestion:
right-sided: hepatomeg, ascites, pleural effusion, edema, JVD
left-sided: tachypnea, nasal flaring/grunting, retractions, pulmonary edema
low CO: fatigue, pallor, sweating, cool extremities, poor growth, dizziness, alt. consciousness, syncope
CHF etiologies
Infectious Myocarditis
Dilated cardiomyopathy
- ARVD (arrhythmogenic RV dysplasia–>can lead to VT/sudden death)
- non-compaction (massive trabeculation)- Uals (tx: defibrillator)
Tako-Tsubo (apical ballooning)
- Stress cardiomyopathy
- typ. older females, emotional stress–>symp. surge, hyper contrac. of LV base
- most reversible
Hypertrophic
- CHF and risk of sudden death (arrhyth, put in defib)
- obstruc. of blood getting out of LV
- myomectomy to relieve
Restrictive (amyloid, biopsy, MRI)
Drug-induced and toxic
amyloid
apple green birefringence on electron microscopy
slide 14-16
names and classes of meds
CHF pt comes into HR: cool/clammy, respiratory distress, edema
what to do:
physical assessment most important
EKG: no STEMI
IV lasix
give O2
BP: 200/100
on no meds
get CXR
see cardiomeg, pulm vasc congestion
tachypnic, crackly
to lower BP: amlodipine (CCB), nitro, or metoprolol??
*will not use amlodipine, for long-term prevention
**cannot use B-blocker 1st time in acute compensated heart failure (unless they are on it), once stabilized can use
use nitro drip: venodilator, reduces pulmonary pressure, preload reduction, some drop in afterload
BIPAP
possible foley cath to measure output
troponin, Cr may be elevated
stabilized pt goes up to heart unit, how tx??
need more info
little old lady heart
low volume, high pressure
diastolic heart
EF>45%
floppy-baggy heart (dilated)
high volume, low pressure
systolic heart
EF
both hearts will have
SOB (pulmonary congestion) elevated LVEDP JVD edema (elevated central vein pressures) BNP elevated (stretch, volume tension, inc. work)
how to tell difference btw hearts?
get an ECHO! determine EF
if hear S3: systolic
FB heart, systolic
ACE inhibs ARBs B-blockers: carbetolol, metoprolol XL/succinate Aldosterone antagonists *reduce mortality*
symptomatic relief:
*diuretic, large doses lasix
digoxin (reduces hospitalization, does not reduce mortality)
Afr. American: hydralizine combo (reduces mortality)
if EF 120ms: cardiac synchronization therapy
ionotropes: dobutamine (stim. EF), noronone (PDE inhibitors, relax pulm congestion, helps pump)
(do not improve mortality, to get out of acute trouble
LOL heart, diastolic failure
nothing reduces mortality!
tx BP, DM
some lasix
(remember to determine etiology)
ICD
under pec, dual-channel device screwed into RV apex, if detects VT will shock
Bi-ventricular ICD (CRT)
LBBB
right atrial and ventricular lead, LV coronary sinus lead
pacing 100% of the time
can’t get pt off balloon pump
LVAD implantation
takes place of LV, sucks blood out of LV and pumps to aorta-bridge to transplantation
OMM in CHF
Lymphatic Pump: fluid mobilization
Diaphragmatic Techniques: abdominal and thoracic
Effluerage: mobilize peripheral fluid
Clavicular releases: promote thoracic duct drainage
CV4: fluid homeostasis and decrease stress
of course: OA, thoracics, lumbar, Chapman pts, fascia
Dilated cardiomyopathies
Systolic dysfunction Eccentric hypertrophy (sarcomeres added in series)
ETOH, beri-beri, coxsackie, chronic cocaine, chagas, doxorubicin, hemachromotosis, sarcoid, peripartum
CHF, S3, systolic regurgitant murmur, cardiomegaly on CXR
Tx: Na+ restriction, ACE-I/ARB, BB, diuretics, digoxin, ICD, OHT
(more)
Hypertrophic Cardiomyopathy
60-70% inherited as AD (Beta-myosin heavy-chain mutation)
Can be a/w friedrich ataxia
Syncope during exercise and sudden death in athletes due to VT
Tx: cessation of high-intensity athletics
BB, CCB, ICD if high risk
(more)
Restrictive/infiltrative cardiomyopathy
Sarcoid, amyloid, postradiation fibrosis, Loffler (endocardial fibroelastosis a/w eosinophilic infiltrate), and hemochromotosis (dilated can also occur)
(more)
