CHF lecture Flashcards
Explain the CHF - RAAS loop.
Congestive Heart Failure (CHF) is a _____.
Syndrome, not a disease
Syndrome is a______.
constellation of signs and symptoms occurring together and characterizing a particular abnormality or condition
The same syndrome may occur with different diseases, which may have distinctly different etiologies and pathogenesis
CHF Clinical Syndrome in which
an abnormality of cardiac structure or function is responsible for the inability of the heart to eject or fill with blood at a rate sufficient to meet the demands of the metabolizing tissues.
Pump failure
CHF Epidemiology.
Prevalence is 5,000,000 patients
Incidence is 500,000 patients per year
1 million of hospital admissions a year
50,000 death a year
Systolic Heart failure results from
inadequate cardiac output (C.O.)/Ejection Fraction (E.F.)
C.O. = S.V. x H.R.
S.V. = E.D.V. – E.S.V.
E.F. = S.V./E.D.V.
Diastolic Heart Failure results from
inability of the ventricles to relax and fill normally with blood during diastole.
Forward vs. Backward Heart Failure. Explain?
Forward failure is decrease in perfusion of the organs/tissues down-stream from the heart
Backward failure is “backing up” of the blood into the organs upstream, increasing hydrostatic pressure, which leads to congestion/edema
Left ventricle CHF caused by?
Caused by conditions primarily affecting left ventricle
CAD/MI
Aortic/Mitral valves problems
HTN
Cardiomyopathies
Forward failure symptoms in left ventriclular CHF
Forward failure symptoms are primarily in systemic circulation (downstream)
Backward failure symptoms in left ventricular CHF?
symptoms/congestion in the lungs (upstream)
Right ventricle CHF caused by?
Caused by conditions primarily affecting right ventricle
Pulmonary diseases/cor pulmonale
Tricuspid/pulmonary valves
Pulmonary Hypertension
Pulmonary emboli
Right ventricle CHF primary effects
Backward failure symptoms/congestion in the systemic venous circulation (upstream)
Biventricular Failure is?
End result of left and right failure
Acute HF is caused by
due to a sudden and severe event
Massive MI
Chorda tendinae rupture
Large PE
Acute HF symptoms?
Predominantly forward failure
Flash Pulmonary Edema
Compared to Acute HF, Chronic HF does what?
Progresses slowly
Has exacerbation
Predominantly backward failure
Dilated Cardiomyopathy is due to?
Due to death or functional ischemic dysfunction of myocardial tissue due to complete or partial blockage of coronary arteries
In Dilated Cardiomyopathy the Degree of dysfunction depends on
the percent of myocardium affected
Describe the path of effects in Dilated Cardiomyopathy due to HTN.
Describe the path of effects in Dilated Cardiomyopathy due to valvular heart disease.
One of the main causes of dilated cardiomyopathy?
Infective Myocarditis
etiological agents of Infective Myocarditis
Viral
Bacterial
Fungal
Helminthic
In Infective Myocarditis ______ or _______ frequently precedes cardiac symptoms by few weeks.
Febrile illness or URI
Non-infective toxic Myocarditis can be caused by?
Chemotherapy
Doxorubicin (Adriamycin)
Heavy metals (copper, iron, lead)
Lithium
Malaria drugs
Radiation causing inflammation and fibrosis
Autoimmune/ CTD associated Myocarditis can be caused by?
Giant Cell Myocarditis
PM/DM
SLE/RA
Cocaine can cause CHF through which mechanisms?
May cause vasospasm leading to MI
May cause arrhythmia
May cause drug-induced myocarditis/cardiomyopathy due to released catecholamines
How can ETOH cause CHF?
Alcoholic Cardiomyopathy
From prolonged chronic alcohol use (at least 10 years of chronic exposure)
Due to direct toxic effect of alcohol on myocardium
When is Peripartum Cardiomyopathy most common?
Between last month of pregnancy and first 5 months after delivery
Do patient recover from Peripartum Cardiomyopathy?
More than ½ of patients improve within 6 months
Peripartum Cardiomyopathy is due to?
Likely due to immune-mediated process
Takotsubo Cardiomyopathy’s other names?
A.K.A. Stress cardiomyopathy
A.K.A. Apical Ballooning Syndrome
A.K.A. Broken Heart Syndrome
Takotsubo Cardiomyopathy is caused by?
Triggered by an acute medical illness or by intense emotional or physical stress
Takotsubo Cardiomyopathy symptoms?
Symptoms are similar to an acute MI
CP, SOB, Syncope,
What is Hypertrophic Cardiomyopathy
Myocardial hypertrophy unrelated to any pressure or volume overload
Hypertrophic Cardiomyopathy is due to?
Due to different genes mutations
Myosin heavy chains
Proteins regulating Calcium handling
Most are autosomal dominant
Which portion of the heart is unproportionally effected in Hypertrophic Cardiomyopathy?
Inter-ventricular septum often disproportionally involved
causing sub-aortic stenosis
Hypertrophic Cardiomyopathy mostly causes what type of dysfunction?
Mostly causes diastolic, not a systolic dysfunction
Symptoms/signs of HOCM
SOB
Chest Pain
Syncope (often after exercise)
Arrhythmias
Atrial Fibrillation
Ventricular arrhythmias
Sudden death
Systolic murmur along the left sternal border
increases with Valsalva maneuver/upright position
decreases with squatting
What differences are present in non-genetic, or HTN HOCM?
Similar to HOCM except for more generalized thickening with no disproportional involvement of the septum
Aortic stenosis-related hypertrophy
Symptoms of HTN HOCM d/t diastolic dysfunction? Obstructive dysfunction? (2 each)
Related to diastolic dysfunction
SOB
Edema
Related to Obstruction
Syncope
Chest Pain
Restrictive Cardiomyopathy Characterized by?
impaired filling causing predominantly diastolic dysfunction
Restrictive Cardiomyopathy is due to?
- Infiltrative disease
- Amyloidosis
- Sarcoidosis
- Systemic storage diseases
- Hemochromatosis
- Glycogen Storage Diseases
- Metabolic disorders
- Fibrotic
- Radiation
- Scleroderma
- Endomyocardiac
- Loffler’s endocarditis
- Endomyocardial Fibrosis
Typical pulmonary pressures?
20/10mmHg
Idiopathic Pulmonary Hypertension characteristics
Uncommon (2 cases per million)
Females>males
30-50 is predominant age of onset
12-20% is autosomal dominant genetic disorders with incomplete penentrance
Mean survival is 2-3 years from diagnosis
Left to right shunting results in PHTN due to which defects?
Ventricular septal defect
Patent ductus arteriosus
Atrial septal defect
Atrioventricular septal defect
Drugs-associated Pulmonary HTN
Fenfluramine (weight loss pill)
Direct effect on pulmonary vasculature
Secondary effect via right sided valvular heart disease
Amphetamines
Cocaine
What is Cor Pulmonale
Heart disease due to lung disease
Most common cause of PHTN?
Typical origin of pulmonary embolism?
Usually originates from lower extremities
Pulmonary Embolism results in?
Results in increase in pulmonary artery pressure therefore increasing after-load for right ventricle
May lead to right ventricular failure
High Output Failure is?
Increase metabolic demand doesn’t match with cardiac output
High Output Failure caused by?
Thyrotoxicosis
Anemia
AV fistula
Conditions decreasing peripheral vascular resistance (Beriberi, sepsis etc)
Symptoms of CHF from Backward Left heart failure?
Pulmonary edema
SOB, cough (frosty)
PND
Orthopnea
Pleural effusions
Symptoms of CHF from Backward right heart failure?
Lower extremity swelling/edema
Anasarca/ascitis/pleural and pericardial effusion
Could affect lungs as well
End organ damage
Congestive hepatopathy/nutmeg liver
Splenomegaly with hypersplenism
Intestinal congestion leading to GI symptoms
Symptoms of Forward failure CHF
Mostly in left heart failure
Hypotension
Weakness
Exercise intolerance
End organ damage
Cardiac ischemia
Watershed infarcts
Renal failure
Bowel ischemia
Shock liver
New York Heart Association (NYHA)
Functional Classification?
Class I: Symptoms with more than ordinary activity
Class II: Symptoms with ordinary activity
Class III: Symptoms with minimal activity
Class IIIa: No dyspnea at rest
Class IIIb: Recent dyspnea at rest
Class IV: Symptoms at rest
Stages of Heart Failure
ACC/AHA 2005 Guidelines
CHF typical VS
BP may be low in advanced CHF
Tachycardia is often present
Tachypnea and hypoxia in severe cases
CHF. Physical findings.
Neck?
Jugular Vein Distention
Hepato-jugular (Abdominal-jugular) reflux
Thyroid enlargement in toxic goiter may be present
CHF. Physical findings.
Lungs
Crackles/rales.
- Usually bilateral
- Bi-basilar
The higher you can hear them, the worse CHF is
Sometimes decrease breath sounds on bases
Dullness on percussion
Tactile Fremitus
- Decreased in case of bilateral pleural effusion
- Increased in case of alveolar/interstitial edema
CHF. Physical findings.
Heart Palpation
PMI is displaced if LV is enlarged
Parasternal lift (heave) if RV is enlarged
Arrhythmia is common
CHF. Physical findings.
Heart Auscultation
S1 may be diminished if LV function is very poor
P2 (Pulmonic component of S2 ) may be accentuated when pulmonary hypertension is present.
An apical third heart sound (S3) with low EF
S4 is usually present with diastolic dysfunction
Murmurs may indicate the presence of significant valvular disease as the cause of heart failure or the result of it.
Signs of Left Ventricular Hypertrophy
Signs of Right Ventricular Hypertrophy
Signs of Biventricular Hypertrophy
Cor Pulmonale (R.A. hypertrophy + R.V. Hypertrophy)
Atrial Fibrillation
Ventricular ectopy
Brain Natriuretic peptide BNP produced by?
heart cells (ventricles)
BNP with ANP (atrial natriuretic peptide, which is produced by atrial cells) released in response to?
increased ventricular/atrial filling pressures
Both BNP and ANP have ____, ______and ______effect (compensatory effect in response to increase in ventricular filling pressures)
diuretic
natriuretic
hypotensive
Problems with using BNP?
High false positive rates
Increased in other conditions
Old age
Renal failure
Cor pulmonale
Pulmonary hypertension
Pulmonary embolism
Doesn’t rule out other causes of dyspnea
Chronic elevation in cardiomyopathy doesn’t help with diagnosing exacerbations
Heart Failure. CXR findings.
Kerley B lines
Echocardiogram looks at?
Size of the heart chambers
Thickness of the walls
Contractility
Ejection fraction
Wall motion abnormality
Septal defects
Valvular structures and their integrity
Intracardiac structures (clots, tumors)
Diastolic dysfunction
Pulmonary pressures
CHF treatment, meds.
Diuretics
ACE inhibitors
ARBs
Digoxin
β − Blockers
Aldosterone antagonists
Nitrates
Hydralazine
Which diuretics are used in CHF?
Loop diuretics
How do diuretics help in CHF?
Help with “congestion” part of CHF
Improvement of symptoms, but not mortality
What to watch for when using diuretics in CHF?
May worsen renal function and cause electrolytes abnormalities
Why are ACE inhibitors used in CHF?
Decrease after-load ► increase ventricular function
Improves symptoms and mortality.
Why are ARBs used in CHF?
Decrease after-load
Improve symptoms and mortality
Why is digoxin used in CHF?
Increases contractility
Improves symptoms, decrease hospitalizations
What to watch out for with digoxin use?
No effect on mortality
May cause arrhythmia
Narrow therapeutic index
Why are ß blocker used in CHF?
Which three are shown to reduce mortality?
Used only with low EF
Improves symptoms
Prolongs life
Started only in stable patients
Counter-intuitive treatment
Usually decrease contractility and C.O.
Only 3 beta-blockers have a proven effect on mortality
Metoprolol Succinate
Carvedilol
Bisoprolol
ß blockers in CHF. That doesn’t make since. How does it work?
Upregulate beta receptors improving inotropic and chronotropic responsiveness of the myocardium ► improvement in contractile function.
Reduce the level of vasoconstrictors ► decreased after-load.
Have a beneficial effect on LV remodeling ► improvement in LV geometry ► ^ contractility.
Reduce myocardial consumption of oxygen.
Decrease the frequency of ventricular premature beats and the incidence of sudden cardiac death (SCD), especially after a myocardial infarction
Why are Aldosterone antagonists used in CHF?
Diuretic and a final piece of the renin-angiotensin-aldosterone axis
Decreases mortality in severe heart failure
Why are nitrates used in CHF?
Decrease preload and somewhat after-load
Improve symptoms of acute CHF
In combination with hydralasine improve mortality in African-Americans
Why is hydralizine used in CHF?
Decrease after-load, because dilates arterioles only.
