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CHF ppt- Pales Flashcards

1
Q

syndrome vs disease

A

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

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2
Q

CHF defn

A

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

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3
Q

Systolic components of heart function/ dysfunction

A

Myocardial function
How strong the muscle is

Preload (EDV)
The more heart fibers are stretched the more difficult it is for them to contract increasing work/pressures and causing hypertrophy (Starling law)

After-load
Resistance against heart contraction/ejection of blood

Heart rate
Too slow—decreases cardiac output ( CO = SV x HR)
Too fast — not enough time to fill ( CO = SV x HR)

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4
Q

diastolic components of heart function/ dysfunction

A

Impaired relaxation –functional problem
Ischemia

Impaired compliance (“stiff” ventricle) –anatomical problem related to interstitial fibrosis
Hypertrophy
Hypertension

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5
Q

High output failure

A

Normal heart function with
increased metabolic demand
Increased peripheral blood flow from decreased PVR

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6
Q

systolic vs diastolic heart failure

A

Systolic Heart failure results from inadequate cardiac output (C.O.)/Ejection Fracture (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.

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7
Q

Forward vs. Backward Heart Failure

A

Relates to clinical manifestations of the heart failure as a result of pump failure

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

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8
Q

Left-sided Heart Failure

A

Left Ventricle primarily affected.

Caused by conditions primarily affecting left ventricle
- CAD/MI
- Aortic/Mitral valves problems
HTN
- Cardiomyopathies

Forward failure symptoms are primarily in systemic circulation (downstream)

Backward failure symptoms/congestion in the lungs (upstream)

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9
Q

Right-sided heart failure

A 
Right ventricle primarily affected.
Caused by conditions primarily affecting right ventricle
- Pulmonary diseases/cor pulmonale
- Tricuspid/pulmonary valves
- Pulmonary Hypertension
- Pulmonary emboli

Backward failure symptoms/congestion in the systemic venous circulation (upstream)

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10
Q

Biventricular Failure

A

End result of left and right failure

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11
Q

Acute heart faillure

A 
due to a sudden and severe event
- Massive MI
- Chorda tendinae rupture
- Large PE
Predominantly forward failure
Flash Pulmonary Edema
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12
Q

chronic heart failure

A

Progresses slowly
Has exacerbation
Predominantly backward failure

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13
Q

Heart Failure vs. Cardiomyopathy

A

Heart failure is a syndrome

Cardiomyopathy is a large group of heterogeneous disorders of myocardial function in the absence of abnormal loading conditions such as with hypertension, CAD or valvular disease.

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14
Q

Left Heart Failure.CAD/MI

A

Due to death or functional ischemic dysfunction of myocardial tissue due to complete or partial blockage of coronary arteries

Degree of dysfunction depends on the percent of myocardium affected

Ischemic cardiomyopathy (Old term, still widely used)

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15
Q

Infectious Myocarditis

A

One of the main causes of dilated cardiomyopathy and left heart systolic failure in young patients.

Multiple etiological agents

  • Viral
  • Bacterial
  • Fungal
  • Helminthic

Febrile illness or URI frequently precedes cardiac symptoms by few weeks

Symptoms can present acutely (fulminant) or gradually

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16
Q

Non-infective Myocarditis

A

Toxic Myocarditis

  • Chemotherapy
  • Doxorubicin (Adriamycin)
  • Heavy metals (copper, iron, lead)
  • Lithium
  • Malaria drugs
  • Radiation causing inflammation and fibrosis

Autoimmune/ CTD associated Myocarditis

  • Giant Cell Myocarditis
  • PM/DM
  • SLE/RA
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17
Q

Cocaine and myocardium

A

May cause vasospasm leading to MI
May cause arrhythmia
May cause drug-induced myocarditis/cardiomyopathy due to released catecholamines

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18
Q

Alcoholic Cardiomyopathy

A

From prolonged chronic alcohol use (at least 10 years of chronic exposure)

Due to direct toxic effect of alcohol on myocardium

Different from beriberi disease, although thiamine deficiency is frequent in alcoholics

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19
Q

Peripartum Cardiomyopathy

A

Between last month of pregnancy and first 5 months after delivery
Likely due to immune-mediated process
No preexisting cardiac disease
More than ½ of patients improve within 6 months

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20
Q

Takotsubo Cardiomyopathy

A

A.K.A. Stress cardiomyopathy
A.K.A. Apical Ballooning Syndrome
A.K.A. Broken Heart Syndrome

stress- neurogenic –> myocardial stunning, heart failure, angina, coronary spasm, arrhythmias, stress cardiomyopathy

80% are women

Triggered by an acute medical illness or by intense emotional or physical stress

Postulated mechanisms include

  • catecholamine excess
  • coronary artery spasm
  • microvascular dysfunction
  • OR dynamic mid-cavity or left ventricular outflow tract obstruction which may contribute to apical balooning.

Symptoms are similar to an acute MI
- CP, SOB, Syncope,

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21
Q

Hypertrophic CardiomyopathyGenetic (HOCM)

A

Group of disorders

Myocardial hypertrophy unrelated to any pressure or volume overload

Due to different genes mutations
Myosin heavy chains
Proteins regulating Calcium handling

Most are autosomal dominant

Inter-ventricular septum often disproportionally involved

Sub-aortic stenosis is often present

May cause diastolic or systolic dysfunction

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22
Q

Valsalva maneuver

A

decreases pre-load

with aortic stenosis the murmur decreases

with HOCM it increases

23
Q

HOCM. Clinical manifestations

A

Affects younger people

Symptoms/signs
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
24
Q

Restrictive Cardiomyopathy

A

Characterized by impaired filling causing predominantly diastolic dysfunction

Primary genetic forms are uncommon

Secondary forms are due to other conditions

25
Restrictive Cardiomyopathy- causes
Infiltrative disease - Amyloidosis - Sarcoidosis Systemic storage diseases - Hemochromatosis - Glycogen Storage Diseases Metabolic disorders Fibrotic - Radiation - Scleroderma Endomyocardiac - Loffler’s endocarditis - Endomyocardial Fibrosis
26
Pulmonary Hypertension
Pulmonary circulation is a low pressure circulation 20/10 (pulmonary) vs. 120/80 (systemic) Blood flow is the same as in systemic circulation Pulmonary vascular resistance is much less than systemic vascular resistance Pulmonary HTN is increased pressures in the pulmonary circulation
27
Idiopathic Pulmonary Hypertension(Primary)
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
28
(congenital) Pulmonary Hypertension.Left to Right Shunt
Communication between left and right heart High pressure systemic circulation gets dumped into low pressure pulmonary circulation Due to various heart defects - Ventricular septal defect - Patent ductus arteriosus - Atrial septal defect - Atrioventricular septal defect
29
Drugs-associated Pulmonary HTN
``` Fenfluramine (weight loss pill) Direct effect on pulmonary vasculature Secondary effect via right sided valvular heart disease Amphetamines Cocaine ```
30
Cor Pulmonale
most common cause of pulmonary HTN pulmonary disease--> pulmonary HTN--> increased RV afterload--> RV Hypertrophy--> RV failure
31
Pulmonary Embolism
Usually originates from lower extremities May also come from upper extremities, abdominal veins, heart Results in increase in pulmonary artery pressure therefore increasing after-load for right ventricle May lead to right ventricular failure
32
High Output Failure
Normal heart Increase metabolic demand doesn’t match with cardiac output - Thyrotoxicosis Excessive blood flow overwhelms normal abilities of the pump - Anemia - AV fistula - Conditions decreasing peripheral vascular resistance (Beriberi, sepsis etc)
33
Left-sided failure symptoms
paroxysmal nocturnal dyspnea elevated pulmonary capillary wedge pressure pulmonary congestion (cough, crackles, wheezes, blood-tinged sputum, tachypnea, restlessness, confusion, orthopnea, tachycardia, exertional dyspnea, fatigue, cyanosis)
34
symptoms of right-sided failure
``` fatigue increased peripheral venous pressure ascites enlarged liver and spleen may be secondary to chronic pulmonary problems distended jugular veins anorexia and complaints of GI distress weight gain dependent edema ```
35
backward failure from left heart failure CHF symtoms
``` Pulmonary edema SOB, cough (frosty) PND Orthopnea Pleural effusions ```
36
Right heart failure | symptoms
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
37
Forward failure | symptoms
``` Mostly in left heart failure Hypotension Weakness Exercise intolerance End organ damage Cardiac ischemia: - Watershed infarcts - Renal failure - Bowel ischemia - Shock liver ```
38
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
39
Stages of heart failure
Stage A- at risk but without structural heart disease Stage B- structural heart disease, but without symptoms or signs of heart failure stage C- structural heart disease, with prior or current symptoms of heart failure Stage D- refractory heart failure. Requiring specialized intervention
40
CHF. Physical findings.
VS: BP may be low in advanced CHF Tachycardia is often present Tachypnea and hypoxia in severe cases Jugular Vein Distention Hepato-jugular (Abdominal-jugular) reflux Thyroid enlargement in toxic goiter may be present 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 Heart PMI is displaced if LV is enlarged Parasternal lift (heave) if RV is enlarged Arrhythmia is common
41
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.
42
CHF diagnostic testsBNP
Brain Natriuretic peptide Hormone produced by heart cells (ventricles) Alone with ANP (atrial natriuretic peptide, which is produced by atrial cells) released in response to increased ventricular filling pressures Both BNP and ANP have diuretic, natriuretic and hypotensive effect (compensatory effect in response to increase in ventricular filling pressures) BNP is used as a marker of heart failure
43
BNP drawbacks
``` 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 Shown benefit in CHF clinics
44
Echocardiogram
Ultrasound examination of the heart ``` 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 ```
45
CHF treatment: diuretics
Loop diuretics Help with “congestion” part of CHF Improvement of symptoms, but not mortality May worsen renal function and cause electrolytes abnormalities
46
CHF treatment: ACE inhibitors
Decrease after-load --> increase ventricular function | Improves symptoms and mortality.
47
CHF treatment: ARBs
Decrease after-load | Improve symptoms and mortality
48
CHF treatment: digoxin
``` The oldest drug used for CHF Increases contractility Improves symptoms, decrease hospitalizations No effect on mortality May cause arrhythmia Narrow therapeutic index ```
49
CHF treatment: beta blockers
``` 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 ```
50
Why beta blockers work in heart failure?
Upregulate beta receptors improving inotropic and chronotropic responsiveness of the myocardium improvement in contractile function. Reduce the level of vasoconstrictors 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
51
CHF treatment: aldosterone antagonists
Diuretic and a final piece of the renin-angiotensin-aldosterone axis Decreases mortality in severe heart failure
52
Nitrates
Decrease preload and somewhat after-load Improve symptoms of acute CHF In combination with hydralasine improve mortality in African-Americans
53
Hydralazine
Decrease after-load
54
All mortality improvements are for CHF patients with
decreased systolic function/ejection fracture.

CV 2 Exam 3 (23 decks)

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