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103-theme 3 > chronic heart failure > Flashcards

chronic heart failure Flashcards

1
Q

what is chronic heart failure? 2

A
  • a state which develops when the heart fails to maintain an adequate cardiac output to meet the demands of the body
  • results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (systolic HF) or fill with blood (diastolic HF)
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2
Q

what is stroke volume affected by? 3

A
  • contractility
  • preload
  • afterload
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3
Q

what does an excessively high heart rate result in?

A

a decrease in the amount of time allowed for the ventricles to fill in diastole which causes SV and thus CO to fall

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4
Q

what is preload?

A

the volume of blood or stretching of the cardio myocytes at the end of diastole prior to the next contraction

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5
Q

what affects preload? 4

A
  • by the venous blood pressure and the rate of venous return to the heart
  • this, in turn, is affected by venous tone and volume of circulating blood
  • preload increases with increasing blood volume and vasoconstriction
  • decreases with blood volume loss and vasodilation
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6
Q

what is the frank-sterling law? 4

A
  • describes relationship between preload and cardiac output
  • an increase in volume of blood filling, stretching the heart muscle fibres, causing greater contractile forces which in turn increases the stroke volume
  • is true only up to a certain point, at some stages the fibres can become overstretched and the force contraction is reduced
  • increase in preload, increases stretch, increases contraction and increases SV and CO
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7
Q

what is afterload? 3

A
  • the resistance/ end load against which the ventricle contracts to eject blood
  • the pressure in the aorta/ PA that the ventricular muscles must overcome to eject blood
  • the greater the pressure in the aorta/ PA, the greater the afterload on the ventricles
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8
Q

what affects afterload? 3

A
  • increases with hypotension and vasoconstriction
  • decreases with vasodilation
  • as the afterload increases, cardiac output decreases
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9
Q

name 2 types of low output heart failure?

A

systolic

diastolic

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10
Q

describe high output heart failure? 2

causes? 5

A
  • occurs in context of other medical conditions which increase the demand on the cardiac output causing a clinical picture of HF
  • the heart is functioning normally, but cannot keep up with the high demand for blood in one or more organs in the body
  • thyrotoxicosis
  • anaemia
  • pregnancy
  • acromegaly
  • sepsis
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11
Q

what is systolic heart failure? 4

A
  • progressive deterioration of myocardial contractile function
  • ischaemic injury
  • volume overload
  • pressure overload
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12
Q

what is diastolic heart failure? 5

A
  • inability of the heart chamber to relax, expand and fill sufficiently during diastole to accommodate an adequate blood volume
  • significant left ventricular hypertrophy
  • infiltrative disorders
  • constrictive pericarditis
  • restrictive cardiomyopathy
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13
Q

name some causes of heart failure? 5

A
  • coronary heart disease
  • hypertensive heart disease
  • valvular heart disease
  • myocardial disease/ cardiomyopathies
  • congenital heart disease
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14
Q

what are cardiomyopathies?

name 3 different types?

A
  • diffuse disease of the heart muscle leading to functional impairment
  • dilated cardiomyopathy
  • hypertrophic cardiomyopathy (hereditary)
  • restrictive cardiomyopathy
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15
Q

describe dilated cardiomyopathy? 4

A
  • various causes 50% familial
  • ETOH, pregnancy, systemic disease, muscular dystrophies
  • drug toxicities
  • myocarditis
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16
Q

what is the main cause of restrictive cardiomyopathy?

A

amyloid

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17
Q

describe the pathophysiology of heart failure? 3

A
  • pump failure leads to the reduced SV and CO. compensatory mechanisms kick in to maintain arterial pressure and perfusion of vital organs
  • the frank sterling mechanism
  • myocardial structural change: augmented muscle mass (hypertrophy) with or without cardiac chamber
18
Q

describe the activation of the neurohormonal system? 3

A
  • release of noradrenaline= increases the heart rate and myocardial contractility- causes vasoconstriction
  • release of ANP/BNP
  • activation of RAAS
19
Q

how can compensatory mechanisms worsen heart failure? 3

A
  • vasoconstriction= increased resistance against which heart has to pump and may decrease CO
  • Na and water retention= increased fluid volume which increases preload. if too much it will stretch, decreasing contractile strength and CO
  • excessive tachycardia= decreased diastolic filling time leads to decreased ventricular filling and decreased SV and CO
20
Q

what are the clinical types of heart failure? 3

A
  • left sided, right sided and biventricular failure
  • acute and chronic failure
  • compensated and decompensated heart failure
21
Q

describe left sided heart failure?

- what are the causes? 4

A
  • blood backs up progressively from the left atrium to the pulmonary circulation
  • ischaemic heart disease
  • hypertension
  • valvular disease
  • myocardial disease
22
Q

how does left ventricular failure affect the lungs? 3

A
  • pressure on the pulmonary veins is transmitted retrogradely to the capillaries and the arteries
  • this leads to pulmonary congestion and oedema
  • heavy wet lungs
23
Q

what do heavy wet lungs lead to? 3

A
  • breathlessness exaggeration of the normal breathlessness that follows exertion
  • orthopnoea= breathlessness lying flat that is relived by sitting or standing
  • paroxysmal nocturnal dyspnoea= an extension of orthopnoea with attacks of extreme dyspnoea bordering on suffocation usually at night
24
Q

describe how left ventricular failure can affect the kidney? 4

A
  • decreased cardiac output
  • reduction in renal perfusion
  • activation of renin-angiotensin-aldosterone system
  • retention of salt and water with consequent expansion of interstitial fluid and blood volumes
25
Q

how can left ventricular failure affect the brain? 5

A
  • hypoxic encephalopathy
  • irritability
  • loss of attention
  • restlessness
  • stupor or coma
26
Q

describe right sided heart failure? 4

A
  • usually as a consequence of left sided heart failure (congestive cardiac failure)
  • cor-pulmonale: right sided heart failure due to significant pulmonary hypertension due to increased resistance within pulmonary circulation. usually as a result of respiratory disease
  • valvular heart disease
  • congenital heart disease
27
Q

what are the systemic effects of heart failure? 5

A
  • liver and portal system= congestive hepatomegaly, centrilobular necrosis when severe, cardiac cirrhosis
  • spleen= congestive splenomegaly
  • abdomen=ascites-accumulation of transudate in peritoneal cavity
  • subcutaneous tissue= peripheral oedema of dependent portions of the body especially the ankle and pretibial
  • pleural and pericardial space= effusions
28
Q

describe biventricular failure? 3

A
  • (congestive cardiac heart failure)
  • either due to the same pathological process on each side of the heart
  • or a consequence of left heart failure leading to volume overload of the pulmonary circulation and eventually the right ventricular causing right ventricular failure
29
Q

what is the clinical presentation of heart failure? 8

A
  • due to excess fluid accumulation:
  • dyspnoea
  • orthopnoea
  • oedema
  • hepatic congestion
  • ascites
  • due to reduction in cardiac output:
  • fatigue
  • weakness
30
Q

how do we classify heart failure? 4

A
  • class I: no limitation of physical activity
  • class II: slight limitation of ordinary activity
  • class III: marked limitation, even during less than ordinary activity
  • class IV: severe limitation with symptoms at rest
31
Q

what are the clinical symptoms of heart failure? 8

A
  • cool, pale extremities
  • tachycardia -elevated JVP
  • third heart sound - gallop rhythm
  • displaced apex-left ventricular enlargement
  • crackles or decreased breath sounds at bases on chest auscultation
  • peripheral oedema
  • ascites
  • hepatomegaly
32
Q

what are the clinical tests we use to determine heart failure? 5

A
  • CXR
  • ECG
  • blood investigations
  • echocardiogram, cardiac MRI
  • coronary angiography
33
Q

name 2 loop diuretics?
what they do? 3
side effects?

A
  • frusemide, bumetanide
  • inhibit Na+ reabsorption from the proximal tube
  • K+ loss from the distal tube
  • can be given IV or orally
  • electrolyte abnormalities and diminished renal perfusion
34
Q

name 2 mineralocorticoid receptor antagonists?
what they do? 3
side effects? 2

A

-eplerenone, spironolactone

  • acts on the distal tube
  • promotes Na+ excretion and K+ reabsorption
  • reduced hypertrophy and fibrosis
  • gynaecomastia
  • electrolytes and renal function abnormalities
35
Q

name 5 ACE inhibitors?
what they do? 3
side effects? 3

A

-ramipril, perindopril, enalapril, captopril, lisinopril

  • act on activated RAAS
  • given orally in small doses with slow titration
  • block the production of angiotensin causing vasodilation, BP lowering, reduce cardiac work
  • cough
  • hypotension
  • renal impairment
36
Q

name 3 beta blockers?
what they do? 4
side effects?2

A

-bisoprolol, carvedilol, metoprolol

  • block the action of adrenaline and noradrenaline on adrenergic beta receptors
  • small HR, reduce BP
  • given orally in small doses with slow titration
  • treat arrhythmias
  • bronchospasm
  • claudication
37
Q

name a SA node blockade?
what they do? 3
side effects? 2

A
  • ivabradine
  • blocks the If channels within the SA node
  • slow heart rate, no effect on BP
  • given orally with dose titration
  • visual aura
  • bradycardia
38
Q

name an ARNI
what they do? 4
side effects? 2

A

-sacubitril valsartan

  • acts on activated renin-angiotensin system
  • also blocks the breakdown of ANP/BNP
  • blocks the production of angiotensin causing vasodilation, low BP and lower cardiac work
  • promote natriuresis= sodium exertion, vasodilation, reduce hypertrophy and fibrosis
  • hypotension
  • renal impairment
39
Q

what is digoxin? 4

A
  • increases myocardial contractility
  • slows conduction at the AV node- use in AF
  • excreted by the kidney- toxicity important
  • given in acute HF, especially in AF, in chronic HF in selected cases
40
Q

name some other therapies for heart failure? 7

A
  • Cardiac resynchronisation therapy (CRT)
  • Implantable cardioverter defibrillator (ICD)
  • Dialysis and ultrafiltration
  • Ventricular assist device (LVAD/RVAD)
  • Intra-aortic balloon pump
  • Cardiac transplantation
  • Stem cell therapy
41
Q

what is CRT? 3

A

cardiac resynchronisation therapy

  • biventricular pacing
  • standard pacemaker equipped with 2 wires conducting pacing signals to specific regions of the heart

103-theme 3 (18 decks)

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