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Cardiology > Congestive Heart Failure > Flashcards

Congestive Heart Failure Flashcards

1
Q
  1. Heart failure is a disorder in which what occurs?

2. What are the two main forms

A
  1. the heart pumps blood inadequately, leading to reduced blood flow, and back up of blood in the veins and lungs
  2. systolic dysfunction and less common diastolic dysfunction.
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2
Q

Describe HF from systolic dysfunction?

What is the result of this?

A

In systolic dysfunction, the heart contracts less forcefully and cannot pump out as much of the blood that is returned to it.

As a result, more blood remains in the ventricles.

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3
Q

Describe HF from diastolic dysfunction?

What is the result?

A

In diastolic dysfunction, the heart is stiff and does not relax normally after contracting. Even though it may be able to pump a normal amount of blood out of the ventricles, the stiff heart does not allow as much blood to enter its chambers from the veins.

As in systolic dysfunction, the blood returning to the heart then accumulates in the veins. Often, both forms of heart failure occur together.

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4
Q

As the blood backs up because of the diminishing ______ _______, pressure in the heart chambers and vessels distal to the “failing” pumping chamber ______ will occur.

Additionally the kidneys may respond by ______ ____ and _____.

The body becomes congested and the term congestive heart failure is used to describe the condition

A

cardiac output
edema

retaining fluid
salt

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5
Q

A study of healthy adults in the United States found the following causes/ risks for CHF:
6

A
  1. Ischaemic heart disease 62%
  2. Cigarette smoking 16%
  3. Hypertension (high blood pressure) 10%
  4. Obesity 8%
  5. Diabetes 3%
  6. Valvular heart disease 2% (much higher in older populations)
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6
Q

Rarer causes of heart failure include:

8

A
  1. Viral myocarditis (an infection of the heart muscle)
  2. Infiltrations of the muscle such as amyloidosis
  3. HIV cardiomyopathy (caused by human immunodeficiency virus)
  4. Connective tissue diseases such as systemic lupus erythematosus
  5. Abuse of drugs such as alcohol and cocaine
  6. Pharmaceutical drugs such as chemotherapeutic agents
  7. Arrhythmias.
  8. Obstructive sleep apnea (a condition of sleep wherein disordered breathing overlaps with obesity, hypertension, and/or diabetes) is regarded as an independent cause of heart failure.
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7
Q

What determines pump function?

4

A
  1. Electrical System
  2. Heart muscle excursion- Ejection Fraction
  3. Priming the pump- Preload
  4. Resistance to Ejection- Afterload
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8
Q
  1. Cardiac arrest, also known as cardiopulmonary arrest or circulatory arrest, is what?
  2. Medical personnel may refer to an unexpected cardiac arrest as what?
A
  1. the cessation of normal circulation of the blood due to failure of the heart to contract effectively.
  2. a sudden cardiac arrest (SCA).
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9
Q

Arrested blood circulation prevents delivery of oxygen to the body. Lack of oxygen to the brain causes loss of consciousness, which then results in what?

Brain injury is likely to happen if cardiac arrest goes untreated for more than ____ _______. For the best chance of survival and neurological recovery, immediate and decisive treatment is imperative.

A

abnormal or absent breathing.

five minutes

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10
Q
  1. What happens to contraction as the ventricle is overloaded?
  2. In a normal heart increased filling of the ventricle affects contraction how? Cardiac Output how?
  3. How does this change in HF?
A
  1. Reduced force of contraction
  2. increased force of contraction (by the Frank–Starling law of the heart) and thus a rise in cardiac output\
  3. Muscle contraction becomes less efficient because ability of actin and myosin filaments to crosslink are reduced in an overstretch heart.
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11
Q
  1. What is the most common cause of systolic dysfunction HF?

2. How much of the heart can it affect?

A
  1. Coronary artery disease is a common cause of systolic dysfunction.
  2. may impair the entire heart or one area of the heart.
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12
Q
  1. What is the most common cause of diastolic dysfunction?

2. How does the heart pump less blood in diastolic dysfunction?

A
  1. Inadequately treated high blood pressure is the most common cause of diastolic dysfunction
  2. Eventually, the heart’s walls thicken (hypertrophy), then stiffen. The stiff heart does not fill quickly or adequately, so that with each contraction, the heart pumps less blood than it normally does.
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13
Q

What are the clinical signs and symtpoms of CHF?

6

A
  1. Exertional dyspnea
  2. Paroxysmal noctural dyspnea
  3. Orthopnea
  4. JVD
  5. Crackles
  6. Displaced apical impulse
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14
Q

WHat are the sgns of congestion that are common in CHF?

6

A
  1. cough
  2. Pulmonary edema
  3. pumping action of the heart grow weaker
  4. pleural effusion
  5. swelling in abs (ascites)
  6. leg edema
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15
Q

How does RAAS mechanism affect HF?

Explain how it does this? 4

A

Worsens failure

  1. Decreased renal blood flow secondary to low cardiac output triggers renin secretion by the kidneys:
  2. Aldosterone is released → increase in Na+ retention → water retention
  3. Preload increases
  4. Worsening failure
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16
Q

Mechanisms and Examples that Cause Left Sided Heart Failure 4

A

Systolic Dysfunction:

  1. Impaired Contractility
  2. Volume overload (increased preload)

Diastolic Dysfunction:

  1. Impaired ventricular relaxation
  2. Increased Afterload (pressure overload)
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17
Q

What causes impaired contractility that causes systolic dysfuntion and LSHF? 4

A
  1. Myocardial infarction
  2. Transient myocardial ischaemia
  3. Chronic volume overload
    a. Mitral regurgitation
    b aortic regurgitation
  4. Dilated cardiomyopathy
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18
Q

What causes causes Volume overload (increased preload) that leads to systolic dysfuntion and LSHF? 3

A
  1. Mitral insufficiency
  2. Aortic insufficiency
  3. Atrial and/or Ventricular septal defect
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19
Q

What causes impaired ventricular relaxation that causes diastolic dysfuntion and LSHF?
4

A
  1. Left ventricular hypertophy
  2. Hypertrophic cardiomyopathy
  3. Restrictive cardiomyopathy
  4. Transient myocardial ischaemia
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20
Q

What causes Increased Afterload
(Pressure Overload) that causes diastolic dysfuntion and LSHF?
4

A
  1. Mitral Stenosis
  2. Pericardial constriction or
    tamponade
  3. Aortic Stenosis
  4. Uncontrolled hypertension
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21
Q

Homeostatic Imbalance of Cardiac Output.

  1. The heart’s pumping action ordinarily maintains a balance between what?
  2. Congestive Heart Failure:
    Occurs when the pumping efficiency of the heart is so low that blood circulation cannot meet _____ _____.
A
  1. cardiac output and venous return

2. tissue needs

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22
Q

HF reflects weakening of the myocardium by various conditions which damage it in different ways:
4

A
  1. Coronary Atherosclerosis
  2. Persistent High Blood Pressure
  3. Dilated Cardiomyopathy
  4. Valvular Heart Disease
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23
Q
  1. Coronary Atherosclerosis is what?
  2. Heart becomes increasingly _______ and begins to contract ineffectively
  3. Myocardial ischemia occurs when what happens?
A
  1. Clogging of the coronary vessels with fatty buildup
  2. hypoxic (inadequate oxygen)
  3. myocardial availability to meet metabolic requirements just doesn’t happen (supply doesn’t meet demand)
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24
Q

Damage to endothelial cells will lead to:

2

A
  1. Decreased Nitric Oxide and Prostacyclin production

2. Increased Endothelin production

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25
Q

Decreased Nitric Oxide and Prostacyclin production
Increased Endothelin production will lead to?
3

A
  1. Vasoconstriction
  2. Vasospasm
  3. Thrombosis
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26
Q

In myocardial ischemia what causes the impaired mycardial contraction and cell death?
3steps

A
  1. Increased intracellular Na
  2. Decreased Na/Ca exchange
  3. Intracellular Ca++ overload
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27
Q
  1. Diastolic Dysfunction:
    When a sufficient amount of myocardium is rendered ischemic, then ______ rises
  2. ________ is impaired, and myocardial compliance ________.
A
  1. LVEDP
  2. Relaxation
    decreases
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28
Q

HOMEOSTATIC IMBALANCE
1. What is angina pectoris?

  1. What may this result from?
  2. How are the myocardial cells affected by the lack of oxygen in angina?
A
  1. Thoracic pain (discomfort) caused by a fleeting deficiency in blood delivery to the myocardium
  2. May result from stress-induced spasms of the coronary arteries or from increased physical demands on the heart
  3. Myocardial cells are weakened by the temporary lack of oxygen but do not die
29
Q

HOMEOSTATIC IMBALANCE

  1. What is MI?
  2. What are affected cells replaced with?
A
  1. There is prolonged coronary blockage that leads to cell death 2. most areas of cell death are repaired with noncontractile scar tissue

Whether or not a person survives a myocardial infarction depends on the extent and location of the damage (a 99.9999% Left main could be serious….remember your anatomy)

30
Q

Persistent High Blood Pressure

  1. Aortic pressure is normally __mm Hg during diastole
  2. When aortic diastolic blood pressure rises to __ mm Hg or more, the myocardium conpensates how?
  3. What does this cause?
  4. Stress takes its toll and the myocardium becomes progressively _______.
A
  1. 80
    • -90
    • -must exert more force to open the aortic valve and pump out the same amount of blood
  3. Myocardium hypertrophies (increased size of tissue / organ)
  4. weaker
31
Q

Eccentric hypertrophy:

  1. What is the precipitating stress?
  2. How does the ventricle respond?
  3. What results from the ventricles response?
  4. The wall thickness increases in proportio with what?
A
  1. If the precipitating stress is volume overload,
  2. the ventricle responds by adding new sarcomeres in-series with existing sarcomeres.
  3. This results in ventricular dilation while maintaining normal sarcomere lengths.
  4. The wall thickness normally increases in proportion to the increase in chamber radius.
32
Q

Concentric hypertrophy?

  1. What is the precipitating stress?
  2. What will change due to this stress (as opposed to what?)
  3. This type of ventricle is capable of generating greater forces and higher pressures, while the increased wall thickness maintains normal wall stress. This type of ventricle becomes?
A
  1. If the precipitating stress is chronic pressure overload,
  2. the wall thickness greatly increases as new sarcomeres are added in-parallel to existing sarcomeres (the chamber radius may not change)
  3. “stiff” (i.e., compliance is reduced) which can impair filling and lead to diastolic dysfunction.
33
Q
  1. Describe Dilated Cardiomyopathy (DCM)

2. Cause?

A
  1. Ventricles stretch and become flabby and the myocardium deteriorates
  2. autoimmune

Drug toxicity (alcohol, cocaine, excess catecholamines, chemotherapeutic agents), hypothyroidism, and inflammation of the heart are implicated in some cases, as is congestive heart failure

34
Q

Dilated Cardiomyopathy (DCM)

The heart’s attempts to work harder result in increasing levels of 1.____ in the cardiac cells which activates a calcium-sensitive enzyme that initiates a cascade which switches on genes that cause 2._____ _________.

Because ventricular contractility is impaired, 3.___ is poor and the condition progressively worsens

A
  1. Ca2+
  2. heart enlargement
  3. CO
35
Q
  1. What is Cardiomyopathy?

2. There are three main types of cardiomyopathy. What are they?

A 
1.  refers to progressive impairment of the structure and function of the muscular walls of the heart chambers.
2.
-dilated
-hypertrophic
-restrictive
36
Q
  1. Describe dilated cardiomyopathy.
  2. Describe hypertrophic cardiomyopathy.
  3. Describe restrictive cardiomyopathy.
A
  1. the ventricles enlarge and impair systolic function.
  2. the walls of the ventricles thicken and become stiff and impair diastolic relaxation.
  3. which is uncommon, the walls of the ventricles become stiff, but not necessarily thickened due to an infiltrated of fibrotic myocardium.
37
Q

In dilated cardiomyopathy what does progressive left ventricular enlargement lead to? 3

In hypertrophic cardiomyopathy, the associated rise in LV pressure is transmitted backwards leading to what? 2

What is the prognosis for restrictive and ultimately leads to what?

A
  1. heart failure
  2. ventricular arrhythmias
  3. embolic complications
  4. elevated left atrial and
  5. consequently pulmonary capillary pressure.

Has a poor prognosis and leads ultimately to congestive heart failure.

38
Q

For there to be an S4 what rhythms must you be in?

A

SR. The sound is dependant on atrial contraction

39
Q

Etiology of Right Heart Failure?

4

A
  1. Acute MI—Inferior MI
  2. Pulmonary disease
  3. Cardiac disease involving the left or both ventricles
  4. LVF (remember this guys, we were just getting to know each other, we have come a long way together)
40
Q

What kind of pulmonary diseases can cause right HF?

3

A
  1. COPD,
  2. fibrosis,
  3. HTN
41
Q

Describe the pathophysiology of right sided heart failure.

A
  1. Decreased right-sided cardiac output or increased pulmonary vascular resistance →
  2. increased right vent. pressures.
  3. As pressures rise, this →
  4. increased pressure in the right atrium and venous system
  5. Higher right atrium pressures →
  6. JVP
42
Q
  1. Decreased right-sided cardiac output or increased pulmonary vascular resistance leads to what?
  2. As pressures rise, this leads to?
  3. Higher right atrium pressures leads to?
A
  1. increased right ventriclular pressures
  2. increased pressure in the right atrium and venous system
  3. JVP
43
Q
  1. How will right sided HF affect stroke volume and why?
  2. Why is end systolic volume increased?
  3. Decreased end diastolic volume results what?
  4. As occurs when?
A
  1. A reduced stroke volume, as a result of a failure of systole, diastole or both.
  2. reduced ventricular excursion.
  3. from impaired ventricular filling 4. as occurs when the compliance of the ventricle falls (i.e. when the walls stiffen).
44
Q

Enlargement of the ventricles, contributing to the enlargement and spherical shape of the failing heart. The increase in ventricular volume also causes 1. WHAT? due to 2. WHAT?

A
  1. reduction in stroke volume

2. mechanical and contractile inefficiency.

45
Q
  1. Physical examination may reveal what? 3
  2. What is frequently assessed as a marker of fluid status?
  3. This can be accentuated by eliciting ________ _____.

If the right ventricular pressure is increased, a 4.________ _____ may be present, signifying the compensatory increase in 5._______ _____.

A
    • pitting peripheral edema
    • ascites
    • hepatomegaly
  2. Jugular venous pressure
  3. hepatojugular reflux
  4. parasternal heave
  5. contraction strength
46
Q

What is the best estimate clinically of right arterial pressure and right side function?

Identify highest point of pulsation
Measure from highest point vertically to the sternal angle. What is an abnormal measurement?

A

Jugular Vein
External - more readily visible
Internal - more reliable

Abnormal if > 3 cm

47
Q
  1. Backward failure of the right ventricle leads what?
  2. This generates excess fluid accumulation in the body termed?
  3. RSHF/JVP affects the _________ parts of the body first
  4. Examples? 2
  5. Nocturia (frequent nighttime urination) may occur with what?
  6. What other things will enlarge? 2
  7. Significant liver congestion may result what? 3
A
  1. to congestion of systemic capillaries
  2. peripheral edema or anasarca
  3. dependent
    • causing foot and ankle swelling in people who are standing up
    • sacral edema in people who are predominantly lying.
  5. increased fluid reabsorption when lying
    • ascites (fluid accumulation in the abdominal cavity)
    • hepatomegaly (enlargement of the liver) may develop)
    • impaired liver function
    • jaundice
    • coagulopathy (problems of decreased blood clotting) may occur.
48
Q
  1. Left ventricular/ Backward failure causes congestion of what with what kind of symtpoms?
  2. Can be subdivided into what? 3
  3. What are the most common symptoms? 5
A
  1. pulmonary vasculature, with predominantly respiratory symptoms.
    • failure of the left atrium,
    • the left ventricle or
    • both within the left circuit.
    • Dyspnea on exertion and in severe cases at rest
    • othopna
    • PND
    • Easy fatigue and exercise intolerance
    • Cardiac asthma or wheezing
49
Q
  1. What is systolic dysfunction characterized by?
  2. The strength of ventricular contraction is attenuated and inadequate for creating an adequate stroke volume, resulting in inadequate what?
  3. In general this is caused by what?
A
  1. decreased ejection fraction (less than 45%).
  2. cardiac output
  3. dysfunction or destruction of cardiac myocytes or their molecular components
50
Q
  1. In congenital diseases such as Duchenne muscular dystrophy, the molecular structure of individual _______ is affected.
  2. Myocytes and their components can be damaged by ________(such as in________).
  3. Toxins and pharmacological agents (such as ethanol, cocaine, doxorubicin, and amphetamines) cause________ damage and ________ stress.
A
  1. myocytes
  2. inflammation such as myocarditis
  3. intracellular
    oxidative
51
Q
  1. The most common mechanism of damage is in systolic dysfunction is what?
  2. After myocardial infarction, dead myocytes are replaced by _____ ______, deleteriously affecting the function of the myocardium.
  3. On echocardiogram, this is manifest by what? 2
A
  1. ischemia causing infarction and scar formation
  2. scar tissue
  3. abnormal wall motion (hypokinesia) or absent wall motion (akinesia).
52
Q
  1. In systolic dysfunction the ventricle is inadequately emptied which leads to?
  2. This is transmitted to the ______ and thence to the _______ ________.
  3. The resultant increased _________ pressure favors extravasation of fluid into the lung parenchyma, causing pulmonary edema
  4. What sound does this cause??
A
  1. ventricular end-diastolic pressure and volumes increase
  2. atrium
    pulmonary vasculature
  3. hydrostatic
  4. 3rd heart sound
53
Q

SYSTOLIC DYSFUNCTION

On the right side of the heart, the increased pressure is transmitted to the systemic 1.______ _______ and systemic 2._______ ______, favoring extravasation of fluid into the tissues of target organs and extremities, resulting in dependent peripheral edema.

A
  1. venous circulation

2. capillary beds

54
Q

Diastolic dysfunction usually resutls from?

A

Usually results from failure of the ventricle to adequately relax and typically denotes a stiffer ventricular wall.

55
Q

Failure of the ventricle to adequately relax and typically denotes a stiffer ventricular wall. This causes?

The failure of ventricular relaxation also results in what?
2

A

inadequate filling of the ventricle, and therefore results in an inadequate stroke volume

  1. elevated end-diastolic pressures, and
  2. the end result is identical to the case of systolic dysfunction (pulmonary edema in left heart failure, peripheral edema in right heart failure.)
56
Q

What is the end result of systolic dysfunction?

2

A
  1. pulmonary edema in left heart failure,

2. peripheral edema in right heart failure

57
Q

Diastolic dysfunction may not manifest itself normally and could be asymptomatic. However they are very sensitive to what? 2

What can this be caused by? 4

What may all this result in? 1

How do we treat this?
What sound can we hear from this?

A
  1. increases in heart rate
  2. sudden bouts of tachycardia

which can be caused simply by physiological responses to

  1. exertion,
  2. fever, or
  3. dehydration, or by
  4. pathological tachyarrhythmias such as atrial fibrillation with rapid ventricular response)
  5. may result in flash pulmonary edema

Beta blocker
4th heart sound

58
Q

New York Heart Association Functional Classification of Congestive Heart Failure:
Describe Classes I through IV?

A

I No limitations of activity; ordinary activity does not cause undue fatigue, palpitations, dyspnea or anginal pain

II Slight limitations of activity; asymptomatic at rest; ordinary activity results in fatigue, palpitations, dyspnea or anginal pain

III Marked limitations of activity; usually asymptomatic at rest; less than ordinary activity causes fatigue, palpitations, dyspnea or anginal pain

IV Inability to carry on any physical activity without discomfort; symptoms at rest; increased discomfort with any physical activity

59
Q

2001 American College of Cardiology/American Heart Association working group. Describe Stages A through D of Heart Failure.

A

Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder.

Stage B: a structural heart disorder but no symptoms at any stage.

Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment.

Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.

60
Q

Goals for Treating Diastolic Heart Failure

A
  1. Treat precipitating factors and underlying disease.
  2. Prevent and treat hypertension and ischemic heart disease.
  3. Surgically remove diseased pericardium.
  4. Improve left ventricular
    - –ACE inhibitors
    - –Calcium channel blockers
  5. Regress left ventricular hypertrophy (decrease wall thickness and remove excess collagen).
    - –ACE inhibitors and ARBs
    - –Aldosterone antagonists
    - –Beta blockers
    - –Calcium channel blockers
  6. Maintain atrioventricular synchrony by managing tachycardia (tachyarrhythmia).
    - –Beta blockers (preferred)
    - –Calcium channel blockers (second-line agents)
    - –Digoxin (controversial)
  7. Optimize circulating volume (hemodynamics).
  8. Improve survival.
  9. Prevent relapse by intensifying outpatient follow-up.
61
Q

What meds would we use to improve left ventricular relaxation? 2

A
  • –ACE inhibitors

- –Calcium channel blockers

62
Q

What meds would help regress left ventricular hypertrophy? 4

A
  • –ACE inhibitors and ARBs
  • –Aldosterone antagonists
  • –Beta blockers
  • –Calcium channel blockers
63
Q

What meds would maintain atrioventricular synchrony by managing tachycardia (tachyarrhythmia)? 3

A
  • –Beta blockers (preferred)
  • –Calcium channel blockers (second-line agents)
  • –Digoxin (controversial)
64
Q

What meds optimize circulating volume (hemodynamics)?

4

A
  • –ACE inhibitors
  • –Aldosterone antagonists (theoretical benefit)
  • –Salt and water restriction
  • –Diuresis, dialysis, or plasmapheresis
65
Q

What meds improve survival?

2

A
  • –Beta blocker

- –ACE inhibitors

66
Q

What will prevent relapse by intensifying outpatient follow-up?
4

A
  • –Control blood pressure.
  • –Dietary counseling (sodium)
  • –Monitoring volume status (daily weights and diuretic adjustment) —Institute exercise program.
67
Q

Chronic Management goal of CHF?

9

A
  1. Prevent the development of acute decompensated heart failure
  2. Counteract the consequences of ventricular remodeling
  3. Minimize patient’s symptoms
  4. Digoxin
  5. ACE inhibitors –captopril, enalapril, lisinopril, ramipril. all improve survival and quality of life in heart failure patients
  6. Beta blockers
  7. Diuretics
  8. Angiotensin receptor blockers
  9. Aldosterone receptor antagonist spironolactone K sparing/ Na loss
68
Q

PHYSICAL EXAM findings for CHF?

8

A
  1. Vital signs BP HR RR Temp
  2. Pallor-anemia
  3. Cyanosis
  4. Jaundice
  5. Clubbing
  6. Peripheral edema
  7. Jugular venous pressure
  8. Cardiac impulse, 3rd or 4th heart sounds
69
Q
  1. Acute decompensation CHF: What is the immediate goal?

2. WHat does this entail?

A
  1. to re-establish adequate perfusion and oxygen delivery to end organs.

This entails

  • -ensuring that airway, breathing, and circulation are adequate.
  • -Immediate treatments usually involve some combination of vasodilators such as

nitroglycerin,
diuretics such as furosemide, and possibly

non invasive positive pressure ventilation (NIPPV).

Cardiology (19 decks)

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