CVPR 03-27-14 09-10am Heart Failure-Diagnosis - Allen Flashcards
HF symptoms associated with decreased Cardiac Output
Decreased organ perfusion, FATIGUE
HF symptoms associated with increased Pulmonary Venous Pressure (Left-sided)
—> increases pressure in the lungs —> Breathlessness (DYSPNEA)
HF symptoms associated with increased Central Venous Pressure (Right-sided)
Edema (ascites, pleural edema/effusion, swelling in ankles/legs)
HF symptoms associated with Low Flow
- Decreased cerebral perfusion (sleepiness, confusion); 2. Decreased muscle perfusion (fatigue, weakness); 3. Decreased gut perfusion (anorexia, wasting/cachexia); 4. Decreased kidney perfusion (RAAS activation, reduced urine output, progressive renal dysfunction)
HF symptoms associated with increased Left-Sided Pressure
Increased Pulmonary venous pressure –> breathlessness (dyspnea), dyspnea on exertion, orthopnea (dyspnea when lying flat), paroxysmal nocturnal dyspnea, acute pulmonary edema
Positional Shortness of Breath - Orthopnea
Immediate SOB when lying flat; in HF, relates to lost venous pooling of blood in legs —> when lie down, no longer gravity working against heart —> rt. atrial filling pressure immediately goes up —> rt. ventricular contractions thus go up, pushing more blood to lt side —> if lt. ventrical is already stiff w/ already high pressure, back up of pressure in lungs
Positional Shortness of Breath -Paroxysmal nocturnal dyspnea (PND)
Delayed SOB, waking pts from sleep; classically relieved by pt getting out of bed & ambulating; relates to mobilization of edema from tissue through lymphatics back into blood stream (over the day, gravity pools fluid in lower extremities, increasing pressure & causing edema; when lie flat, no longer this pressure –> fluid leaches back into veins over time, increasing venous pressure –> increases preload & thus rt. ventricular contraction, filling of dysfunctional lt side, pressure build up in lungs (but delayed b/c fluid must leach back in)
HF symptoms associated with increased Right-Sided Pressure
Increased central venous pressure (RV failure) —> Peripheral swelling/dependent edema, Ascites, Hepatic congestion, Intestinal congestion (protein-losing enteropathy)
Edema in HF
Increased central venous pressure (CVP) upsets the balance of Starling forces: Ventricular dysfunction —> Increased filling/venous pressure —> Hydrostatic pressure pushing water out of veins is greater than normal so that oncotic pressure can’t make up for it & pull water back into veins —> Edema
Precipitating factors producing acute or worsening symptoms in HF
- Increased circulating volume (preload)…..2. Increased pressure (afterload)…..3. Worsened contractility (inotropy)…..4. Arrhythmia (rate)…..5. Increased metabolic demands…..6. Non-adherence with HF meds!!!
Factors that increase circulating volume (preload) & thus exacerbate HF
SODIUM LOAD IN DIET; Renal failure
Factors that increase pressure (afterload)) & thus exacerbate HF
Uncontrolled HTN (LV); Worsening aortic stenosis (LV); Pulmonary embolism
Factors that worsened contractility (inotropy) & thus exacerbate HF
Myocardial ischemia; Initiation of negative inotrope (beta-blocker, calcium channel blocker)
Factors related to Arrhythmias (rate) that thus exacerbate HF
Bradycardia, Atrial fibrillation
Factors that increase metabolic demands & thus exacerbate HF
Fever/infection, Anemia, Hyperthyroidism, Pregnancy
NYHA HF rating
Based on assessment of symptoms: I Asymptomatic….II Symptomatic w/moderate exertion….III Symptomatic w/minimal exertion (going up flight of stairs)…..IV Symptomatic at rest
American College of Cardiology and American Heart Association (ACC/AHA HF) Stages
A – High risk for HF (HTN, CAD) but w/out structural heart disease or symptoms of HF….. B – Structural heart disease but w/out symptoms of HF….. C – Structural heart disease w/prior or current symptoms of HF….. D – Refractory HF requiring specialized interventions…. Can move between stages (can move from C after a salty meal, back to B with treatment, etc)
Importance of Symptoms
Symptoms decrease quality of life, define the severity of the disease (which is one of the strongest predictors of death in HF), often determine therapy (e.g., more aggressive therapies for more advanced disease); Can treat heart disease before HF develops & prevent it!
Clinical Course of HF
Nonlinear; Can look really bad after a big salty meal (Class C), but then go back to Class B w/no symptoms after treatment
Signs of Low Flow in HF
- Cool extremities (peripheral vasoconstriction to redirect scant existing blood flow to vital organs)….. 2. Tachycardia (Compensation for low SV)….. 3. Low pulse pressure = difference btwn systolic & diastolic pressure (reflection of low output; in late HF, go from HTN to Hypotension = bad sign of advanced disease)