Exam 4 Heart Failure Flashcards
Heart failure is a complex clinical syndrome resulting from any _______ or ______ impairment of ventricular filling or ejection of blood. The heart cannot meet metabolic tissue requirements or fill completely.
- Structural (Pericardium, myocardium, endocardium, heart valves, great vessels)
- Functional (Systolic, Diastolic)
HF w/ reduced EF (HFrEF). EF is < or equal _______ %
- 40%
HF w/ preserved EF (HFpEF). EF > or equal to _______%
- 50%
Characteristics of LV Diastolic Dysfunction.
- Increased myocardial stiffness
- Reduction in LV compliance
- Restricted LV filling
- Delayed LV relaxation (LV weakens over time)
What is the difference b/w HFrEF vs HFpEF?
- HFrEF is a systolic failure (pumping problem d/t eccentric remodeling)
- HFpEf is a diastolic failure (filling problem d/t concentric hypertrophy)
LV systolic dysfunction effects on
Contractility
SV
ESV
EDV
LV End Diastolic Pressure
- ↓ Contractility
- ↓ SV
- ↑ ESV
- ↑ EDV
- ↑ LV End Diastolic Pressure
LV Systolic dysfunction will lead to compensatory LV dilation → fluid back into LA → Pulmonary venous congestion.
Left atrial systolic and diastolic dysfunction effects on
LV compliance
LV pressure
LA pressure
- ↓ LV compliance
- ↑ LV pressures
- ↑ LA pressure to preserve LV filling
Over time, this dysfunction will dilate the LA and reduce LA compliance reducing LA filling. → Atrial Fibrillation
What will be the results of LV diastolic dysfunction?
- LA HTN
- LA systolic and diastolic dysfunction
- Pulmonary venous congestion
- Exercise intolerance.
What is systolic heart failure?
- Systolic dysfunction – decreased ventricular systolic wall motion
What are the causes of systolic heart failure?
- CAD
- Dilated cardiomyopathy
- Chronic pressure overload from aortic stenosis or chronic HTN
- Chronic volume overload from regurgitant valvular lesions or high-output cardiac failure
- Ventricular Dysryhtmias - LBB
Systolic Heart Failure will decrease EF.
The hallmark of chronic LV systolic dysfunction.
- Decrease EF, < 40%
What is diastolic HF?
- Abnormal ventricular relaxation (ventricles don’t relax as much) and reduced compliance
Causes of Diastolic HF?
- IHD
- Long-standing systemic HTN
- Progressive aortic stenosis
- Age dependent
Classes of Diastolic HF
- Class I - abnormal LV relaxation pattern with normal left atrial pressure
- Classes II, III, and IV - abnormal relaxation and reduced LV compliance, increasing LV End Diastolic Pressure
What is Acute Decompensated HF
- Worsening symptoms of a preexisting condition
Chronic HF that has gotten acutely worse.
What is de novo acute HF
- A sudden increase in intracardiac filling pressures and/or acute myocardial dysfunction
Example: Giant MI. This is an Emergent situation
CHF is present in pts with long-standing cardiac disease.
CHF is often accompanied by __________, but BP is maintained d/t adaptive mechanisms of action.
- Venous congestion
Frank-starling Relationship.
SV directly related to _______.
- LVEDP
The magnitude of the increase in SV produced by changing the __________of ventricular muscle fibers depends on myocardial ________.
- Tension; Contractility
How does SNS Activation maintain BP in CHF patients?
- Promotes arteriolar and venous constriction
- Arteriolar constriction
- The increased venous tone shifts blood from peripheral sites to the central circulation: ↑ Venous Return to LA
- ↓ Renal blood flow activates RAAS
↑ SNS activity contributes to the deterioration of HF in the long term
What is an Inotropic State?
- Myocardial contractility is reflected by the velocity of contraction developed by cardiac muscle.
What is Afterload?
- The tension the ventricular muscle must develop to open the aortic or pulmonic valve.
Systolic HF with a low CO will have a _________ SV.
Fixed
Systolic HF is a pumping problem. SV can’t increase to compensate for low CO. HR will need to increase CO.
Diastolic HF with tachycardia leads to decreased _______.
Cardiac Output
Diastolic HF is a filling issue. Tachycardia doesn’t allow the heart to fill adequately. Need to control HR in Diastolic HF.
In an attempt to counterbalance these mechanisms, the heart evolves into an “endocrine” organ. What hormones does the heart release?
- ANP (release from atrial muscle) - released d/t ↑ atrial pressure.
- BNP (release from atrial and ventricular myocardium)
- In the failing heart, the ventricle becomes the principal site of BNP production.
Physiologic effects of natriuretic peptides
- Diuresis
- Natriuresis (Na+ excretion)
- Vasodilation
- Anti-inflammatory effect
- Inhibition of the RAAS and SNS
ANP and BNP inhibit cardiac _______ and ________.
- Hypertrophy
- Fibrosis
This is the heart’s protective mechanism.
What are the various endogenous mechanisms the body uses to maintain CO?
- Mechanical
- Neurohormonal
- Genetic
These factors change LV size, shape, and function
_______ injury is the most common cause of myocardial remodeling and encompasses both hypertrophy and dilatation of the left ventricle.
- Ischemic
Myocardial hypertrophy represents the compensatory mechanism for chronic pressure overload. How are the effects of this mechanism limited?
- Hypertrophied cardiac muscle functions at a lower inotropic state than normal cardiac muscle.
Cardiac dilatation occurs in response to volume overload and increases cardiac output by the Frank-Starling relationship. However, the increased cardiac wall tension produced by an enlarged ventricular radius is associated with increased ________ requirement and decreased _________.
- Increased Myocardial Oxygen Requirements
- Decreased Pumping Efficiency
Types of Myocardial Remodeling
- Cardiac Dilatation - d/t chronic volume overload
- Eccentric Hypertrophy- d/t chronic volume overload
- Concentric Hypertrophy - d/t chronic pressure overload
Signs and Symptoms of HF (long list)
What is your earliest finding?
- Dyspnea (earliest finding)
- Orthopnea (pt needs to sleep sitting up.)
- Paroxysmal nocturnal dyspnea
- Pulmonary edema
- Peripheral edema (Assess Pitting Edema)
- Fatigue and weakness at rest or with minimal exertion (This will indicate ↓Cardiac Reserve and ↓CO.)
- Anorexia, nausea, or abdominal pain (Liver congestion)
- Confusion, difficulty concentrating, insomnia, anxiety, or memory deficits (d/t ↓ cerebral blood flow).
- S3 gallop (occurs in early diastole at the end of rapid diastolic filling- Ken-tuc-ky)
- JVD (d/t weakened right ventricle)
- Exercise intolerance (quantify with METs)
What medical imagings are used for HF?
Which imaging has the lowest predictive value of CHF?
- ECG (Lowest predictive valve of CHF)
- CXR
- ECHO
What is used to dx HFpEF?
- ECHO
An ECHO evaluate left and right ventricular structure and function in both systole and diastole, as well as valvular function, and can detect the presence of pericardial disease.
What are HF findings in a CXR?
- Distention of the pulmonary veins in the upper lobes
- Kerley lines
- Alveolar edema (butterfly patternn)
- Pleural effusion and pericardial effusion
- Cardiac enlargement (wide mediastinum)
Where are each of Kerley’s lines located:
Kerley Line A
Kerley Line B
Kerley Line C
- Kerley Line A - Upper lung fields
- Kerley Line B - Lower lung fields (perpendicular to chest wall)
- Kerley Line C - Basilar Regions of the lungs
Kerley Lines produce a honeycomb pattern on the CXR.
What lab values will be obtained with HF patients?
- BNP levels
- Troponins
- C-reactive proteins
- Growth differentiation factor 15
A BNP level above what number correlates with a 90% positive predictive value of HF.
- 500 pg/mL
What BNP level will detect dyspnea of cardiac origin?
- 300 pg/mL
Classification of heart failureNew York Heart Association
Classification of heart failure2005 ACC/AHA Classification
Acute Heart Failure is an emergent situation characterized by what?
- High ventricular filling pressure
- Low CO
- Hypertension or Hypotension
What meds are given to someone with Acute HF?
- Diuretics (Loop diuretics improve symptoms rapidly)
- Vasodilators (Nitroglycerin and nitroprusside)
- Inotropic drugs (Epinephrine, norepinephrine, dopamine, dobutamine, PDE inhibitors)
- Mechanical assist devices (IABP, VADs)
- Emergency surgery
What INTERMACS score will require some type of assistance immediately to sustain life?
- 1 or 2
Lifestyle modifications for HF.
- Smoking cessation
- Adherence to a healthy diet with moderate Na restriction
- Weight control
- Exercise
- Moderation of alcohol consumption
- Adequate glycemic control
How do diuretics treat HF?
- Reduces LV filling pressures
- Decreases pulmonary venous congestion
What diuretics are recommended for HF therapy?
- Thiazides
- Loop diuretics
What is the first-line therapy for patients presenting with acute heart failure?
Diuretics
Beta-Blockers for HF patients.
* What does it do to SNS?
* What does it do to morbidity and hospitalization?
* What does it do to the quality of life?
* What will it do to EF and ventricular remodeling?
* Is it beneficial for HFrEF or HFpEF?
- Reverses the effects of SNS activation
- Reduces morbidity and the number of hospitalizations
- Improves both qualities of life and length of survival
- Increases EF and decreases ventricular remodeling
- Beneficial for the treatment of HFrEF
ACE inhibitors and ARBs for HF.
* ACE inhibitors recommended for HFrEF or HFpEF?
* What do both drugs do to ventricular remodeling?
* What do both drugs do to morbidity and mortality?
* ACE inhibitors combined with what drug will have good long-term outcomes?
* ARBS is useful for the control of arterial pressure in patients with ______ and ______.
- ACE-I recommended for HFrEF
- Proven to decrease ventricular remodeling
- Reduce morbidity and mortality at any stage of HF
- Therapy with ACE-I and β-blockers favorably influences long-term outcome
- ARBS is useful for the control of arterial pressure in patients with HTN and HFpEF
Effects of Statins for HF.
- Anti-inflammatory and lipid-lowering effects
- Decrease morbidity and mortality in pts with systolic and diastolic HF
- Recommended use of statins in all HF pt.
Use of Vasodilators in HF therapy.
- Relaxes vascular smooth muscle
- Decreases resistance to LV ejection, reduce afterload
- Results in increased SV and decreased ventricular filling pressures
What will cardiac resynchronization therapy do?
- Increases contractility
- Increase CO
Types of resynchronization therapy.
- Dual-chamber cardiac pacemaker
- Implantable cardioverter-defibrillator (ICDs)
What NYHA Class qualifies for cardiac resynchronization therapy?
- Class III or IV
LVEF < _______ and QRS duration of ________ (range) warrants cardiac resynchronization therapy.
LVEF < 35%
QRS: 120-150 ms (ventricular conduction delay)
Surgical Management of HF
What is the gold standard?
- PCI or CABG
- Repair/replace valves
- Cardiac transplantation (gold standard)
What are Ventricular Assist Devices, and what do they do?
- Mechanical support of the circulation
- Increased survival, improved quality of life > medical treatment
- Mechanical pumps that take over the ventricle
Using VAD for the bridge to recovery
Require temporary ventricular assistance to allow the heart to recover its function.
Using VAD for the bridge to therapy
Awaiting cardiac transplantation
Using VAD for the bridge to decision
Pts on inotropic drugs or IABP with potentially reversible medical conditions
Using VAD for destination therapy
Advanced HF who are not transplant candidates
Destination to Heaven
What are the types of VAD?
IABP
* Increases aortic diastolic blood pressure and coronary perfusion pressure
* Enhances LV ejection
Impella system
* Miniaturized axial-flow rotary blood pump that draws blood from LV to ascending aorta.
* Generate CO of up to 5 L/min
Pre-operative evaluation (long list)
- TX precipitating factors for HF aggressively before elective surgery
- ID previously recognized HF and assess the current degree of compensation relative to baseline
- Establish the underlying cause of HF
- ID and address coexisting conditions that may precipitate HF during the peri-op period
- Exclude or confirm a new HF diagnosis in patients with dyspnea, fatigue, edema, congestion, or arrhythmias
- Document the level of activity that elicits HF symptoms
- Determine the stability of HF
- β-blockers reduce perioperative morbidity and mortality
- Electrolytes, renal function, and liver function tests
- ECG and echocardiogram
What will be d/c for surgery in HF patients?
- Diuretics (d/c on the day of surgery)
- ACE inhibitors
Anesthetic considerations
- GA – adjust drug dosages
- Avoid hypotension - use ephedrine, phenylephrine, or vasopressin to manage BP.
- Monitor fluids
- Neuraxial anesthesia can be beneficial (watch for ↓ SVR)
How does the heart physically compensate for LV systolic dysfunction?
- LV dilation
First-line therapy in all patients with heart failure.
- ACE-inhibitors
- Aldosterone Antagonist
- Diuretics
