Exam 4 - Heart Failure -organized Flashcards
1
Q
Stages of Heart Failure
Stage A:
Stage B:
Stage C
Stage D:
A
Stage A: At risk (risk factors but no structural changes or symptoms)
Stage B: Pre- heart failure (structural changes but no symptoms)
Stage C: Heart failure (symptoms like shortenss of breath and fatigue)
Stage D: Advanced heart failure (symptoms don’t respond to treatment)
S1
2
Q
Heart Failure is defined as a complex syndrome that results from:
A
any structural or functional impairment of ventricular filling or blood ejection
2
3
Q
Five signs of tissue-hypoperfusion that result from HF:
A
fatigue, dyspnea, weakness, edema, and weight gain
2
4
Q
HF may be caused by structural abnormalities of what 5 cardiac structures?
A
pericardium, myocardium, endocardium, heart valves, or great vessels
2
5
Q
what EF % classifies HF with reduced EF (aka systolic HF)?
A
EF ≤ 40%
2
6
Q
what EF % classifies HF with preserved EF (aka diastolic HF)?
A
EF ≥50%
2
7
Q
A pt with clinical symptoms with an EF between ___ - ___% is labeled as having borderline HF w/ preserved EF
A
40-50%
2
8
Q
True or false: Diastolic dysfunction is present in both HFrEF and HFpEF.
A
True!
2
9
Q
Patters of what 2 things are the major distinguishing features between HFrEF and HFpEF?
A
LV dilation and remodeling
2
10
Q
What serves as the main marker for establishment of HF risk factors, treatment, and outcome?
A
Ejection Fraction!
2
11
Q
Which of the 2 HFs are women more likely to be affected by?
A
HF w preserved EF
Diastolic HF
3
12
Q
Which of the 2 HFs are men more likely to be affected by?
A
HF with reduced EF
Systolic HF
3
13
Q
Which HF is more likely to have modifiable risk factors and a higher prevalence of MI, previous coronary intervention, CABG, and PVD?
A
HF w reduced EF
3
14
Q
what is the primary determinant of HFpEF?
A
left ventricular diastolic dysfunction
4
15
Q
what 5 things determine LV’s ability to fill?
A
pulmonary venous blood flow
LA function
mitral valve dynamics
pericardial restraint
active and passive elastic properties of LV
4
16
Q
What 3 things are majority of measurements of LV Diastolic dysfxn dependent on?
A
HR, loading conditions, and myocardial contractility
4
17
Q
Higher ________ are required to achieve normal end-diastole volume in pts with HFpEF.
A
LV filling pressures
4
18
Q
What is the steeper rise of the end-diastolic pressure-volume curve indicative of?
what does it result in regarding LV compliance?
A
delayed LV relaxation and an increase in myocardial stiffness
resulting in reduced LV compliance that restricts filling
5
19
Q
The reduced LV compliance that eventually restricts filling can precipitate what (regarding the left atrium and pulm system)?
A
LA hypertension, LA systolic & diastolic dysfunction,
pulmonary venous congestion, and exercise intolerance
5
20
Q
What does the left picture indicate about contractility?
what does the right picture indicate regarding LV compliance?
A
Left: a decrease in myocardial contractility as indicated by a decrease in the slope of the end-systolic pressure-volume relation
Right: a decrease in LV compliance as indicated by an increase in the position of the end-diastolic pressure-volume relation
These diagrams emphasize that heart failure may result from LV systolic or diastolic dysfunction independently
5
21
Q
List some common causes of Left Ventricular Diastolic Dysfxn
A
8
22
Q
LV End- diastolic dysfunction or delay in relaxation which is considered a form of “active stiffening” is complicated by
A
Failure of the actin-myosin disassociation, which occurs due to inadequate perfusion or dysfunctional intracellular Ca++ homeostasis
9
23
Q
Causes of LV relaxation
A
Due to afterload, which is elevated in hypertensive pts. Tachycardia exacerbates the failure of LV relaxation.
9
24
Q
What is commonly seen w/ HFpEF despite having only a modestly depressed LV systolic fx?
A
Profound exercise intolerance
9
25
Prolonged compression of coronary arteries restricts diastolic coronary blood flow, which contributes to ____ ____ and a further reduction in exercise tolerance.
subendocardial ischemia
## Footnote
9
26
What are the most common symptoms of HF?
Fatigue, tachypnea, dyspnea, paroxysmal nocturnal dyspnea, orthopnea, S3 gallop, JVD, peripheral edema, exercise intolerance, and reduced tissue perfusion.
## Footnote
10
27
What are the most common symptoms of HFpEF?
paroxysmal nocturnal dyspnea, pulmonary edema, dependent edema
## Footnote
10
28
What is the most common sign of HFrEF?
S3 gallop
## Footnote
10
29
When EF is reduced, the presence of HF symptoms establishes the diagnosis of?
HFrEF (following standard guidelines)
## Footnote
10
30
What does cardiac catheterization define?
Elevated LV systolic and diastolic stiffness using pressure-volume analysis or provocative testing (s/a exercise & rapid IV volume expansion)
## Footnote
11
31
What other diagnostic measure can offer further information about severity of HFpEF?
Direct measurement of RV filling.
## Footnote
11
32
Which type of HF is harder to diagnose?
**HFpEF** is often more difficult to diagnose, especially when the pt has little/no symptoms at rest
## Footnote
11
33
What diagnostic finding provides strong evidence of HFpEF and is a predictor of mortality?
Mean pulmonary capillary wedge pressure >15mmHg at rest or 25mmHg during exercise
## Footnote
11
34
What would you expect to see on CXR of someone w/ HF?
pulmonary dz, cardiomegaly, pulmonary venous congestion, and interstitial or alveolar pulmonary edema.
## Footnote
13
35
What is an early radiographic sign of LV failure and pulmonary venous HTN?
distention of the pulmonary veins in the upper lobes of the lungs
36
You read in the chart that the pt has perivascular edema, so you look at pt's CXR and you see...
hilar or perihilar haze with ill-defined margins
## Footnote
13
37
Pt presents with edematous interlobular septae. What would you expect to see on CXR?
Kerley lines, which produce a honeycomb pattern
## Footnote
13
38
Pt presents with alveolar edema, what would you expect to see on CXR?
homogeneous densities in the lung fields, typically in a butterfly pattern
## Footnote
13
39
Radiographic evidence of pulmonary edema may lag behind the clinical evidence of pulmonary edema by up to ____hours
12 hours
## Footnote
13
40
Which criteria is more specific in diagnosis of HFpEF and incorporates several echocardiographic indexes based on 2-dimensional measurements?
European Society of Cardiology (ESC)
## Footnote
15
41
ESC guidelines rely entirely on ____ echocardiogram; and are limited because they do not incorporate ____testing.
resting
provocative
## Footnote
15
42
European Society of Cardiology criterias
## Footnote
15
43
Which diagnostic testing has low predictive value for diagnosis or risk- prediction of heart failure?
EKG alone
## Footnote
16
44
What underlying pathologies are common in HF pts with EKG abnormalities?
LVH, previous MI, arrhythmias and conduction abnormalities
## Footnote
16
45
What are 2 important biomarkers in the diagnosis of HF?
BNP and N-terminal pro-BNP
## Footnote
17
46
HF preserved EF is associated w/ lower BNP and NT-proBNP levels *[than HF reduced EF]* due to what characteristics?
concentric hypertrophy, normal LV chamber size and lower LV end diastolic wall stress
## Footnote
17
47
CRP and GDF15 (growth differentation factor 15 represent what component of HF?
inflammatory component of HF
## Footnote
17
48
The NYHA system focuses primarily on ____ to classify HF?
the degree of physical limitation
## Footnote
18
49
The ACC/AHA focus on ____ to classify HF?
on the presence & severity of HF
## Footnote
18
50
What should be noted with classification of HF?
* note that these stages are progressive
* often classified using a combination of both scoring systems
## Footnote
18
51
Which NYHA Classification has no limitation and no symptoms from ordinary activity?
NYHA Class I
## Footnote
18
52
What NYHA Classification has mild limitation with activity and comfortable at rest or with mild exertion?
NYHA Class II
## Footnote
18
53
Which NYHA Classification has significant limitation with any activity and comfortable only at rest?
NYHA Class III
## Footnote
18
54
Which NYHA Classification has discomfort with any physical activity and symptoms occuring at rest?
NYHA Class IV
## Footnote
18
55
Which ACC/AHA classification has high risk of developing heart failure but no functional or structural heart deficits?
ACC/AHA Class A
## Footnote
18
56
Which ACC/AHA classification has structural heart deficit but no symptoms?
ACC/AHA Class B
## Footnote
18
57
Which ACC/AHA classification has heart failure symptoms due to underlying structural heart deficit with medical management?
ACC/AHA Class C
## Footnote
18
58
Which ACC/AHA classification has advanced disease requiring hospitalization, transplant, or palliative care?
ACC/AHA Class D
59
Which condition has improved survival rate in the past three decades: HFrEF or HFpEF?
HFrEF
## Footnote
19
60
Which condition benefits with using medications: HFrEF or HFpEF?
HFrEF
## Footnote
19
61
What are the treatments for HFpEF?
* Mitigation of sx’s
* treat associated conditions
* exercise
* weight loss
## Footnote
19
62
What are the treatments for HFrEF?
* Beta Blockers
* ACE-Inhibitors
## Footnote
19
63
What are the medical treatments for Chronic HF?
* Diuretics
* B-blockers
* ACE-inhibitors & ARBs
* Lifestyle change
## Footnote
21-22
64
How does Loop Diuretics help CHF?
* reduce LV filling pressures
* decrease pulmonary venous congestion
* improve HF sx
## Footnote
21
65
Which type of pts. are Thiazide diuretics useful and why?
pts with poorly controlled HTN
to prevent the onset of HFpEF
## Footnote
21
66
Which type of CHF are Beta-Blockers strongly recommended for?
**HFrEF**
(HF with reduced EF)
prescribed for other indications (HTN, MI, HR control w/Afib)
## Footnote
21
67
What is the mainstay treatment for HFrEF?
ACE-inhibitors and ARBs
(studies do not show benefit in HFpEF unless used for treatment of HTN)
## Footnote
22
68
What are the lifestyle changes that pt. can do to treat CHF?
* Aerobic fitness
* Weight loss
* Salt-restricted, Dietary Approaches to Stop Hypertension (DASH) diet
* Control of HTN and blood glucose
## Footnote
22
69
What is the goal of surgical treatment for CHF?
to prevent ventricular remodeling and retain the natural geometry of the heart
## Footnote
23
70
What are the benefits of coronary revascularization via CABG or PCI?
can reverse LV dysfunction following MI
* may prevent permanent EF reductions
* reduce 10-year mortality by 7% (CABG)
## Footnote
23
71
What is another name for Cardiac resynchronization therapy (CRT) and what is the treatment for?
“biventricular pacing”
tx for HF w/ ventricular conduction delay (prolonged QRS)
## Footnote
23
72
# Cardiac resynchronization therapy (CRT)
Placement of a ____ cardiac pacemaker (w/RA & RV leads), an additional lead is introduced through the coronary sinus and advanced until it reaches the lateral wall of the ____.
This stimulates the heart to contract more ____ and efficiently and improve COP
dual chamber
LV
synchronously
## Footnote
23
73
What NYHA class is CRT recommended?
NYHA class III or IV w/ EF < 5% and a QRS duration 120-150 ms
## Footnote
23
74
What NYHA class is CRT recommended?
NYHA class III or IV w/ EF < 5% and a QRS duration 120-150 ms
## Footnote
23
75
What are the outcomes of CRT?
* fewer HF sx
* better exercise tolerance
* improved ventricular function
* less hospitalizations
* decreased mortality
76
What are the benefits of coronary revascularization via CABG or PCI?
* can reverse LV dysfunction following MI
* may prevent permanent EF reductions
* reduce 10-year mortality by 7% (CABG)
## Footnote
23
77
What are the risks of CRT?
* infection
* misplacement
* device failure
## Footnote
23
78
How does a implantable hemodynamic monitoring improve chronic HF?
it allows remote observation of intracardiac pressures to guide tx and prevent decompensation
## Footnote
24
79
How does a Implantable cardioverting-defibrillators (ICDs) helps patients with chronic Heat failure?
Its used to prevent sudden death in pts with advanced heart failure?
## Footnote
24
80
̴ ____% HF deaths are d/t sudden cardiac dysrhythmias
50%
## Footnote
24
81
What is the name of the device used by patients in the terminal stages of HF that may benefit from mechanical circulatory support (MCS) by a ventricular assist device (VAD)?
LV assist device
## Footnote
25
82
LVAD is used for
* temporary ventricular assistance while heart is recovering its function
* Pts awaiting cardiac transplant
* Pts are on inotropes or balloon pump (IABP) with potentially reversible medical conditions
* Pts with advanced HF who aren’t transplant candidates
## Footnote
25
83
What is disease process is classified as a long-standing HF disease?
Chronic heart failure
## Footnote
27
84
True or false: Acute heart failure: Slow onset, often presenting w/life-threatening conditions
False: Acute heart failure: rapid onset, often presenting w/life-threatening conditions
*Pts may require hospitalization, tx is aimed at decreasing volume & stabilizing hemodynamics*
## Footnote
27
85
The term Acute heart failure applies to what patient population?
* present with worsening
* preexisting HF present for the first time with HF
## Footnote
27
86
What are the sx of ADHF?
* **fluid retention
* weight gain
* dyspnea**
*as the result of decompensation due to inadequate compensation*
## Footnote
27
87
What are the characteristics of De novo AHF?
* increase in intracardiac filling
* pressures or acute myocardial dysfunction
* decreased peripheral perfusion
* pulmonary edema
## Footnote
28
88
What is the leading caused of de novo HF?
* Cardiac ischemia cause by a coronary occlusion
## Footnote
28
89
Nonischemic cause of de novo HF include
* drug-induced (toxic)
* peripartum cardiomyopathies
## Footnote
28
90
De novo HF may lead to _____ _________ dysfunction.
long-term cardiac dysfunction
*management of the underlying cause may allow for complete restoration *
## Footnote
28
91
How can a SRNA stabilize a patient with cardiac ischemia caused by a coronary occlusion ?
* stabilizing hemodynamics
* restoring myocardial perfusion
* improving myocardial contractility
## Footnote
28
92
The hemodynamic profile that is included in acute HF?
* low cardiac output
* high ventricular filling pressures
* HTN or HoTN
## Footnote
29
93
What is the first line of treatment for AHF should be given immediately in pts with fluid overload to mitigate?
Diuretics
## Footnote
29
94
What are the diruetic given as a bolus followup by a continous infusion
Furosemide
Bumetanide
Torsemide
*given as bolus or continuous infusions*
## Footnote
29
95
Reducing in_________ _________ leads to decreased________ ________ and ________ _______ _________ __________ (______), reducing pulmonary congestion.
intravascular volume
central venous
pulmonary capillary wedge pressures (PCWP)
## Footnote
29
96
True of false: An AHF patient with hypotension or cardiogenic shock may first require hemodynamic support prior to diuretic therapy.
True
## Footnote
29
97
What class of medication is proven to correct elevated filling pressures and reduce afterload.
Vasodilators
## Footnote
30
98
Which medication is effective in rapidly decreasing afterload?
Which medicatioin is used as an adjunct to diurectic therapy?
* SNP
* NTG
## Footnote
30
99
What is class of medication emerged as potential adjunct therapy, to reduce the arterial constriction, hyponatremia, and the volume overload associated with AHF?
Vasopressin receptor antagonists
## Footnote
30
100
What is an example of Vasopressin receptor antagonists?
Tolvapatan
## Footnote
30
101
What class of medication stimulate β-receptors on the myocardium to activate adenylyl cyclase to increase cAMP?
Catecholamines
102
What are some examples of catecholamines being use for Acute HF treatment?
epinephrine
norepinephrine
dopamine
dobutamine
## Footnote
31
103
What is a class of medication indirectly increase cAMP by inhibiting its degradation to help treat acute HF?
What is an example of this medication ?
PDE-inhibitors
milrinone
## Footnote
31
104
What are the 6 most common inotropic drugs used in AHF? (chart)
## Footnote
32
105
Nesiritide works by inhibiting the ________ and promoting arterial, venous, and coronary vaso-____________, decreasing LVEDP and improving ___________.
Nesiritide works by inhibiting the **RAAS **and promoting arterial, venous, and coronary **vasodilation**, decreasing LVEDP and improving **dyspnea**
## Footnote
33 -AHF
106
Nesiritide induces diuresis and ____________, relaxes cardiac muscle, and lacks any ____________ effects
Nesiritide induces diuresis and **natriuresis**, relaxes cardiac muscle, and lacks any **dysrhythmic** effects
*Natriuresis is when the body excretes more sodium and causes a diuretic response*
## Footnote
33-AHF
107
What Exogenous recombinant BNP binds to A and B-type natriuretic receptors?
Exogenous BNP: **Nesiritide**, a recombinant BNP that binds to A- and B-type natriuretic receptors
## Footnote
33- AHF
108
T/F
Nesiritide has shown advantage over traditional vasodilators such as NTG & SNP
False
Nesiritide has **not** shown advantage over traditional vasodilators such as NTG & SNP
## Footnote
33-AHF
109
When medical management fails and organ dysfunction occurs, urgent _________ ___________ __________ (MCS) is indicated.
When medical management fails and organ dysfunction occurs, urgent **mechanical circulatory support** (MCS) is indicated
## Footnote
34- AHF
110
The Society of Thoracic Surgeons (STS) developed a MCS decision-making tool based on pt clinical profiles. What is that tool or Profile System called?
Inter-agency Registry of Mechanically Assisted Circulatory Support
INTERMACS Profile System
## Footnote
34-AHF
111
___________ _______________ Pump: functions by cyclic ____________balloon inflation after ________ valve closure, followed by deflation during __________
**Intraaortic Balloon** Pump (IABP): functions by cyclic helium balloon inflation after **aortic** valve closure, followed by deflation during **systole**
## Footnote
35-AHF
112
IABP improves LV coronary perfusion by ____________ LVEDP
____________and x-ray are the primary modes for placement evaluation
IABP improve LV coronary perfusion by **reducing **LVEDP
TEE and x-ray are the primary modes for placement evaluation
## Footnote
35-AHF
113
IABP degree of support varies because of the set ____________, the ________ of the balloon, and the ____________ of supported beats
IABP degree of support varies b/o the set **volume**, the **size** of the balloon, and the **ratio** of supported beats
## Footnote
35 - AHF
114
Full IABP support would be 1:1 (one inflation for every heartbeat)
In tachycardic pts, a setting of __:__
(________ inflation per every________ heartbeats) is ideal
Full support would be 1:1 (one inflation for every heartbeat)
In tachycardic pts, a setting of **1:2** (**one** inflation per every **two** heartbeats) is ideal
## Footnote
35 - AHF
115
IABP provides only ____________ improvements in cardiac output
(_____-_____ L/min) and render pts immobile, limiting its long-term use
Overall, IABP provides only **modest** improvements in cardiac output (**0.5–1 L/min**) and render pts immobile, limiting its long-term use
## Footnote
35 - AHF
116
What is a Ventricular Assist Device (VAD) that can be placed percutaneously to reduce LV strain and myocardial work in the setting of acute heart failure?
Impella
## Footnote
36
117
How long can an Impella be left in a patient for?
Can be utilized for up to 14 days
## Footnote
36
118
An Impella serves a transition to ____________ or a bridge to ____________ procedures.
What are the four procedures mentioned on this slide?
Serves as a transition to**recovery**
Bridge to **cardiac** procedures **(CABG, PCI, VAD, transplant)**
## Footnote
36
119
The Impella consists of a miniature ____________ blood pump inserted through the ____________ artery, advanced through the aortic valve and is situated in the ______
The Impella consists of a miniature **rotary** blood pump inserted through the **femoral **artery, advanced through the aortic valve and is situated in the **LV **
## Footnote
36
120
The Impella pump draws blood continuously from the LV through the ________port and ejects it into the ascending aorta through its ____________ port
The Impella pump draws blood continuously from the LV through the **distal** port and ejects it into the ascending aorta through its **proximal** port
## Footnote
36
121
What VAD/ECMO device is necessary for cardiorespiratory support or as an alternative to Peripheral VAD/ECMO?
Why would we use this device over Peripheral VAD/ECMO?
**Central ECMO** may be necessary for cardiorespiratory support or as an alternative to peripheral ECMO
We would use Central ECMO *if adequate flow rates are not achievable* with Peripheral VAD.
## Footnote
36
122
Where are Central VAD/ECMO devices placed (2 spots)?
How are these spots surgically accessed?
Central cannulas are placed in the **right atrium and aorta**
Accessed:
Invasive and require **sternotomy** or **thoracotomy** for placement
## Footnote
36
123
What are the three benefits of Central VAD/ECMO?
Benefits:
1. complete ventricular decompression
2. avoidance of limb impairment
3. avoidance of SVC syndrome
## Footnote
36
124
____________ VAD: support devices that can provide extracorporeal membrane oxygenation (ECMO)
Consists of a small pump & controller, which is helpful for transport, but generates ________, causing more ________ and lower flows.
**Peripheral** VAD: support devices that can provide extracorporeal membrane oxygenation (ECMO)
Consists of a small pump & controller, which is helpful for transport, but generates **heat**, causing more **hemolysis** and lower flows
## Footnote
38
125
Peripheral VAD: If these devices have an ____________, they are considered ECMO, and used to support the right or left side of the heart
If these devices have an **oxygenator**, they are considered ECMO, as opposed to having no oxygenator, but used to support the right or left side of the heart
## Footnote
38
126
Due to ECMO ____________anesthetics may be significantly limited by functional shunting around the lungs
For this reason what other anesthetic techniques are considered?
**Inhaled anesthetics **may be significantly limited by functional shunting around the lungs
*higher amount of inhaled anesthetics may be required*
**TIVA** should be considered for pts on ECMO
## Footnote
39
127
The CRNA should recognize that the ECMO membrane is ____________, causing many agents, including fentanyl, to become ____________within the circuit.
CRNA must recognize that the ECMO membrane is **lipophilic**, causing many agents, including fentanyl, to become **sequestered** within the circuit
## Footnote
39
128
T/F
Pts on ECMO likely have increased lung perfusion as blood bypasses the lungs before returning to the aorta
FALSE
Pts on ECMO likely have **reduced** lung perfusion as blood bypasses the lungs before returning to the aorta
## Footnote
39
129
**Biventricular assist device (BiVAD)**:
* Once a pt on central ECMO is stabilized, it may be desirable to __________ support of the ventricles with two ___________ circuits to allow for _________ of either the left- or right-sided support
* Separate circuits can be achieved by ____________ placement to support the right and left sides, separately
* Alternatively, the right and left sides can be __________ cannulated individually
* decouple
* independent
* weaning
* percutaneous
* centrally
## Footnote
40
130
# Pre- Op Management of HF Patients:
HF pts have an increased risk of developing ________ failure, sepsis, __________, and _________ arrest.
* require longer periods of ___________ ventilation; and have an overall increased _____-day mortality
* renal
* pneumonia
* Cardiac
* mechanical
* 30
## Footnote
41
131
# Pre- Op Management of HF Patients:
* All pts with HF should have a comprehensive preop exam to determine if they are _____________ or require treatment
* Comorbidities s/a uncontrolled HTN, ______, angina, ______, and _________ failure, should be examined and optimized.
* compensated
* DM
* afib
* renal
## Footnote
41
132
# Pre- Op Management of HF Patients:
Surgery should be _________ in pts experiencing ____________ , a recent change in clinical status, or in de novo _______ heart failure
* postponed
* decompensation
* acute
## Footnote
41
133
# Pre- Op Management of HF Patients:
* HF pts usually take several _______ that may affect anesthetic mgmt.
* ______________ be held on the day of surgery
* BB maintenance is essential, studies show they reduce perioperative ________ and ________.
* __________ may put pts at risk of intraop HoTN
---------2014 ACC/AHA guidelines recommend maintaining therapy in the perioperative period
* meds
* diuretics
* morbidity and mortality
* ACE-i
## Footnote
42
134
# Pre- Op Management of HF Patients:
* ___________ is recommended in any pt w/cardiovascular dz
* A ____________ is indicated in pts w/worsening dyspnea during their preop evaluation
* 12-Lead EKG
* TEE
## Footnote
42
135
# Pre- Op Management of HF Patients:
* Labs: CBC, electrolytes, ______ function, and ________ studies
* ______ is not routinely recommended
* _______ and ___________ should be interrogated prior to surgery
* liver
* coagulation
* BNP
* ICD and pacemaker
## Footnote
42
136
# Cardiomyopathies:
* Cardiomyopathies are a group of myocardial diseases associated with _________ and/or __________ dysfunction that usually exhibit ________ hypertrophy or dilation.
* Cardiomyopathies are either confined to the ________ or are part of ___________ disorders, often leading to cardiovascular ________ or disability
* mechanical
* electrical
* ventricular
* heart
* systemic
* death
## Footnote
43
137
# Cardiomyopathies:
Cardiomyopathies can be divided into 2 groups:
* ________ cardiomyopathies: are confined to ______ muscle
* ________ cardiomyopathies: pathophysiologic cardiac involvement in the context of a __________ disorder
* Primary
* Heart
* Seconday
* Multiorgan
## Footnote
43
138
# Hypertrophic Cardiomyopathy:
* HCM is a complex primary cardiomyopathy with _______ clinical features
* HCM can affect all ______ and has a prevalence of about 2-5 per 1,000 ppl
* It is the most common _________ cardiovascular disease
* diverse
* ages
* genetic
## Footnote
44
139
# Hypertrophic Cardiomyopathy:
* characterized by ______ in the _________ of other diseases capable of inducing ventricular hypertrophy
* HCM usually presents w/ hypertrophy of the interventricular _________ and the ____________free wall
* Histologic features include __________ myocardial cells and _______myocardial scarring
* LVH
* absense
* septum
* anterolateral
* hypertrophy
* patchy
## Footnote
44
140
Myocardial hypertrophy, dynamic LV outflow obstruction, mitral regurg, diastolic dysfunction, myocardial ischemia and dysrhythmias are all related to what condition?
hypertrophic cardiomyopathy
## Footnote
45
141
Hypertrophied myocardium has a ____ relaxation time and ___ compliance
prolonged relaxation and decreased compliance!
## Footnote
45
142
# T or F?
Myocardial ischemia is present in Hypertrophic cardiomyoapthy whether or not they have CAD
True
## Footnote
45
143
Dysthytmias are the most sudden cause of death in young pts w/ hypertrophic cardiomyopathy. What causes dysrthymias?
disorganized cellular architecture, scarring, and an expanded interstitial matrix
## Footnote
45
144
What characterizes dilated cardiomyoapthy
what is the initial symptom?
LV [or biventricular] dilation, biatrial dilation, decreased ventricular wall thickness, and systolic dysfunction
initial symptom--> HF (CP may occur as well)
## Footnote
46
145
In asymptomatic patients, what is the only sign of Hypertrophic cardiomyopathy?
unexplained left ventricular hypertrophy
## Footnote
46
146
What are some diagnostic abnormalities in patients w/ hypertrophic cardiomyopathy?
hint: ekg and echo
EKG abnormalities (75-90% pt) show high QRS voltage, ST segment and T wave abnormalities, abnormal Q, and atrial enlargment
Echo: myocardial wall thickness >15mm; and EF >80%
*terminal states: EF severely depressed*
## Footnote
46
147
# hypertrophic cardiomyopathy
Cardiac catherization allows direct measurement of ______ ____?
left ventricular end diastolic pressure
## Footnote
46
148
Medical treatment for hypertrophic cardiomyopathy (4)
-BB, CCB
-if develop HF--> diuretics
-disopyramide (add on if still symptomatic)
-amiodarone if develops dysrhythmias! (most effective)
| disopyramide has negative inotropic effect- improves LV outflow obsructi
## Footnote
47
149
What complication that develops in hypertrophic cardiomyopathy is associated w/ increased risk of thromboembolism, HF and death?
What is the treatment
a-fib--> amiodarone!
Need long term anticoagulation if chronic
## Footnote
47
150
# hypertrophic cardiomyopathy
Surgery is reserved for pt w/ large outflow tract gradients & severe symtoms despite medical tx. What are 3 surgical strategies?
What treatment if *still* symptomatic?
-septal myomectomy
-cardiac cath w/ injection to induce ischemia to septal perforator arteries
-echo guided percutaneous septal ablation
*If still symptomatic, MVR can be done to counteract systolic anterior motion of mitral leaflet*
## Footnote
48
151
# hypertrophic cardiomyopathy
What is the primary tx for pt at risk for death r/t dysrhytmias?
ICD Placement!
## Footnote
48
152
Common complications in dilated cardiomyopathy? (4)
dysrhythmias, conduction abnormalities, emboli and sudden death
## Footnote
49
153
# dilated cardiomyopathy
Ventricular dilation may lead to what 2 valve abnormalities?
mitral and tricuspic regurgitation
## Footnote
49
154
Common echo and EKF findings in dilated cardiomyopathy are?
- echo: dilation of all 4 chambers, especially the LV. Global hypokinesis
- EKG: ST and T wave abnormalities w/ LBBB
- comon dyrhythmias: PVC and AFIB
155
Treatment for dilated cardiomyopathy
Tx is similiar to chronic HF. AC initiated as well.
Prophylactic ICD--> decreases sudden death by 50%
Ultimately--> cardiac transplant :( (DCM is the main indication for transplant)
## Footnote
50
156
Common symptoms in stress cardiomyopathy? What is the most common cause?
chest pain, dyspnea.
Stress is most common cause
women > men
## Footnote
51
157
Stress cardiomyopathy aka apical ballooning syndrome is a temporary primary cardiomyopathy characterized by what abnormalities?
LV apical hypokinesis and ischemic EKG changes (coronary arteries are still patent)
-Temporary dysruption of contractility in LV apex (and rest of heart has normal contractility)
## Footnote
51
158
* Peripheral VAD = __________ membrane oxygenation (ECMO)
* Consists of a small pump & controller = helpful for _______,
* but generates ____ >> ______ and lower flows
* If oxygenator = ECMO,
* no oxygenator = used to ______ R or L heart
## Footnote
AHF Surgical Treatment
* extracorpeal
* transport
* heat ... hemolysis
* support
159
# Central VAD/ECHMO
* cannulas placed in ___ atrium + aorta
* invasive _____ / ______ to place
* benefits = complete _____ decompresion ,, avoid ____ impairment ,, avoid ____ syndrome
## Footnote
AHF Surgical treatment
* Right
* sternotomy / thoracotomy
* ventriuclar ,, limb ,, SVC
160
# ECMO
* Pts on ECMO have reduced ____ perfusion bc blood bypasses before returning to aorta
* Inhaled Anes = ____ bc of shunting
* _____ should be considered for ECMO pts
* ECMO membrane = ____ + may cause agents like ____ to become sequestered within circuit
## Footnote
AHF Surgical Tx
* lung
* limited
* TIVA
* lipophilic ,, fentanyl
161
# Biventricular Assist Device
* Used to _____ support of ventricles with 2 independent circuits
* This allows for ______ of either L or R sided support
* separate circuits achieved by _____ placement
* R + L sides can be centrally ______ individually
## Footnote
AHF Surgical Tx
* decouple
* weaning
* percutaneous
* cannulated
162
* HF pts have increased risk of :: ___ failure, ______, pna, + require longer periods of ______ _________
* Comprehensive preop exam to determine if ______ or require treatment
* 3 reasons to POSTPONE surgery ??
## Footnote
AHF Preoperative Mgnt
* Renal failure ,, sepsis ,, mechanical ventilation
* compensated
* decompensation ,, change in status ,, De Novo AHF
163
* ____ held on day of surgery
* continue ____ bc it's managment is essential
* ______ put pt at risk for intraop Hotn
* perform a _______ if worsening dyspnea
* 4 labs necessary ??
* ____ lab is not routine
* ICDs and Pacemakers should be ______ prior to surgery
## Footnote
AHF Preoperattive Mgmt
* Diuretics
* Beta blockers
* ACE-I
* TTE -- echo
* CBC , lytes , LFTs , coagulation
* BNP
* interrogated
164
* Group of myocardial disease with ___________ or _____ dysfx
* These exhibit as ventricular __________ or ________
* Cardiomyopathy is either confined to __________ (**primary**) or part of _____ disorders (**secondary**)
## Footnote
Cardiomyopathies
* mechanical or electrical
* hypertrophy or dilation
* heart or systemic
165
* affects all ___
* most common ______ CV disease
* characterized by _____ + absence of other diseases that could cause it
* presents with hypertrophy of the ___________________ and ________________
* Histologic features are hypertrophied ____ cells and ________ myocardial scarring
## Footnote
Hypertrophic Cardiomyopathy
* ages
* genetic
* L Ventricle Hypertrophy
* intraventricular septum and antero-lateral free wall
* myocardial ,, patchy
