Exam 4 Heart Failure Part 1 Flashcards
Heart failure is an emerging worldwide epidemic with more than ____ million pts in the US will be treated for the condition by 2030
8 million
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HF is defined as a complex syndrome that results from any structural or functional impairment of ____ or _____.
ventricular filling or blood ejection
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HF leads to:
- tissue-hypoperfusion
- causingfatigue
- dyspnea
- weakness
- edema
- weight gain
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HF may be caused by structural abnormalities of the ….?
- pericardium
- myocardium
- endocardium
- heart valves
- or great vessels
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HF with reduced EF (HFrEF, aka ____HF) is classified as HF w/ EF ___
- systolic HF
- ≤40%
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HF with preserved EF (HFpEF, aka ____ HF) is diagnosed as HF w/ EF____
- diastolic HF
- ≥50%
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HF symptoms and an EF btw 40-49%
Borderline HFpEF
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____ dysfunction is present in both HFrEF andHFpEF
Diastolic
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what are distinguishing features between HFrEF and HFpEF?
- LV dilation patterns
- remodeling
- also have different responses to medicaltreatment
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____ remains a useful tool, as it is easily measured onechocardiogramand serves asthe main marker for determining HF risk factors, treatment, and outcomes
Ejection fraction
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̴1/2 HF pts have normal (____%) ejection fraction
- > 50%
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The proportion of pts with HFpEF is increasing d/t its relationship w/conditions such as :
- HTN
- DM
- A-fib
- obesity
- metabolic syndrome
- COPD
- renal insufficiency
- anemia
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Pts with HFrEF are more likely to have modifiable risk factors (smoking, hyperlipidemia) as well as a higher incidence of :
- myocardial ischemia & infarction
- previous coronary intervention
- CABG
- PVD
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- ____% HF cases are HFpEF
- ____% are HFrEF
- ____% are borderline HFpEF (EF 40-49%)
- 52% HF cases are HFpEF
- 33% are HFrEF
- 16% are borderline HFpEF (EF 40-49%)
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- ____ are more likely to be affected by HFpEF
- ____ more likely to be affected by HFrEF
- Women are more likely to be affected by HFpEF
- Men more likely to be affected by HFrEF
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LV diastolic dysfunction (LVDD) is the primary determinant of ____, whereas contractile dysfunctionis the primary determinant for ____.
- HFpEF
- HFrEF
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The LV’s ability to fill is determined by:
- pulmonary venous blood flow
- LA function
- mitral valve dynamics
- pericardial restraint
- the active & passive elastic properties of LV
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LV diastolic function is normal when these factors combine to provide a LVEDV (preload) that provides sufficient ____ for cellular metabolism without elevating ____ and ____.
- cardiac output
- pulmonary venous pressures and LA pressures
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LVDD
The majority ofLVDD measurements depend on:
- HR
- loading conditions
- andmyocardial contractility
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In HFpEF, higher LV filling pressures are required to achieve normal ____
end-diastole volume
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A steeper rise of the end-diastolic pressure-volume curve is indicative of ____ LV relaxation and ____ myocardial stiffness. This leads to:
- delayed
- increased
Leads to:
* reduced LV compliance and precipitates LA hypertension
* LA systolic &diastolic dysfunction
* pulmonary venous congestion
* exercise intolerance
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- what does the left LV pressure volume loop show?
- what does the right LV pressure volume loop show?
- Left: decreased contractility is indicated by a decrease in the slope of the end-systolic pressure-volume relation(HFrEF)
- Right: decreased in LV compliance is indicated by an increase in the end-diastolic pressure-volume relation slope (HFpEF)
- These diagrams emphasize that heart failure may result from LV systolic or diastolic dysfunction independently
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what are common causes of left ventricular diastolic dysfunction?
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Delays in relaxation are a form of “____” c/b failure of the actin-myosin disassociation, which occurs due to ____ or ____.
- active stiffening
- occurs d/t: inadequate perfusion or dysfunctional intracellular Ca++ homeostasis
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LV relaxation d/o afterload, which is typically elevated in ____ pts
hypertensive
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____ exacerbates the failure of LV relaxation
Tachycardia
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- Profound exercise intolerance is seen w/HFpEF despite having only a modestly depressed ____
- In addition, prolonged compression of the coronary arteries restricts diastolic coronary blood flow, which contributes to ____ and a further reduction in exercise tolerance
- LV systolic function
- subendocardial ischemia
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Most common symptoms of HF?
- fatigue
- tachypnea
- dyspnea
- paroxysmal nocturnal dyspnea
- orthopnea
- S3 gallop
- JVD
- peripheral edema
- exercise intolerance
- reduced tissue perfusion
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what symptoms are more common with HFpEF?
- paroxysmal nocturnal dyspnea
- pulmonary edema
- dependent edema
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what sypmtom is more common with HFrEF
S3 gallop
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When EF is reduced, the presence of HF symptoms establishes the diagnosis of ____(following standard guidelines)
HFrEF
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In contrast to ____ , the initial diagnosis of____is often more difficult,especially when the pt has little/no symptoms at rest
- HFrEF
- HFpEF
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Cardiac catheterization defines ____ and ____ usingpressure-volume analysis or provocative testing (s/a exercise & rapid IV volumeexpansion)
elevated LV systolic and diastolic stiffness
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Direct measurement of RV filling pressures offers further information about the severity of____
HFpEF
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Mean pulmonary capillary wedge pressure >____mmHg at rest or ____mmHg duringexercise provides strong evidence ofHFpEFand is a predictor of mortality
- > 15 mmhg
- 25 mmhg
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CXR may detect what?
- pulmonary dz
- cardiomegaly
- pulmonary venous congestion
- interstitial or alveolar pulmonary edema
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CXR
An early radiographic sign of LV failure & pulmonary venous HTN is distention of ?
the pulmonary veins in the upper lobes of the lungs
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Perivascular edema appears as ?
a hilar or perihilar haze with ill-defined margins
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____, produce a honeycomb pattern, reflect interlobular edema & may be present in HF
Kerley lines
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____ produces homogeneous densities in the lung fields, typically in a butterfly pattern
Alveolar edema
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what may be present in CXR with HF?
Pleural effusion and pericardial effusion
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Radiographic evidence of pulmonary edema may lag behind the clinical evidence of pulmonary edema by up to ____ hours
12 hours
slide 13
echocardiogram
The ACC/AHA diagnostic criteria d/o 3 factors:
- HF sx
- EF >50%
- evidence of LVDD
- This approach is useful for pts with clear symptomatology, but may be too simplistic for subclinical HFpEF
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The ESC criteria is ____ specific and incorporates several echocardiographic indexes based on ____ measurements
- more
- 2-dimensional
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ESC guidelines rely entirely on resting echocardiogram; and are limited because?
they do not incorporate provocative testing
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ACC/AHA criteria vs ESC crietria of HF?
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- Electrocardiogram: EKG abnormalities are common in HF pts and are typically related to?
- EKG alone has a ____ predictive value for diagnosis or risk-prediction of heart failure
related to
* underlying pathology s/a LVH
* previous MI
* arrhythmias
* conduction abnormalities
EKG alone has a LOW predcitvie value
slide 16
what labs can be used to diagnose HF?
- Brain natriuretic peptide (BNP)&N-terminal pro-BNP
- Troponins
- C-reactive protein(CRP)
- growth differentiation factor-15(GDF15)
slide 17
Brain natriuretic peptide (BNP)&N-terminal pro-BNPareimportant ____.
biomarkers
slide 17
- Natriuretic peptide concentrations are related to LV end-diastolic wall stress,which is higher in HFrEFd/t LV dilation & ____ remodeling
- In contrast, HFpEF is assoicatedw/ ____ hypertrophy, relatively normal LV chamber size, and lower LV end-diastolic wallstress, allowing for lower BNP or NT-proBNPlevels
- eccentric
- concentric
slide 17
`
____are systemically released d/t myocardial damage and serve as ameasure of risk prediction
Troponins
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BothC-reactive protein(CRP) andgrowth differentiation factor-15(GDF15)represent what?
the inflammatory component of HF
slide 17
The New York Heart Association (NYHA) and the ACC/AHA created classification systems for HF. The NYHA system focuses primarily on ____ whereas the ACC/AHA focus on ____.
- NYHA: the degree of physical limitation
- ACC/AHA: the presence & severity of HF
slide 18
Classification of HF
- Since progression of HF is linked to reduced 5-year survival, it is important to note that these stages are ____
- Pts are oftenclassified using a combination of ____?
- progressive
- both scoring systems(NYHA and ACC/AHA)
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Chronic HF treatment
- Survival of pts w/ ____ has improved during the past three decades, but the mortality in those with ____ remains unchanged
- Medication treatments are ineffective for____, although benefit is seen in pts with ____
- HFrEF | HFpEF
- HFpEF | HFrEF
slide 19
- HFpEF tx:
- HFrEF tx:
- HFpEF tx: Mitigation of sx’s, treat associated conditions, exercise, weight loss
- HFrEF tx: ΒB’s and ACE-inhibitors
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what is the treatment algorithm for HFpEF?
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CHF Tx (Diuretics)
- ____diuretics are recommended per ACC & ESC guidelines as they reduce LV filling pressures, decrease pulmonary venous congestion, and improve HF sx
- ____ diuretics may be useful in pts with poorly controlled HTN to prevent the onset of HFpEF
- Loop diuretics
- thiazide diuretics
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- ____ strongly recommended for HFrEF.
- this medication is not clearly establised for HFpEF but are prescribed for indications such as?
- beta blockers
- other indications: HTN, MI, HR control w/Afib
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what is the mainstay treatment for HFrEF?
- ACE-I and ARBs
- however, studies do not show benefit in HFpEF unless used for treatment of HTN
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what lifestyle changes cna help treat HF?
- Aerobic fitness reduces symptoms, and increases quality of life in HF pts
- Weight loss significantly reduces major risk factors for HF, including HTN & DM
- Salt-restricted Dietary Approaches to Stop Hypertension (DASH) diet improves LV diastolic function, decreases arterial stiffness, and facilitates LV-arterial coupling in pts w/ HFpEF
- Control of HTN and blood glucose are also important
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The goal of surgical treatment for chronic HF is to prevent ventricular remodeling and retain the natural geometry of the heart. What are surgical treatments mentioned in class?
- revascularization
- Cardiac resynchronization therapy (CRT):
- Implantable hemodynamic monitoring
- Implantable cardioverting-defibrillators (ICDs)
- LV assist devices
slide 23-25
- ____ via CABG or PCI can reverse LV dysfunction following MI
- Successful early intervention may prevent ____
- ____ has been shown to reduce 10-year mortality by 7%
- Coronary revascularization
- permanent EF reductions
- CABG
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Aka “biventricular pacing,” is a tx for HF w/a ventricular conduction delay (prolonged QRS)
Cardiac resynchronization therapy (CRT)
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How is CRT performed?
- placement of a dual-chamber 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 LV
- This stimulates the heart to contract more synchronously and efficiently and improve COP
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CRT is recommended for pts with NYHA class ____ or ____ w/ EF < ____% and a QRS duration ____ms
- III or IV
- EF < 5%
- QRS duration 120-150 ms
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CRT outcomes:
- fewer HF sx
- better exercise tolerance
- improved ventricular function
- less hospitalizations
- decreased mortality
slide 23
risks of CRT include
- infection
- misplacement
- device failure
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____ allows remote observation of intracardiac pressures to guide tx and prevent decompensation
plantable hemodynamic monitoring
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The ____ system allows for management of LV filling pressures based on daily measurement of noninvasive PAP obtained at home by the pt and then uploaded to their physician
CardioMEMS Heart Failure
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- ____ is used for prevention of sudden death in pts with advanced heart failure
- ̴ ____% HF deaths are d/t sudden cardiac dysrhythmias
- Implantable cardioverting-defibrillators (ICDs)
- ~50%
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Pts in the terminal stages of HF may benefit from mechanical circulatory support (MCS) by a ____
ventricular assist device (VAD)(LV assist device)
slide 25
- Studies show an increased survival and improved quality of life in HF pts treated w/____ compared to medical therapy alone
- These mechanical pumps can take over ____ or ____ function of the damaged ventricle and facilitate restoration of normal hemodynamics and perfusion
- VADs
- partial or total
slide 25
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
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____ is classified as long-standing HF disease
Chronic heart failure
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- ____ has rapid onset, often presenting w/life-threatening conditions
- Pts may require hospitalization, txis aimed at ____ and ____
- Acute heart failure
- tx is aimed at: decreasing volume & stabilizing hemodynamics
slide 27
The term “acute heart failure” applies to
- pts who present with worsening preexisting HF (acute decompensated heart failure [ADHF])
- those who present for the first time with HF (de novo acute heart failure [de novo AHF])
slide 27
acute decompensated HF (ADHF) symptoms include:
- fluid retention
- weight gain
- dyspnea
as the result of decompensation due to inadequate compensation
slide 27
____ is characterized by a sudden increase in intracardiac filling pressuresor acute myocardial dysfunction,leading to decreased peripheral perfusion and pulmonary edema
De novo AHF
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Cardiac ischemia c/b a coronary occlusion is the leading cause of de novo HF; therefore,management is focused on:
- stabilizing hemodynamics
- restoring myocardial perfusion
- improving myocardial contractility
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Less common nonischemic causes of de novo HF include:
- viral
- drug-induced (toxic)
- peripartum cardiomyopathies
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de novo HF may lead to long-term cardiac dysfunction; however, management of theunderlying causemay allow for ____
complete restoration
slide 28
As pts present either in ____ or ____ the CRNA may be faced with stabilizing these pts for urgent/emergent surgery
ADHF or de novo HF
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The hemodynamic profile of acute HF includes:
- low cardiac output
- high ventricular filling pressures
- HTN or HoTN
slide 29
what is the 1st line of treatment for acute HF? when should the be given and why?
- diuretics
- give immediately in pts with FVO
- to migate sx and decrease mortality
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AHF pt with ____ or ____ may first require hemodynamic support prior to diuretic therapy
HoTN or cardiogenic shock
slide 29
what diuretics should be used for AHF?
- Furosemide
- Bumetanide
- Torsemide
- given as bolus or continuous infusions
slide 29
diuretics reduce intravascular volume which leads to ?
Reducing in intravascular volume leads to decreased central venous and pulmonary capillary wedge pressures (PCWP), reducing pulmonary congestion
slide 29
____ areproven to correct elevated filling pressures and reduceafterload; however, evidence is lacking on their efficacy inAHF
Vasodilators
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careful consideration of vasodilators is critical and b/o the underlying ____
hemodynamics
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____ is effective to rapidly decrease afterload, whereas ____ is commonly used as an adjunct to diuretic therapy
- SNP
- NTG
slide 30
routine use of is not shown toimprove outcomes in AHF
vasodilators
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Vasopressin receptor antagonists: such as ____ have emerged as potential adjunct therapy in AHF to reduce ….?
- Tolvaptan
- to reduce the arterial constriction, hyponatremia, and the volume overload associated with AHF
slide 30
medications used for acute HF:
- diuretics
- vasodilators
- vasopressin receptor antagonist
- Positie inotropes (catecholamines and PDE-i)
- exogenous BNP
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