Exam 4 Heart Failure Part 2 Flashcards by Kyle & Marlea

What is the mainstay Tx for patients who have acute reduced contractility or cardiogenic shock?

Positive Inotropes

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Several inotropes increase ____, which increases intracellular ____ and ____

cAMP
Ca
excitation-contraction coupling

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Catecholamines stimulate ____ receptors on the ____ to activate ____ to increase ____

beta
myocardium
adenylyl cyclase
cAMP

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PDE inhibitors ____ increase cAMP by inhibiting its degredation

indirectly

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Epinephrine v. NE
MOA
CO
MAP
HR

CHART ALERT!

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Dobutamine, dopamine, milrinone, levosimendan
MOA
CO
MAP
HR

CHART

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What is another name for exogenous BNP?
How does it work?

Nesiritide
recombinant BNP that binds to A- and B-type natriuretic receptors, inhibiting the RAAS and promotingarterial, venous, and coronary vasodilation, decreasing LVEDP and improving dyspnea
It also induces diuresis and natriuresis, relaxes cardiac muscle, and lacks any dysrhythmic effects

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Nesiritide has not shown advantage over traditional vasodilators such as ____ & ____

NTG and SNP

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What is indicate for acute HF when medical management fails and organ dysfunction occurs?

Urgent mechanical circulatory support

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The Society of Thoracic Surgeons developes ____ which is a mechanical circulatory support decision making tool based on pt clinical profiles

INTERMACS
Inter-agency Registry of Mechanically Assisted Circultorary Support

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How does intra-aortic balloon pump function?

cyclic helium balloon inflation after aortic valve closure, followed by deflation during systole

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IABP improves what 2 things?

LV coronary perfusion and reduces LVEDP

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What is used as the primary mode for placement evaluation of an IABP?

TEE and XRAY

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IABP degree of support varies based on the ____, ____ and ____

set volume, size of the balloon, and ratio of supported beats

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Full support with IABP is a ____ ratio
____ratio is ideal for tachycardic patients

1:1
1:2

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IABP only provides ____ improvememnts in CO (____)
it renders patients ____ so it does not have good ____ use

modest
0.5-1
immobile
long-term

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____ is a VAD that can be placed percutaneously to reduce LV strain and myocardial work in the setting of acute heart failure

Impella

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How long can impella be used for?
What does it serve as?

14 days
transition to recovery or a bridge to a cardiac procedure (CABG, PCI, VAD, transplant)

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impella consists of miniature ____ inserted through the ____ artery, advanced through the ____ and is situated in the ____

rotary blood pump
femoral
AV valve
LV

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the impella draws blood from the ____ through the ____ port and ejects it into the ____ through the ____ port

LV
distal
ascending aorta
proximal

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Impella is also known as what?

The world’s smallest heart pump

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____ is a support devices that can provide extracorporeal membrane oxygenation (ECMO)

Peripheral VAD

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A peripheral VAD consists of a small pump and controller which is helpful for ____, but it generates ____ causing more ____ and ____

transport
heat
hemolysis
lower flows

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If the peripheral VAD has an oxygenator it can be considered ____
If there is no oxygenator it is just used to ____

ECMO
support the right or left side of the heart

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If we cant achieve adequate flows w/ peripheral VAD, ____ then ____ may be necessary

Central VAD/ECMO | Slide 38

A central VAD/ECMO has cannulas placed in the ____ and ____ it is invasive and requires ____ or ____ for placement What are the benefits?

RA, aorta sternotomy, thoracotomy benefits: complete ventricular decompression, avoidance of limb impairment, and avoidance of SVC syndrome | Slide 38

T/F Pts on ECMO do not have reduced lung perfusion

False Pts on ECMO likely have reduced lung perfusion as blood bypasses the lungs before returning to the aorta | Slide 39

inahled anesthetics may be signficantly limited by ____ around the lungs

functional shunting | Slide 39

What type of anesthetic should be considered for patients on ECMO?

TIVA | Slide 39

Since the ECMO membrane is ____, many of our drugs including ____ will become ____ in the circuit

lipophilic fentanyl sequestered | Slide 39

Once a patient on ECMO is stabilized, what can we do to start weaning?

decouple support of the ventricles with two independent circuits to allow for weaning of either the left- or right-sided support | Slide 40

How do separate circuits be achieved with ECMO?

percutaneous placement to support the right and left sides separately | Slide 40

What is another alternative method for separating the assistance of the L and R sides of the heart?

The right and left sides can be centrally cannulated individually | Slide 40

HF patients are at increased risk for developing what 4 things? They require longer periods of ____ and have an overall increased ____ day mortality

Renal failure sepsis pneumonia cardiac arrest mechanical ventilation 30 | Slide 41

Pre-op, we need to examine whether HF patients are ____ or require ____

compensated treatment | Slide 41

Surgery for HF should be postponed in what 3 scenarios?

decompensation a recent change in clinical status in de novo acute heart failure | Slide 41

Which medications reduce peri-operative morbidity and mortality?

Beta blockers

generally, which type of medications used for HF should be held on the day of the surgery?

Diuretics | Slide 42

Because ACE inhibitors increase the risk of HoTN, the AHA guidelines reccommend discontinuing ACE inhibitors before surgery. T/F?

False- maintain therapy peri-operatively | Slide 42

EKG is recommended in any patient with ____ disease

cardiovascular | Slide 42

TTE is indicated in patients with ____ during their pre-op eval

worsening dyspnea | Slide 42

What labs are recommended in HF patients? Which labs are not routinely recommended?

CBC, electrolytes, liver function, and coag studies BNP is not routinely recommended | Slide 42

Which devices should be interrogated prior to surgery?

ICD's and pacemakers | Slide 42

Cardiomyopathies have ____ or ____ dysfunction and usually exhibit ventricular ____ or ____

mechanical or electrical hypertrophy or dilation | Slide 43

2 groups that cardiomyopathies can be divided into. Define them

Primary: confined to the heart muscle secondary: pathophysiologic cardiac involvement in the context of multiorgan disorder | Slide 43

hypertrophic Cardiomyopathy affects ____ ages and has a prevalence of about ____ per 1,000 people

all 2-5 | Slide 44

What is the most common genetic cardiovascular disease?

Hypertrophic cardiomyopathy | Slide 44

Hypertrophic cardiomyopathy is characterized by ____ in the absence of other diseases capable of inducing ____

LVH ventricular hypertrophy | Slide 44

Hypertrophic cardiomyopathy usually presents with hypertrophy of which portions of the LV?

interventricular septum anterolateral free wall | Slide 44

What are histological features of hypertrophic cardiomyopathy?

hypertrophied myocardial cells and patchy myocardial scarring | Slide 44

What are 6 phathophysiological features that hypertrophic cardiomopathies can cause?

myocardial hypertrophy dynamic LVOT obstruction mitral regurgitation diastolic dysfunction myocardial ischemia dysrhythmias | Slide 45

hypertrophied myocardium has a ____ relaxation time and ____ compliance

prolonged decreased | Slide 45

T/F Myocardial ischemia is present in patients with hypertrophic cardiomyopathy regardless of whether or not they have CAD

True | Slide 45

What is the cause of sudden death in HCM?

Dysrythmias | Slide 45

What causes dysrhythmias in HCM?

disorganized cellular architecture, myocardial scarring, and an expanded interstitial matrix | Slide 45

If patients with HCM are asymptomatic, what may be the only sign?

LVH | Slide 46

HCM patients have ____ seen in 75-90% of them. This includes what 5 things?

EKG abnormalities high QRS voltage, ST segment alterations, T wave alterations, abnormal Q waves, and LA enlargement | Slide 46

HCM wall thickness in Echo is ____ EF is ____ reflecting ____, except in patients in ____ states where EF is ____

**>**15mm **>**80% hypercontractility Terminal, severely depressed | Slide 46

How can we directly measure LVEDP??

Cardiac Catheterization | Slide 46

The initial medical therapy for HCM is ____ and ____. If patients develop HF despite management with these meds, they may show improvement with ____

BB and CCB diuretics | Slide 47

after giving BB, CCB, and diuretics, patients who have HCM may consider ____ as an add-on therapy. it has ____ intotropic effects which improves ____ obstruction and heart failure symptoms

Disopyramide negative LVOT | Slide 47

what common dysrhthmia develops with HCM? what does this put them at risk for? What is the most effective anti-dysrhythmic treatment in these pts?

A-fib thromboembolism, HF, and sudden death amiodarone | Slide 47

long-term anticoagulation is indicated for recurrent or chronic ____

a fib | Slide 47

This subgroup of patients in HCM can be treated with surgery

HCM with Large outflow tract gradients and severe symptoms despite treatment | Slide 48

What are the 3 surgical strategies for HCM?

septal myomectomy cardiac cath w/injection to induce ischemia of the septal perforator arteries echocardiogram-guided percutaneous septal ablation | Slide 48

A ____ can be inserted to counteract the systolic anterior motion of the mitral leaflet in ____ patients

prosthetic mitral valve HCM | Slide 48

What is the primary treatment for patients at risk for sudden cardiac death d/t dysrhythmias

ICD placement | Slide 48

Dilated Cardiomyopthy is a PRIMARY myocardial disease characterized by what 4 abnormalities?

by LV or biventricular dilatation, biatrial dilation, decreased ventricular wall thickness, and systolic dysfunction w/o abnormal loading conditions or CAD | Slide 49

What is the initial symptom of dilated cardiomyopathy (DCM)?

HF, chest pain may also occur | Slide 49

# DCM What leads to mitral or tricuspid regurg?

ventricular dilation | Slide 49

What is common with DCM?

dysrhythmias, conduction abnormalities, emboli, and sudden death | Slide 49

Echo in pts with DCM reveals dilation of ____ chambers, predominantly the ____ as well as ____ ____

all LV global hypokinesis | Slide 50

What is the treatment of DCM similar to? What is an addition that is commonly initatied?

HF anti-coagulation | Slide 50

EKG of DCM shows ____, ____, and ____

ST segment abnormalities T wave abnormalities LBBB | Slide 50

What are common dysrhythmias seen in DCM?

PVC and A fib

Prophylactic ____ placement decreases risk of sudden death by ____% in DCM

ICD 50% | Slide 50

What is the principle indication for cardiac transplant?

DCM | Slide 50

Stress cardiomyopthy is also known as ____ and is a ____ primary cardiomyopathy characterized by LV apical hypokinesis w/ischemic EKG changes, however the coronary arteries remain patent

Apical ballooning syndrome temporary | Slide 51

Stress cardiomyopthy has a temporary dysruption in the contractility in the ____ while the rest of the heart has normal contractility

LV apex | Slide 51

what are common symptoms of stress cardiomyopathy? What is the main causative factor? Which population has higher amounts?

chest pain and dyspnea stress (physical or emotional) Women more than men

What is a rare type of primary cardiomyopathy? What kind of cardiomyopathy is it? When does it arise?

peripartum cardiomyopathy dilated 3rd trimeester to 5months post-partum | Slide 52

Peripartum cardiomyopathy is diagnosed based on what 3 criteria? What diagnostic studies can we do?

development of HF in the period surrounding delivery absence of another explainable cause LV systolic dysfunction with a LVEF <45% Dx studies include: EKG, Echocardiogram, CXR, cardiac MRI, cardiac cath, endomyocardial biopsy & BMP levels | slide 52

Secondary cardiomyopathies are d/t ____ that produce myocardial infiltration and severe diastolic dysfunction.

systemic diseases

What is the most common cause of secondary cardiomyopathy? Other causes?

amyloidosis Other causes: hemochromatosis, sarcoidosis, and carcinoid tumors | Slide 53

Secondary cardiomyopathy should be considered in patients who have HF, but no evidence of what?

cardiomegaly or systolic dysfunction | Slide 53

What is the BP in patients with secondary cardiomyopathy? what can patients develop?

low to normal orthostatic hypotension | Slide 53

How are primary cardiomyopathies classified?

Genetic Mixed Acquired Other | Slide 54

How are secondary cardiomyopathies classified?

infiltrative storage toxic inflammatory endomyocardial endocrine neuromuscular autoimmune | Slide 55

____ is RV enlargement (hypertrophy and/or dilatation) that may progress to right-sided heart failure

Cor Pulmonale | Slide 56

What are common causes of Cor Pulmonale?

Causes: pulmonary hypertension, myocardial disease, congenital heart disease, or any significant respiratory, connective tissue, or chronic thromboembolic disease | Slide 56

What is the most common cuase of Cor Pulmonale?

COPD | Slide 56

EKG changes with Cor Pulmonale

RA and RV enlargement RA is suggested by peaked P waves in leads II, III, and aVF Right axis deviation and RBBB are also often seen | Slide 56

What diagonistics outside of EKG can be done for Cor Pulmonale?

TEE, Right heart cath, and CXR | Slide 56

HF is a complex state in which the heart is unable to ____ or ____ blood at a rate appropriate to meet tissue requirements

Fill with or eject | Slide 58

HFrEF is commonly d/t what problem?

Ischemic Heart Disease | Slide 58

HFpEF is increasing in prevalence and is primarily the result of ____ lifestyle choices and ____

poor comorbidities | Slide 58

Factors that induce LVOT obstruction in HCM include what?

hypovolemia, tachycardia, increased myocardial contractility, and decreased afterload | Slide 59

DCM is the most common form of ____ and is the ____ most common cause of HF

cardiomyopathy 2nd | Slide 59

Cor Pulmonale is ____ enlargement that may progress to ____ HF. it is caused by dieseases that promote ____.

RV Right HF pulmonary HTN | Slide 59

What is the most important determinant of pulmonary HTN and cor pulmonale in patients with chronic lung disease? How do we treat it?

alveolar hypoxia long-term oxygen therapy | Slide 59