Heart Failure

Question 1

Heart failure, often referred to as _________

Answer 1

congestive heart failure (CHF)

Question 2

Heart failure is the common end point for many forms of cardiac disease and
typically is a progressive condition with a poor prognosis

T/F

Answer 2

T

Question 3

Roughly one half of patients of heart failure die within ______ of receiving a diagnosis of CHF

Answer 3

5 years

Question 4

CHF occurs when the heart cannot generate ______ to meet the metabolic demands of the tissues, or
can only do so at ___________;

Answer 4

sufficient output

higher-than-normal filling pressures

Question 5

in a (minority or majority ?) of cases, heart failure is a consequence of greatly increased tissue demands, as in ______, or decreased oxygen carrying capacity, as in ________ (high output failure).

Answer 5

Minority
hyperthyroidism

anemia

Question 6

ONSET
The onset of CHF is sometimes abrupt, as in the setting of a (small or large?) myocardial infarct or (acute or chronic?) valve dysfunction. •

Answer 6

Large

Acute

Question 7

ONSET
In most cases, however, CHF develops ______ and ______ owing to the cumulative effects of _________ or —————- of myocardium.

Answer 7

gradually and insidiously

chronic work overload

progressive loss

Question 8

CAUSES of heart failure

Heart failure may result from ______ or ______ dysfunction. L

Answer 8

systolic or diastolic

Question 9

CAUSES of heart failure

Systolic dysfunction results from inadequate myocardial _______ function, usually as a consequence of ischemic heart disease or hypertension.

Answer 9

contractile

Question 10

CAUSES of heart failure
Diastolic dysfunction refers to an inability of the heart to adequately _____ and ____, which may be a consequence of massive ____________, Myocardial _____,
_____ deposition, or constrictive pericarditis.

Answer 10

relax and fill

left ventricular hypertrophy

fibrosis; amyloid

Question 11

Approximately one half of CHF cases are attributable to (systolic of diastolic?) dysfunction, with a greater frequency seen in ____, _______ patients, and (men or women?) .

Answer 11

Diastolic

older adults, diabetic

Women

Question 12

OTHER CAUSES of CHF

______ dysfunction (e.g., due to endocarditis)

may occur following rapid increases in _______ or_______, even if the heart is normal.

Answer 12

valve

blood volume

blood pressure

Question 13

PATHOGENESIS of CHF: FORWARD-BACKWARD FAILURE

When, the failing heart can no longer efficiently pump blood, there is an increase in _______ ventricular volumes, increased _______ pressures, and elevated _______ pressures.

Thus, inadequate ________— called (forward or backward?) failure—is almost always accompanied by
increased ____________—that is, (forward or backward?) failure.

Answer 13

end-diastolic

end-diastolic

venous

cardiac output ; Forward

congestion of the venous circulation; backward

Question 14

PATHOGENESIS
FORWARD-BACKWARD FAILURE

Although the root problem in CHF typically is deficient _______, virtually every other organ is _______ by some combination of ________ and _______

Answer 14

cardiac function

eventually affected

forward and backward failure.

Question 15

PATHOGENESIS of CHF

The cardiovascular system attempts to compensate for reduced myocardial contractility or increased hemodynamic burden through several homeostatic mechanisms:

___________ mechanism
Activation of _______ systems
Activation of the _________ system Release of ____________
Myocardial ________ changes

Answer 15

Frank-Starling

neurohumoral

renin-angiotensin-aldosterone

atrial natriuretic peptide

structural

Question 16

PATHOGENESIS
• The Frank-Starling mechanism.

Increased end-diastolic filling volumes ____ the heart and cause increased __________; these lengthened fibers ________________ , thereby increasing cardiac output.

Answer 16

dilate; cardiac myofiber stretching

contract more forcibly

Question 17

PATHOGENESIS
• The Frank-Starling mechanism.
If the dilated ventricle is able to maintain cardiac output by this means, the patient is said to be in ______________

However, ventricular dilation comes at the expense of ________ and magnifies the ____________ of an already-compromised myocardium.

With time, the failing muscle is no longer able to propel sufficient blood to meet the needs of the body, and the patient develops _____________

Answer 17

compensated heart failure.

increased wall tension

oxygen requirements

decompensated heart failure.

Question 18

PATHOGENESIS
• Activation of neurohumoral systems:

Release of the neurotransmitter _________ by the autonomic nervous system increases _____ and augments myocardial ______ and vascular ______.

Answer 18

norepinephrine

heart rate

contractility

resistance

Question 19

PATHOGENESIS

• Activation of the renin-angiotensin-aldosterone system spurs ____________(augmenting circulatory volume) and increases ________

Answer 19

water and salt retention

vascular tone.

Question 20

PATHOGENESIS
• Release of atrial natriuretic peptide acts to balance the _________ through _____ and ____________.

Answer 20

renin- angiotensin-aldosterone system

diuresis

vascular smooth muscle relaxation

Question 21

PATHOGENESIS

• Myocardial structural changes, including augmented ______. Cardiac myocytes adapt to increased workload by _________, a change that is accompanied by myocyte ______ (_______)

Answer 21

muscle mass

assembling new sarcomeres

enlargement

hypertrophy

Question 22

PATHOGENESIS
In pressure overload states (e.g., hypertension or valvular stenosis), new sarcomeres tend to be added in (parallel or series?) to the (short or long?) axis of the myocytes, adjacent to existing sarcomeres. The growing muscle fiber diameter thus results in ( concentric or eccentric ?) ________—the ventricular wall _______ increases (with or without ?) an increase in the _______

Answer 22

Parallel ; long

Concentric

hypertrophy

thickness

Without ; size of the chamber.

Question 23

PATHOGENESIS
In volume overload states (e.g., valvular regurgitation or shunts), the new sarcomeres are added in (parallel or series?) with existing sarcomeres, so that the muscle fiber _____ increases.

Consequently, the ventricle tends to ____, and the resulting wall thickness can be _____,______, or ______; thus,

Answer 23

Series; length

dilate

increased, normal, or decreased

Question 24

heart _____—rather than ________—is the best measure of hypertrophy in volume-overloaded hearts.

Answer 24

Weight

wall thickness

Question 25

The most common causes of left-sided cardiac failure are _________ disease m ________ hypertension, ______ or ______ valve disease, and primary diseases of the myocardium (e.g., amyloidosis).

Answer 25

ischemic heart systemic mitral or aortic

Question 26

The morphologic and clinical effects of left-sided CHF stem from diminished _____ and elevated ________ within the _______ circulation.

Answer 26

systemic perfusion back-pressures pulmonary

Question 27

Left-Sided Heart Failure: MORPHOLOGY The gross cardiac findings depend on the __________ process, for example, myocardial ______ or ____ deformities may be present.

Answer 27

underlying disease infarction ; valvular

Question 28

Left-Sided Heart Failure MORPHOLOGY - the left ventricle usually is _____ and can be ____, sometimes massively. (With the exception of failure due to _________ or _______ cardiomyopathies)

Answer 28

hypertrophied dilated mitral valve stenosis; restrictive

Question 29

Left-Sided Heart Failure MORPHOLOGY Left ventricular dilation can result in ______ insufficiency and ______ enlargement, which is associated with an increased incidence of _______

Answer 29

mitral left atrial atrial fibrillation.

Question 30

Left-Sided Heart Failure MORPHOLOGY The microscopic changes in heart failure are (specific or nonspecific?) , consisting primarily of myocyte _______ with _______ of variable severity. Superimposed on this background may be other lesions that contribute to the development of heart failure (e.g., recent or old myocardial infarction).

Answer 30

nonspecific hypertrophy; interstitial fibrosis

Question 31

Left-Sided Heart Failure: MORPHOLOGY-Lungs. In acute left-sided heart failure, rising pressure in the _______ is ultimately transmitted back to the _____ and _____ of the lungs, resulting in ______ and ____ as well as pleural effusion due to an increase in ________ in the venules of the visceral pleura.

Answer 31

pulmonary veins capillaries and arteries congestion and edema hydrostatic pressure

Question 32

Left-Sided Heart Failure: MORPHOLOGY-Lungs. The lungs are (light or heavy?) and boggy, and microscopically show perivascular and interstitial _____, alveolar ________, and accumulation of edema fluid in the alveolar spaces.

Answer 32

Heavy ; transudates septal edema

Question 33

Left-Sided Heart Failure: MORPHOLOGY- Lungs. In chronic heart failure, variable numbers of ______ extravasate from the __________ into the _______, where they are ______ by _____. The subsequent breakdown of red cells and haemoglobin leads to the appearance of ____________macrophages—so-called ______ cells—that reflect _______ of ________

Answer 33

red cells leaky capillaries into alveolar spaces phagocytosed; macrophages hemosiderin-laden alveolar ; heart failure previous episodes pulmonary edema.

Question 34

Left-Sided Heart Failure CLINICAL FEATURES _______ on exertion _______ is also common • As failure progresses, patients experience _______ when recumbent (______) ___________________________

Answer 34

Dyspnea; cough dyspnea; orthopnea Paroxysmal nocturnal dyspnea

Question 35

____________ is usually the earliest and most significant symptom of left-sided heart failure

Answer 35

Dyspnea on exertion

Question 36

Left-Sided Heart Failure CLINICAL FEATURES cough is also common as a consequence of _______________ into __________.

Answer 36

fluid transudation into air spaces

Question 37

Left-Sided Heart Failure CLINICAL FEATURES dyspnea when recumbent (orthopnea); this occurs because the ______ position increases ________ from the lower extremities and also elevates the ______. Orthopnea typically is relieved by _____ or ———-, so patients usually sleep in a _______ position.

Answer 37

supine; venous return; diaphragm sitting or standing; semi-seated

Question 38

Left-Sided Heart Failure CLINICAL FEATURES Paroxysmal nocturnal dyspnea is a particularly ______ form of breathlessness, awakening patients from ___ with ________ bordering on feelings of _________.

Answer 38

dramatic sleep extreme dyspnea suffocation

Question 39

Left-Sided Heart Failure: CLINICAL FEATURES Other manifestations of left ventricular failure include _______ heart (______) _____cardia a ______ sound (___), and ______ at the lung bases, caused by the opening of ___________

Answer 39

an enlarged; cardiomegaly tachy third heart; S3 fine ráles ; edematous pulmonary alveoli.

Question 40

Left-Sided Heart Failure CLINICAL FEATURES With progressive ventricular dilation, the _____ muscles are displaced ____ward, causing _______ and a ________ murmur.

Answer 40

papillary; out mitral regurgitation systolic

Question 41

Left-Sided Heart Failure CLINICAL FEATURES Subsequent chronic dilation of the left atrium can cause ________, manifested by an “__________” heartbeat. Such uncoordinated, chaotic atrial contractions reduce the ______ to ________, thus reducing the __________

Answer 41

atrial fibrillation irregularly irregular atrial contribution to ventricular filling ventricular stroke volume.

Question 42

Left-Sided Heart Failure CLINICAL FEATURES Atrial fibrillation also causes _____ of the blood (particularly in the _________), frequently leading to the formation of ____ that can shed ____ and cause _____ and manifestations of infarction in other organs.

Answer 42

stasis atrial appendage thrombi; emboli strokes

Question 43

Left-Sided Heart Failure: CLINICAL FEATURES Renal: Diminished cardiac output leads to decreased renal perfusion that in turn triggers the __________ axis, increasing intravascular volume and pressures Unfortunately, with a failing heart, these compensatory effects ______ the pulmonary edema.

Answer 43

renin-angiotensin-aldosterone exacerbate

Question 44

Left-Sided Heart Failure CLINICAL FEATURES Renal: With further progression of CHF, ______ may supervene, with impaired _____ of nitrogenous wastes and increasing metabolic derangement.

Answer 44

prerenal azotemia excretion

Question 45

Left-Sided Heart Failure CLINICAL FEATURES In severe CHF, diminished cerebral perfusion may manifest as ___________ marked by irritability, diminished cognition, and restlessness that can progress to _______ and _______

Answer 45

hypoxic encephalopathy stupor and coma.

Question 46

Left-Sided Heart Failure: Treatment for CHF typically focused—at least initially—on _______________ In lieu of such options, the clinical approach includes _______ or _______

Answer 46

correcting the underlying cause salt restriction or pharmacologic agents

Question 47

Left-Sided Heart Failure Treatment for CHF pharmacologic agents that variously -reduce volume overload (e.g., ______), -increase myocardial contractility (so-called “_________”), or -reduce afterload (______ blockade or inhibitors of __________ enzymes).

Answer 47

diuretics positive inotropes adrenergic angiotensin-converting

Question 48

Left-Sided Heart Failure: Treatment for CHF Angiotensin-converting enzyme inhibitors appear to benefit patients not only by opposing __________________, but also by limiting ________________ through uncertain mechanisms.

Answer 48

aldosterone mediated salt and water retention cardiomyocyte hypertrophy and remodeling

Question 49

Left-Sided Heart Failure Treatment for CHF Although cardiac ______ therapy (exogenous pacing of both the right and left ventricles) and cardiac _____ modulation (exogenous stimulation of cardiac muscle) have recently augmented the cardiologist’s armamentarium, CHF remains a serious cause of human morbidity and mortality.

Answer 49

resynchronization contractility

Question 50

Right-sided heart failure is usually the consequence of left-sided heart failure T/F With reason

Answer 50

T since any pressure increase in the pulmonary circulation inevitably produces an increased burden on the right side of the heart.

Question 51

the causes of right-sided heart failure include all of those that induce left-sided heart failure. T/F

Answer 51

T

Question 52

Right-Sided Heart Failure Right-Sided Heart Failure Isolated right-sided heart failure is (frequent or infrequent?) and typically occurs in patients with one of a variety of disorders affecting the _____; hence it is often referred to as __________

Answer 52

infrequent lungs cor pulmonale.

Question 53

Besides parenchymal lung diseases, cor pulmonale also may arise in secondary lung diseases T/F

Answer 53

T

Question 54

cor pulmonale also may arise secondary to disorders that affect the pulmonary vasculature T/F

Answer 54

T

Question 55

Right sided heart failure The common feature of these disorders is _________ which results in ______ and _____ of the right side of the heart.

Answer 55

pulmonary hypertension hypertrophy and dilation

Question 56

In cor pulmonale, myocardial hypertrophy and dilation generally are confined to ________________________, although bulging of the ________ to the ____ can reduce cardiac output by causing ____________

Answer 56

the right ventricle and atrium ventricular septum Left outflow tract obstruction.

Question 57

Right-Sided Heart Failure The major morphologic and clinical effects of pure right sided heart failure differ from those of left-sided heart failure in that ________________________________ typically is pronounced and __________ is minimal.

Answer 57

engorgement of the systemic and portal venous systems pulmonary congestion

Question 58

Right-Sided Heart Failure Systemic venous congestion due to right-sided heart failure can lead to transudates (effusions) in the ______ and ________ spaces,

Answer 58

pleural and pericardial

Question 59

Right-Sided Heart Failure usually cause pulmonary parenchymal edema. T/F

Answer 59

F usually does not cause pulmonary parenchymal edema.

Question 60

Right-Sided Heart Failure Pleural effusions are most pronounced when there is ____________________________ leading to elevated ___________ pressures.

Answer 60

combined right- sided and left-sided heart failure pulmonary and systemic venous

Question 61

Right-Sided Heart Failure A combination of __________ (with or without diminished albumin synthesis) and __________ can lead to peritoneal transudates (ascites). If uncomplicated, effusions associated with right- sided CHF are _____ with a low protein content and lack of ______ cells.

Answer 61

hepatic congestion portal hypertension trasudates; inflammatory

Question 62

Right-Sided Heart Failure Subcutaneous Tissues. Edema of___________ of the body, especially the _______ and _______, is a hallmark of right sided CHF. In chronically bedridden patients, the edema may be primarily _________.

Answer 62

dependent portions feet and lower legs presacral