Heart Failure Flashcards
Heart failure, often referred to as _________
congestive heart failure (CHF)
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
T
Roughly one half of patients of heart failure die within ______ of receiving a diagnosis of CHF
5 years
CHF occurs when the heart cannot generate ______ to meet the metabolic demands of the tissues, or
can only do so at ___________;
sufficient output
higher-than-normal filling pressures
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).
Minority
hyperthyroidism
anemia
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. •
Large
Acute
ONSET
In most cases, however, CHF develops ______ and ______ owing to the cumulative effects of _________ or —————- of myocardium.
gradually and insidiously
chronic work overload
progressive loss
CAUSES of heart failure
Heart failure may result from ______ or ______ dysfunction. L
systolic or diastolic
CAUSES of heart failure
Systolic dysfunction results from inadequate myocardial _______ function, usually as a consequence of ischemic heart disease or hypertension.
contractile
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.
relax and fill
left ventricular hypertrophy
fibrosis; amyloid
Approximately one half of CHF cases are attributable to (systolic of diastolic?) dysfunction, with a greater frequency seen in ____, _______ patients, and (men or women?) .
Diastolic
older adults, diabetic
Women
OTHER CAUSES of CHF
______ dysfunction (e.g., due to endocarditis)
may occur following rapid increases in _______ or_______, even if the heart is normal.
valve
blood volume
blood pressure
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.
end-diastolic
end-diastolic
venous
cardiac output ; Forward
congestion of the venous circulation; backward
PATHOGENESIS
FORWARD-BACKWARD FAILURE
Although the root problem in CHF typically is deficient _______, virtually every other organ is _______ by some combination of ________ and _______
cardiac function
eventually affected
forward and backward failure.
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
Frank-Starling
neurohumoral
renin-angiotensin-aldosterone
atrial natriuretic peptide
structural
PATHOGENESIS
• The Frank-Starling mechanism.
Increased end-diastolic filling volumes ____ the heart and cause increased __________; these lengthened fibers ________________ , thereby increasing cardiac output.
dilate; cardiac myofiber stretching
contract more forcibly
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 _____________
compensated heart failure.
increased wall tension
oxygen requirements
decompensated heart failure.
PATHOGENESIS
• Activation of neurohumoral systems:
Release of the neurotransmitter _________ by the autonomic nervous system increases _____ and augments myocardial ______ and vascular ______.
norepinephrine
heart rate
contractility
resistance
PATHOGENESIS
• Activation of the renin-angiotensin-aldosterone system spurs ____________(augmenting circulatory volume) and increases ________
water and salt retention
vascular tone.
PATHOGENESIS
• Release of atrial natriuretic peptide acts to balance the _________ through _____ and ____________.
renin- angiotensin-aldosterone system
diuresis
vascular smooth muscle relaxation
PATHOGENESIS
• Myocardial structural changes, including augmented ______. Cardiac myocytes adapt to increased workload by _________, a change that is accompanied by myocyte ______ (_______)
muscle mass
assembling new sarcomeres
enlargement
hypertrophy
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 _______
Parallel ; long
Concentric
hypertrophy
thickness
Without ; size of the chamber.
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,
Series; length
dilate
increased, normal, or decreased
heart _____—rather than ________—is the best measure of hypertrophy in volume-overloaded hearts.
Weight
wall thickness
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).
ischemic heart
systemic
mitral or aortic
The morphologic and clinical effects of left-sided CHF stem from diminished _____ and elevated ________ within the _______ circulation.
systemic perfusion
back-pressures
pulmonary
Left-Sided Heart Failure: MORPHOLOGY
The gross cardiac findings depend on the __________ process, for example, myocardial ______ or ____ deformities may be present.
underlying disease
infarction ; valvular
Left-Sided Heart Failure
MORPHOLOGY
- the left ventricle usually is _____ and can be ____, sometimes massively. (With the exception of failure due to _________ or _______ cardiomyopathies)
hypertrophied
dilated
mitral valve stenosis; restrictive
Left-Sided Heart Failure
MORPHOLOGY
Left ventricular dilation can result in ______ insufficiency and ______ enlargement, which is associated with an increased incidence of _______
mitral
left atrial
atrial fibrillation.
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).
nonspecific
hypertrophy; interstitial fibrosis
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.
pulmonary veins
capillaries and arteries
congestion and edema
hydrostatic pressure
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.
Heavy ; transudates
septal edema
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 ________
red cells
leaky capillaries into alveolar spaces
phagocytosed; macrophages
hemosiderin-laden alveolar ; heart failure
previous episodes
pulmonary edema.
Left-Sided Heart Failure
CLINICAL FEATURES
_______ on exertion
_______ is also common
• As failure progresses, patients experience
_______ when recumbent (______)
___________________________
Dyspnea; cough
dyspnea; orthopnea
Paroxysmal nocturnal dyspnea
____________ is usually the earliest and most significant symptom of left-sided heart failure
Dyspnea on exertion
Left-Sided Heart Failure
CLINICAL FEATURES
cough is also common as a consequence of _______________ into __________.
fluid transudation into air spaces
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.
supine; venous return; diaphragm
sitting or standing; semi-seated
Left-Sided Heart Failure
CLINICAL FEATURES
Paroxysmal nocturnal dyspnea is a particularly ______ form of breathlessness, awakening patients from ___ with ________ bordering on feelings of _________.
dramatic
sleep
extreme dyspnea
suffocation
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 ___________
an enlarged; cardiomegaly
tachy
third heart; S3
fine ráles ; edematous pulmonary alveoli.
Left-Sided Heart Failure
CLINICAL FEATURES
With progressive ventricular dilation, the _____ muscles are displaced ____ward, causing _______ and a ________ murmur.
papillary; out
mitral regurgitation
systolic
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 __________
atrial fibrillation
irregularly irregular
atrial contribution to ventricular filling
ventricular stroke volume.
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.
stasis
atrial appendage
thrombi; emboli
strokes
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.
renin-angiotensin-aldosterone
exacerbate
Left-Sided Heart Failure
CLINICAL FEATURES
Renal:
With further progression of CHF, ______ may supervene, with impaired _____ of nitrogenous wastes and increasing metabolic derangement.
prerenal azotemia
excretion
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 _______
hypoxic encephalopathy
stupor and coma.
Left-Sided Heart Failure: Treatment for CHF
typically focused—at least initially—on _______________
In lieu of such options, the clinical approach includes _______ or _______
correcting the underlying cause
salt restriction or
pharmacologic agents
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).
diuretics
positive inotropes
adrenergic
angiotensin-converting
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.
aldosterone mediated salt and water retention
cardiomyocyte hypertrophy and remodeling
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.
resynchronization
contractility
Right-sided heart failure is usually the consequence of left-sided heart failure
T/F
With reason
T
since any pressure increase in the pulmonary circulation inevitably produces an increased burden on the right side of the heart.
the causes of right-sided heart failure include all of those that induce left-sided heart failure.
T/F
T
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 __________
infrequent
lungs
cor pulmonale.
Besides parenchymal lung diseases, cor pulmonale also may arise in secondary lung diseases
T/F
T
cor pulmonale also may arise secondary to disorders that affect the pulmonary vasculature
T/F
T
Right sided heart failure
The common feature of these disorders is _________ which results in ______ and _____ of the right side of the heart.
pulmonary hypertension
hypertrophy and dilation
In cor pulmonale, myocardial hypertrophy and dilation generally are confined to ________________________, although bulging of the ________ to the ____ can reduce cardiac output by causing ____________
the right ventricle and atrium
ventricular septum
Left
outflow tract obstruction.
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.
engorgement of the systemic and portal venous systems
pulmonary congestion
Right-Sided Heart Failure
Systemic venous congestion due to right-sided heart failure can lead to transudates (effusions) in the ______ and ________ spaces,
pleural and pericardial
Right-Sided Heart Failure usually cause pulmonary parenchymal edema.
T/F
F
usually does not cause pulmonary parenchymal edema.
Right-Sided Heart Failure
Pleural effusions are most pronounced when there is ____________________________ leading to elevated ___________ pressures.
combined right- sided and left-sided heart failure
pulmonary and systemic venous
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.
hepatic congestion
portal hypertension
trasudates; inflammatory
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 _________.
dependent portions
feet and lower legs
presacral
