Heart Failure Flashcards
What is the definition for abnormal heart function?
Any cardiac structural or functional disorder leading to inadequate cardiac output &/or elevated ventricular filling pressures
Impairs the ability of the ventricle to fill (diastolic) or eject (systolic) blood
What is heart failure?
A complex clinical syndrome with signs and symptoms of:
- Reduced cardiac output (inability to meet metabolic demands of body or abnormally high cardiac pressures)
- Pulmonary or systemic congestion at rest or with stress
What are the mortality rates for heart failure?
10% will die after 30 days
20% will die after 1 year
50% will die after 5 years
Number of HF hospitalizations is a strong predictor of mortality
Is heart failure a stable condition?
No, it is a progressive condition
- Increasing frequency of decompensations punctuate gradual decline in function. Following each acute event, heart function does not return to previous level
What is the pathophysiology of heart failure?
Cardiac output (stroke volume x HR) is decreased in heart failure
Stroke volume is dependent on preload (muscle fiber stretching while filling), contracility (inherent ability of the myocardium to contract normally), afterload (muscle force required to overcome higher pressure in the aorta when pumping blood out)
What is the Frank-Starling Law?
It is the ability of the heart to alter contraction force based on changes in preload
Increased ventricle volume = Increased contactility = Increased stroke volume
Note: If the heart is overstretched (increased preload), it looses its ability to return equal force
What neurohormones do heart failure drugs target?
Norepinephrine
Angiotensin II
Aldosterone
Vasopressin
Pro-inflammatory cytokines
What are the four compensatory responses to reduced cardiac output?
- Increased pre-load (via Na+ and water retention):
a. Improves stroke volume - Vasoconstriction (maintains BP if CO is low)
- Tachycardia (helps maintain CO if stroke volume is low)
- Ventricular hypertrophy and remodelling (helps maintain CO)
What are the consequences of long-lasting increased pre-load?
Pulmonary and systemic congestion (blood is backing up)
What are the consequences of long-lasting vasoconstriction in response to reduced cardiac function?
Shunt blood from nonessential organs to brain and heart
Increased mycocardial oxygen demand
Increased afterload decreases stroke volume (activating further compensatory responses)
What are the consequences of ventricular hypertension and remodelling?
Increased risk of myocardial cell death, myocardial infarction, arrythmia, fibrosis
DIastolic and/or systolic dysfunction
What are some typical symptoms associated with heart failure?
- Breathlessness
- Orthopnea (dificulty breathing while lying down)
- Paroxysmal nocturnal dyspnea (waking up with SOB)
- Swelling of body
If a patient shows symptoms of heart failure, what else do they need to be diagnosed with heart failure?
Assess natriuretic peptides (gold standard biomarkers in HF)
Heart failure is present if patient has one of the following lab values:
- NT pro-BNP (greater than 125pg/mL)
- BNP (greater than 50pg/mL) (preferred in the SHA)
What are natriuretic peptides?
BNP
NT-proBNP (pro homone BNP)
They are synthesized and released by the ventricles in response to pressure or volume overload
BNPs promote natriuresis & diuresis, and attenute RAAS & SNS activation (opposes the action of heart failure compensatory actions, which is good)
What is neprilysin?
It is an enzyme that breaks down BNP
Neprilysin inhibitors like sacubitril are beneficial in reversing the negative heart failure compensatory actions
Can natriuretic peptide values alone be used to diagnose heart failure?
No, should be considered in relation to signs, symptoms, and information from diagnostic imaging
If BNP or NT-proBNP are elevated, what are the next steps?
Send for electrocardiogram & start or intensify neurohormonal blocking agents (ACEi, ARB, beta-blockers, MRAs)
What information can be gleaned from an ECG?
Size and shape of heart
Pumping capacity
Location and extent of damaged tissue (muscle, walls, valves)
Pressure estimates
Quality of ECG readings can vary by 10%
What are the three classifications of heart failure?
Chronic HF (persistent & progressive)
Acute/decompensated HF (gradual or rapid change in HF signs & symptoms, resulting in need for urgent therapy)
Advanced HF (frequent decompensations, mechanical devices, transplantation, palliative therapies)
Why is Left Ventricular Ejection Fraction significant?
Blood leaving left ventricle/blood entering left ventricle
Left ventricular ejection fraction can change depending on preload, contractility, and afterload. Therefore it is a good indicator for heart failure
What is HF-pEF?
Heart failure with preserved ejection fraction
In these HF patients, ejection fraction is above 50%. These patients may have problems with heart stiffness and ventricular relaxation (left ventricular hypertrophy)
Affects:
- Elderly
- Female
- DM, Atrial fibrillation, HTN
What is HF-mEF?
Heart failure with mid-range ejection fraction
In these HF patients, ejection fraction is between 41-49%
What is HF-rEF?
Heart failure with reduced ejection fraction
In these HF patients, ejection fraction is below 40%. These patients may experience systolic dysfunction, problems with the heart pump/contractility
Review slide 40 for the heart failure treatment algorithm?