Heart Failure Flashcards
HF is defined as _
Complex syndrome that results from any structural or functional impairment of ventricular filling or ejection
HF can lead to _
Tissue hypoperfusion
What five signs and symptoms can be seen with tissue hypoperfusion from HF?
Fatigue
Dyspnea
Weakness
Edema
Weight gain
HFrEF is defined as
Systolic HF
EF < 40%
HFpEF is defined as
Diastolic HF
EF >50%
Borderline HFpEF is defined as
HF symptoms with EF 40-49%
Is diastolic dysfunction present in HFrEF and HFpEF?
Yes
What are two distinguishing features between HFrEF and HFpEF?
LV dilation patterns
Remodeling
What is the main diagnostic tool for determining HF risk factors, treatment, and outcomes?
Echocardiogram
What is primarily being measured on an Echocardiogram?
Ejection Fraction
What amount of HF patients have a normal EF?
> 50%
T/F
Patients with HFrEF are more likely to have higher incidences of myocardial ischemia, infarction, previous coronary intervention, CABG, and PVD.
True
What percentage of HF cases are HFpEF?
52%
What percentage of HF cases are HFrEF?
33%
Are men or women more likely to experience HFpEF?
Women
Are men or women more likely to experience HFrEF?
Men
What is the primary determinant of HFpEF?
LV diastolic dysfunction
What is the primary determinant of HFrEF?
Contractile dysfunction
The LV’s ability to fill is determined by what 5 factors?
Pulm venous flow
LA function
MV dynamics
Pericardial restraint
Active/Passive elasticity of the LV
T/F
Higher LV filling pressures are required to achieve normal end-diastolic volume in HFpEF patients
True
T/F
a steep rise of EDPV is indicative of delayed LV relaxation and increased myocardial stiffness
True
Increased myocardial stiffness leads to what 6 problems?
Reduced LV compliance
LA HTN
LA systolic dysfunction
LA diastolic dysfunction
Pulmonary venous congestion
Exercise intolerance
What are some causes of LVDD?
What are the 10 signs/symptoms of HF?
Fatigue
Tachypnea
Dyspnea
Paroxysmal nocturnal dyspnea
Orthopnea
S3 gallop
JVD
Peripheral edema
Exercise intolerance
Reduced tissue perfusion
What symptoms are more common with HFpEF?
Paroxysmal nocturnal dyspnea
Pulmonary edema
Dependent edema
What symptom is more common with HFrEF?
S3 gallop
Which HF is harder to diagnose initially?
HFrEF or HFpEF?
HFpEF
What test do we use to establish cardiac pressures?
Cardiac catheterization
Mean pulmonary capillary wedge pressure >__ at rest or __ during exercise are strong indicators of __ and __
> 15 mmHg
25 mmHg
HFpEF
Mortality
Chest x-ray can detect what 5 things related to HF?
Pulmonary disease
Cardiomegaly
Pulmonary venous congestion
Interstitial edema
Alveolar edema
What are Kerley lines?
Honeycomb pattern which reflects interlobular edema present in HF patients
What does alveolar edema look like on CXR?
Homogenous densities in a butterfly pattern
T/F
Radiographic evidence of pulmonary edema lags behind clinical presentation by up to 12 hours
True
What are the ACC/AHA diagnostic criteria for HFpEF?
HF symptoms
LV EF >50%
Evidence of LV diastolic dysfunction
T/F
The ACC/AHA diagnostic criteria is more specific when compared to the ESC criteria
False
What are the two important biomarkers for HF?
Brain natriuretic peptide (BNP)
N-terminal pro-BNP
Is BNP higher in HFrEF or HFpEF patients? Why?
HFrEF patients
Higher because of LV dilation and eccentric remodeling
Troponins are a measure of what in HF patients?
Risk prediction
C-reactive protein and growth differentiation factor-15 are indicative of what in HF?
Inflammation
What are the NYHA and ACC/AHA classifications?
What is the treatment for HFpEF?
Mitigation of symptoms
Exercise
Weight loss
What is the treatment for HFrEF?
Beta-blockers
ACE-I’s
What are the benefits of diuretics with HF?
Reduced LV pressures
Reduced Pulmonary venous congestion
Improve HF sx
CRT is recommended for what specific HF patients?
NYHA class III or IV w/ EF < 5% and a QRS duration 120-150 ms
What new system allows for monitoring of intracardiac pressures at home?
CardioMEMS Heart Failure System
What percentage of HF deaths are d/t sudden cardiac dysrhythmias?
50%
What are the 4 uses for LVAD therapy?
Temporary ventricular assistance
Awaiting cardiac transplant
Pts on inotropes or IABP
Advanced HF patients who aren’t transplant candidates
What is acute HF?
worsening preexisting HF (ADHF)
First time HF (de novo AHF)
De novo AHF is characterized by:
Sudden increase in intracardiac filling pressures or acute myocardial dysfunction
Leading to decreased peripheral perfusion and pulmonary edema
What is the leading cause of De Novo HF?
Cardiac ischemia via coronary occlusion
What are less common causes of De Novo HF?
Viral
Drug-induced (toxic)
Peripartum Cardiomyopathies
What is the 1st line treatment for acute HF?
Diuretics
(Furosemide, Bumetanide, Torsemide)
What vasodilator is used as an adjunct to diuretic therapy?
Nitroglycerin
What Vasodilator rapidly decreases afterload?
Sodium Nitroprusside
What Vasopressin receptor antagonist is being used for HF managment?
Tolvaptan
What four catecholamines are used in HF?
Epinephrine
Norepinephrine
Dopamine
Dobutamine
What PDE inhibitor is used with HF?
Milrinone
What calcium sensitization agent is used with HF?
Levosimendan
What is the exogenous BNP agent described in lecture?
Nesiritide
What is the INTERMACS?
MCS decision-making tool
What does an IABP help with?
LV coronary perfusion by reducing LVEDP
How do you confirm placement of a IABP?
TEE and X-ray
Describe the two modes of an IABP
1:1 (Full support)
1:2 (Used with tachycardia)
IABPs increase CO by how much?
0.5-1 L/min
Impella’s can stay in place for how many days?
14 days
Impella’s are used for what purpose?
Transition to recovery or bridge to cardiac procedure (CABG, PCI, VAD, Transplant)
What are two cons of using Peripheral VADs?
Hemolysis and lower flow via heat generation
When would you use a Central VAD/ECMO?
If adequate flows are not achievable peripherally
What are benefits of central cannulation?
Complete ventricular decompression
Avoidance of limp impairment
Avoidance of SVC syndrome
T/F
Inhaled anesthetics are limited with ECMO use?
True
Because of shunting of blood around the lungs
What type of anesthetic should be used with ECMO patients?
TIVA
T/F
ECMO patients tend to require higher doses of sedation
True
The ECMO membrane is lipophilic and tends to sequester a majority of administered medications (fentanyl, versed, propofol)
HF patients have an increased risk of developing what 4 conditions?
Renal failure
Sepsis
Pneumonia
Cardiac arrest
T/F
Surgery should be postponed in patients experiencing decompensation, recent clinical change, or de novo AHF
True
T/F
Beta-blockers should be continued prior to surgery
True
ACE-I’s can lead to what condition preoperatively if not held?
Hypotension
What 2 things should be considered in the pre-op exam for HF patients?
12-lead EKG
TTE (for pts with worsening dyspnea)
What consideration should be taken pre-op for patients with ICDs or PPMs?
Interrogation prior to surgery
What are cardiomyopathies?
mechanical and/or electrical dysfunction that usually exhibit ventricular hypertrophy or dilation
What are the two categories of cardiomyopathy?
Primary (confined to the heart muscle)
Secondary (pathophysiologic cardiac involvement in context of multiorgan disorder)
What is the most common genetic cardiovascular disease?
Hypertrophic cardiomyopathy (HCM)
HCM is characterized by what factors?
LVH in absence of other diseases
Hypertrophy of interventricular septum and anterolateral free wall
T/F
myocardial ischemia is present in HCM whether or not they have CAD
True
T/F
Dysrhythmias are a cause of sudden death in young adults with HCM
True
T/F
In asymptomatic patients LVD may be the only sign of HCM
True
What EKG abnormalities occur with HCM?
What percentage of patients have them?
High QRS voltage
ST-segment and T-wave alterations
Abnormal Q waves
LA enlargement
75-90% of patients
Echocardiogram will show what feature with HCM?
Myocardial wall thickness >15 mm
What is a normal EF for patients with HCM?
> 80%
Showing hypercontractility
(in terminal states, may be sev. depressed)
What are the first two choices of medication for HCM?
Beta-blockers
CCBs
What other medication can be added as adjunct for HCM if BBs and CCBs aren’t working?
Diuretics
If BBs, CCBs, and diuretics aren’t working what final medication can be added?
Disopyramide (Sodium channel blocker)
For HCM patients that develop Afib, what is the best antiarrhythmic agent?
Amiodarone
What other consideration must be considered in HCM patients that develop Afib?
Long-term anticoagulation
What surgical strategies are available for severe HCM?
Septal myomectomy
Cardiac cath w/injection to induce ischemia of septal perforator arteries
Echocardiogram-guided percutaneous septal ablation
If still asymptomatic, may insert prosthetic MV to counteract systolic anterior motion of mitral leaflet
What is the primary treatment for patients at risk of sudden cardiac death d/t dysrhythmia?
ICD placement
Dilated Cardiomyopathy (DCM) is characterized by _
LV or biventricular dilation, bi-atrial dilation, decreased ventricular wall thickness, and systolic dysfunction w/o abnormal loading conditions or CAD
What is the initial sign of DCM?
Heart failure
(Potentially CP)
Ventricular dilation with DCM can lead to _
Mitral regurgitation
Tricuspid regurgitation
What conditions are common with DCM?
Dysrhythmias
Conduction abnormalities
Emboli
Sudden death
Echocardiogram with DCM reveals what?
Dilation of all 4 chambers (esp LV)
Global hypokinesis
How do you treat DCM?
Similar to Chronic HF
ACE-I
ARB
Anticoagulation
What EKG changes are noted with DCM?
ST-segment and T-wave abnormalities
LBBB
PVCs
Afib
Prophylactic ICD placement in DCM patients reduces risk of sudden death by _?
50%
What condition is the principal indication for cardiac transplant?
DCM
What is Stress Cardiomyopathy?
Apical Ballooning Syndrome
A temporary primary cardiomyopathy
characterized by LV apical hypokinesis w/ischemic EKG changes, however the coronary arteries remain patent
What signs are present with Stress Cardiomyopathy?
Chest pain
Dyspnea
What is the main causative factor of Stress Cardiomyopathy?
Trick question.
Stress (obviously)
Does Stress Cardiomyopathy occur more in men or women?
Women
What is Peripartum Cardiomyopathy?
Rare primary cardiomyopathy
Unknown cause
Starts in 3rd trimester-5 months post-partum
Diagnosis of Peripartum Cardiomyopathy is dependent on what 3 things?
Development of HF in the period surrounding delivery
Absence of another explainable cause
LV systolic dysfunction with a LVEF <45%
What is Secondary Cardiomyopathy?
d/t systemic diseases that produce myocardial infiltration and severe diastolic dysfunction
What is the most common cause of Secondary Cardiomyopathy?
What are other causes?
Common:
Amyloidosis
Other:
Hemochromatosis
Sarcoidosis
Carcinoid tumors
Diagnosis of Secondary Cardiomyopathy should be considered in _
Patient who have HF but no evidence of cardiomegaly or systolic dysfunction
Secondary Cardiomyopathy patients tend to have _
Low to normal BP
Can develop orthostatic hypotension
What is Cor Pulmonale?
RV enlargement (hypertrophy and/or dilatation) that may progress to right-sided heart failure
What can cause Cor Pulmonale?
pulmonary hypertension
myocardial disease
congenital heart disease
or any significant respiratory, connective tissue, or chronic thromboembolic disease
What is the most common cause of COPD and is more prevalent in males >50 y/o?
Cor Pulmonale
What EKG changes occur with Cor Pulmonale?
RA & RV hypertrophy noted by peaked P-waves in leads II, III, and aVF
Right axis deviation and RBBB
What is the most important determinant of Pulm HTN and Cor Pulmonale?
Alveolar hypoxia
