Heart Failure Flashcards
What categorized advanced heart failure?
Symptoms dont respond to treatment
What type of heart failure causes structural changes but no symptoms?
Pre-heart failure
What is the definition of heart failure?
Complex syndrome that results from any structural or functional impairment of ventricular filling or blood ejection
What is the first line of treatment for acute heart failure?
Diuretics - Furosemide, bumetanide and torsemide given as bolus or infusion
Systemic hypoperfusion from heart failure causes:
- Fatigue
- Dyspnea
- Weakness
- Edema
- Weight gain
How do diuretics help with acute heart failure?
Reduces intravascular volume, which decreases CVP and pulmonary capillary wedge pressures - this reduces pulmonary congestion
What structural abnormalities in the heart may cause heart failure?
- Pericardium
- Myocardium
- Endocardium
- Heart valves
- Great vessels
How do vasodilators help with acute heart failure?
Reduce filling pressures and afterload (evidence is lacking on their efficacy in AHF)
How is systolic heart failure classified?
HF with reduced EF ≤ 40%
What is HFrEF?
HF with reduced EF = Systolic HF
What is HFpEF?
HF with preserved EF = Diastolic HF
How is diastolic HF classified?
HF with EF ≥ 50%
What is borderline HFpEF?
HF symptoms with an EF 40-49%
____________ dysfunction is present in both HFrEF and HFpEF
Diastolic
What are the distinguishing features between diastolic and systolic HF?
- LV dilation patterns
- Remodeling
- Different responses to medical tx
Which vasodilators are used to treat acute heart failure?
- SNP is effective in rapidly decreasing afterload
- NTG is commonly used as an adjunct to diuretic therapy
Why are vasopressin receptor antagonists used for treatment in acute HF?
Used as an adjunct to reduce the arterial constriction, hyponatremia and volume overload associated with AHF
__________ __________ is the main marker for determining HF risk factors, tx, and outcomes
Ejection Fraction
What is the mainstay treatment for patients with acute reduced contractility or cardiogenic shock?
Positive inotropes
What are the two positive inotropes used for acute HF treatment?
Catecholamines and PDE inhibitors
What percent of heart failure patients have normal (>50%) EF?
50%
How do catecholamines work?
Stimulate B receptors on the myocardium to activate adenylyl cyclase to increase cAMP
How to PDE-inhibitors work?
Inhibit cAMP degradation, cAMP increases intracellular calcium and excitation-contraction coupling
Why is the prevalence of HFpEF increasing?
Relationship with HFpEF and these diseases:
- HTN
- DM
- A-fib
- Obesity
- Metabolic syndrome
- COPD
- Renal insufficiency
- Anemia
Inotropic agents graph:
What is an example of an exogenous BNP and how does it work?
- Nesiritide
- inhibits the RAAS and promotes vasodilation, decreasing LVEDP and improving dyspnea
- also induces diuresis and natriureses and relaxes cardiac muscle
Which type of heart failure (systolic or diastolic) is more likely to have modifiable risk factors?
Systolic (HFrEF) → Smoking/hyperlipidemia
Has Nesiritide shown to have an advantage over traditional vasodilators like NTG and SNP?
Nope!
Which type of heart failure poses a higher incidence of MI, coronary intervention, CABG, and PVD?
HFrEF
_____% HF cases are HFpEF
52%
___% HF cases are HFrEF
33%
____% of HF cases are borderline HFpEF
16% (EF 40-49%)
How does an intraaortic balloon pump work?
Functions by balloon inflation after aortic valve closure - followed by deflation during systole
Which HF is more common in women? Which HF is more common in men?
Women→ HFpEF (Diastolic)
Men→ HFrEF (Systolic)
How does an intraaortic balloon pump improve LV coronary perfusion?
By reducing LVEDP
What determines the degree of support with a balloon pump?
- The set volume
- Size of balloon
- Ratio of supported beats
What is the primary determinant of HFpEF?
LV diastolic function
What is the primary determinant of HFrEF?
Contractile dysfunction
What setting is full support with a balloon pump?
What setting is ideal for tachycardic patients?
- Full support = 1:1 (one inflation for every heartbeat)
- Tachycardic = 1:2 is ideal (one inflation for every two beats)
What determines the left ventricle ability to fill?
- Pulmonary venous blood flow
- LA function
- Mitral valve dynamics
- Pericardial restraint
- Elastic properties of the left ventricle
Why are ballon pumps limited for long term use?
They only provide modest improvements in cardiac output (0.5-1L/min) and render patients immobile
What does left ventricle diastolic dysfunction measurement depend on?
- HR
- Loading conditions
- Myocardial contractility
What is required in HFpEF to achieve normal end-diastolic volume?
Higher LV filling pressures
What are the surgical treatment options for acute heart failure?
- Intraaortic balloon pump
- Impella
- Peripheral VAD
- Central VAD/ECMO
- BiVAD
What does a steeper rise in end diastolic pressure volume curve indicate?
Delayed LV relaxation and increased myocardial stiffness
How does an impella work?
Consists of a miniature rotary blood pump inserted through the femoral artery, advanced through the aortic valve and sits in the LV
- the pump draws blood continuously from the LV through the distal port and ejects it into the ascending aorta through the proximal port
An impella is a VAD that is placed percutaneously to reduce __ ____ and ____ ____
LV strain and myocardial work
How long can an impella be used for?
Can be utilized for up to 14 days and serve as a transition to recovery or a bridge to cardiac procedure (CABG, PCI, VAD, transplant)
What does reduced LV compliance lead to?
- ↓ LV compliance
- LA hypertension
- LA systolic and diastolic dysfunction
- Pulmonary venous congestion
- Exercise intolerance
Which pressure volume loop is showing HFrEF?
Left: decreased contractility is indicated by a decrease in the slope of the end-systolic pressure-volume relation(HFrEF)
What is a peripheral VAD and what are the negatives to it?
- Support device that can provide ECMO
- consists of a small pump and controller, which is helpful for transport, but generates heat, causing more hemolysis and lower flows
Which pressure volume loop is showing HFpEF?
Right: decreased in LV compliance is indicated by an increase in the end-diastolic pressure-volume relation slope (HFpEF)
How is a central VAD different than a peripheral VAD?
Central = cannulas in the right atrium and aorta
- may be necessary for cardiorespiratory support or an alternative to peripheral VAD
What are common causes of LV diastolic dysfunction?
What are the positives and negatives to a central VAD with ECMO?
- Negative = more invasive, requires sternotomy or thoracotomy for placement
- Benefits = complete ventricular decompression, avoidance of limb impairment, avoidance of SVC syndrome
What causes the delayed relaxation associated with LV end diastolic dysfunction?
Active stiffening→ failure of the actin/myosin dissociation (occurs due to inadequate perfusion or dysfunctional intracellular Ca++ homeostasis)
In LV end diastolic dysfunction, LV relaxation is dependent on __________
afterload (typically elevated in hypertensive pts)
Why do patients on ECMO likely have reduced lung perfusion?
Blood bypasses the lungs before returning to the aorta
Why might inhaled anesthetics be limited on ECMO?
Functional shunting around the lungs
What type of anesthesia is preferred on ECMO?
TIVA
What is something to consider with IV drugs when a patient is on ecmo?
The membrane is lipophilic so it causes many agents like fentanyl to become sequestered within the unit
___________ exacerbates failure of LV relaxation
Tachycardia
How does a biventricular assist device (BiVAD) work?
Once a patient is stabilized on ECMO, decoupling support of the ventricles with two circuits facilitates weaning of the L or R sided support
Which type of HF is profound exercise intolerance seen with?
HFpEF (despite having only a modestly depressed LV systolic dysfunction)
Profound compression of the coronary arteries restricts _________ coronary blood flow
Diastolic → contributes to subendocardial ischemia and further reduction in exercise tolerance
HF patients have an increased risk of developing what?
- Renal failure
- Sepsis
- Pneumonia
- Cardiac arrest
*require longer periods of mechanical ventilation; have an increased 30-day mortality
When should surgery be postponed in HF patients?
Pts experiencing decompensation, a recent change in clinical status, or in de novo acute heart failure
What are the most common symptoms of heart failure?
- Fatigue
- Tachypnea
- Dyspnea
- Paroxysmal nocturnal dyspnea
- Orthopnea
- S3 gallop
- JVD
- Peripheral edema
- Exercise tolerance
- Reduced tissue perfusion
All patients with HF should have a comprehensive preop exam to determine if they are ____ or ____
Compensated or require treatment
Which symptoms are most common with HFpEF (diastolic)?
- Paroxysmal nocturnal dyspnea
- Pulmonary edema
- Dependent edema
How would you manage a patient in preop if they are on diuretics, beta blockers, or ace-inhibitors?
- Diuretics = held on the day of surgery
- BB = maintenance is essential
- ACE-inhibitors = may put pts at risk of intraop HoTN
What establishes the diagnosis of HFrEF when EF is reduced?
Presence of HF symptoms
Which type of HF is more difficult to diagnose?
HFpEF (especially when pt has few symptoms)
In preop, a TTE is indicated in patients with what?
Worsening dyspnea
What measurement offers further information about the severity of HFpEF?
Direct measurement of RV filling pressures
What labs would you want to get in preop for HF patients?
CBC, electrolytes, liver function, coagulation studies
- BNP is not routinely recommended
What diagnostic is used to define LV systolic and diastolic stiffness using pressure volume analysis ?
Cardiac catheterization
In HF patients, ICDs and pacemakers should be ____ prior to surgery
interrogated
Mean pulmonary capillary wedge pressure >_____mmHg at rest or ____mmHg during exercise provides strong evidence of HFpEF
@ rest: >15mmHg
w/ exercise: 25mmHg
Define cardiomyopathy:
Cardiac disease associated with mechanical and/or electrical dysfunction, often with ventricular hypertrophy or dilation
2 groups of cardiomyopathy:
- Primary = confined to the heart muscle
- Secondary = pathologic cardiac involvement associated with multiorgan disorder
What can CXR be used to detect?
- Pulmonary disease
- Cardiomegaly
- Pulmonary venous congestion
- Interstitial/ alveolar pulmonary edema
What is an early CXR finding of LV failure and pulmonary venous HTN?
Distention of pulmonary veins in upper lobes of lungs
What is the most common genetic CV disease?
Hypertrophic cardiomyopathy
What does CXR with hilar or perihilar haze with ill-defined margins indicate?
Perivascular edema
Is Hypertrophic cardiomyopathy primary or secondary?
It is a complex primary cardiomyopathy
What are Kerley lines on a CXR?
- Produce honeycomb pattern
- Reflect interlobular edema
- May be present in HF
What is hypertrophic cardiomyopathy?
Characterized by left ventricular hypertrophy in the absence of other diseases capable of inducing ventricular hypertrophy
What might a CXR with homogenous densities in the lung field in a butterfly pattern indicate?
Alveolar edema
T/F: CXR evidence of pulmonary edema may appear before clinical evidence of pulmonary edema.
False: CXR evidence of pulm edema may lag behind clinical evidence by up to 12 hours
How does HCM usually present?
Hypertrophy of the interventricular septum and the anterolateral free wall
What is the pathophysiology of HCM related to?
Myocardial hypertrophy, LVOT obstruction, mitral regurgitation, diastolic dysfunction, myocardial ischemia and dysrhythmias
What are these arrows showing?
Kerley lines in HF
How is HFpEF diagnosed?
Echocardiogram
What 3 factors are present for the diagnosis of HFpEF according to ACC/AHA?
- HF symptoms
- EF >50%
- Evidence of LV diastolic dysfunction
this approach is useful for pts with clear sx, may be too simplistic for subclinical HFpEF
What does the European Society of Cardiology guideline for HFpEF rely on for diagnosis?
More specific and incorporates echocardiographic indexes
Why are electrocardiograms useful in diagnosing HF?
EKG abnormalities are common in HF patietns and are typically related to underlying pathology (LVH, MI, Arrythmias, and conduction abnormalities)
______ alone has a low predictive value for HF diagnosis or risk prediciton
EKG
The hypertrophies myocardium has a prolonged ___ and decreased ____
Prolonged relaxation time and decreased compliance
What is the cause of sudden death in young adults with HCM?
Dysrhythmias
What are dysrhythmias caused by in HCM?
Disorganized cellular architecture, myocardial scarring, expanded interstitial matrix
If a patient is asymptomatic, what might be the only sign of HCM?
Unexplained LVH
For HCM, EKG abnormalities are seen in ___% of pts
75-90%
What might an EKG show in patients with HCM?
- High QRS voltage
- ST segment and T wave alterations
- Abnormal Q waves
- Left atrial enlargement
In HCM, an echo may show myocardial wall thickness of what?
> 15 mm
What labs are useful in diagnosing HF?
- Brain natriuretic peptide (BNP)→ related to LV end diastolic wall stress
- N-terminal pro-BNP
- Troponin→ elevated from myocardial damage
- CRP→ inflammatory component
- Growth differentiation factor-15 (GDF15)→ inflammatory component
Which type of HF are natriuretic peptide concentrations higher?
HFrEF from dilated and eccentric remodeling (LV end diastolic wall stress)
What type of hypertrophy is associated with HFpEF?
- Concentric hypertrophy→ normal LV chamber size and lower LV end diastolic wall stress
- Lower BNP and NT proBNP levels)
What does troponin serve to measure?
Elevated trop from myocardial damage and measures risk prediction
What does the New York Heart Association system focus primarily on for HF classification?
Degree of physical limitation
What does the ACC/AHA system focus primarily on for HF classification?
Presence and severity of HF
The stages of HF are ____________
Progressive
Which type of HF are medication treatments ineffective?
HFpEF
What is the treatment for chronic HFpEF?
- Mitigation of symptoms
- Treat associated conditions
- Exercise
- Weight loss
survival rate remains unchanged with treatment
What is the treatment for chronic HFrEF?
- Beta blockers
- ACE-inhibitors
improved survival rate with treatment
Which type of diuretics are recommended to reduce LV filling pressures and decrease pulmonary venous congestion to improve HF symptoms?
Loop diuretics
Which type of diuretics may be useful in poorly controlled HTN patient to prevent HFpEF?
Thiazide diuretics
What is the mainstay treatment for HFrEF (with no benefit in HFpEF unless used for HTN)?
Ace-inhibits and ARBs
What lifestyle changes can help treat chronic HF?
- Aerobic exercise reduces symptoms
- Weight loss (reduce HTN/DM)
- DASH diet (Salt-restricted Dietary Approaches to Stop Hypertension)
- BP control
- Blood glucose control
What is the goal of surgical treatment for chronic HF?
Prevent ventricular remodeling and preserve natural geometry of the heart
What procedure can reverse LV dysfunction after MI?
Coronary revascularization (CABG/ PCI)
successful early revascularization may prevent permanent EF reductions
What is a treatment for HF with a ventricular conduction delay (prolonged QRS)?
Cardiac resynchronization therapy (CRT)
AKA biventricular pacing
When is biventricular (CRT) pacing recommended?
- EF <35%
- QRS 120-150ms
Dual chamber pacemaker stimulates heart to contract more synchronously
What are the outcomes of cardiac resynchronization therapy (CRT)?
- Better exercise tolerance
- Improved ventricular function
- Less hospitalizations
- Decreased mortality
What are risks of CRT?
- Infection
- Misplacement
- Device failure
What surgical treatment for heart failure allows remote observation of intracardiac pressures to guide treatment?
Implantable hemodynamic monitoring
When are implantable cardioverting defibrillators (ICDs) used?
- Prevention of sudden death in pts with advanced heart failure
What is the cause of 50% of HF associated deaths?
Sudden cardiac dysrhythmias
Which patients could benefit from LV assist devices?
Patients in terminal stages of HF → pumps can take over function of the damaged ventricle and restore hemodynamic function/perfusion
What are uses for the LVAD?
- Temporary ventricular assistance while heart is recovering its function
- Pts awaiting cardiac transplant
- Pts on inotropes or balloon pump (IABP) with reversible medical conditions
- Pts with advanced HF who aren’t transplant candidates
What is treatment of acute heart failure aimed at?
Decreasing volume and stabilizing hemodynamics
Does acute heart failure apply to patients who are already diagnosed with HF?
Yes, Acute heart failure refers to exacerbated preexisting HF symptoms and initial onset HF
What is another term for initial onset of heart failure?
De novo acute heart failure
What are symptoms of acute decompensated HF?
- Fluid retention
- Weight gain
- Dyspnea
What are characteristics of De novo acute heart failure?
Sudden increase in filling pressures or acute myocardial dysfunction→ causes decreased perfusion and pulmonary edema
What is the leading cause of de novo HF? What does treatment focus on?
Cardiac ischemia→ Tx focuses on restoring cardiac perfusion, improving cardiac contractility, and stabilizing hemodynamics
What are less common non-ischemic causes of de novo heart failure?
- Viral
- Drug induced
- Peripartum cardiomyopathy
