Heart Failure Flashcards
A complex syndrome leading to impaired ventricular filling or blood ejection
Heart Failure
HF may be caused by structural abnormalities of the pericardium, myocardium, endocardium, heart valves, or great vessels.
HF leads to ______
Systemic hypoperfusion
What are common symptoms of heart failure?
- Fatigue
- Dyspnea
- Weakness
- Edema
- Weight gain
Define HF with reduced EF (HFrEF) aka _____.
HF w/ EF ≤ 40% aka Systolic HF
Define HF with preserved EF (HFpEF). aka_____
HF w/ EF ≥ 50% aka diastolic HF
What is borderline HFpEF?
Symptomatic HF w/ an EF between 40-49%
What type of dysfunction is present in both HFrEF and HFpEF?
Diastolic dysfunction
What distinguishes HFrEF from HFpEF?
- LV dilation patterns
- Remodeling
- Different responses to medical treatment
_____ measured on ____ is the main marker for determining HF risk factors, treatment, and outcomes?
Ejection fraction, measured on echocardiogram
What is normal EF?
> 50%
What proportion of HF patients have a normal ejection fraction?
Approximately 1/2 of HF patients have normal (>50%) ejection fraction
List some conditions associated with the increasing proportion of HFpEF.
- Hypertension
- Diabetes Mellitus
- Atrial fibrillation
- Obesity
- Metabolic syndrome
- Chronic obstructive pulmonary disease (COPD)
- Renal insufficiency
- Anemia
What type of risk factors are more likely in patients with HFrEF?
- Modifiable risk factors (smoking, hyperlipidemia)
Pt’s with HFrEF have higher incidence of:
- Higher incidence of myocardial ischemia & infarction
- Previous coronary intervention
- CABG
- Peripheral vascular disease (PVD)
What percentage of HF cases are classified as HFpEF?
52%
What percentage of HF cases are classified as HFrEF?
33%
What percentage of HF cases are classified as borderline HFpEF?
16%
Who is more likely to be affected by HFpEF?
Women
Who is more likely to be affected by HFrEF?
Men
What is the primary determinant of HFpEF?
Left ventricular diastolic dysfunction
What is the primary determinant of HFrEF?
Left ventricular systolic dysfunction
What factors determine the LV’s ability to fill?
- Pulmonary venous blood flow
- Left atrial (LA) function
- Mitral valve dynamics
- Pericardial restraint
- Elastic properties of the left ventricle
The majority of LVDD depends on: (3)
- HR
- Loading conditions
- Contractility
What does a steeper rise of the end-diastolic pressure-volume curve indicate?
Delayed LV relaxation and increased myocardial stiffness
Reduced LV compliance leads to: (4)
- LA HTN
- LA dysfunction
- Pulmonary venous congestion
- Exercise intolerance
In HFrEF, what is seen on the flow-volume loop?
Decreased contractility shown in the decreased slope of the ESPVR
In HFpEF, what is seen on the flow-volume loop?
Decreased LV compliance is seen by an increase in the EDPVR slope
What is the age demographic of a patient with LVDD?
Age > 60 years
In LVEDD - The delay in relaxation is caused by failure of ______________, that occurs due to inadequate perfusion or dysfunctional ________ homeostasis
Failure of Actin-myosin disassociation
Dysfunctional Intracellular Ca++
What determines LV relaxation?
Afterload (usually elevated in HTN patients)
What can exacerbate diastolic dysfunction?
Tachycardia
What occurs in HFpEF even though there is only a slight depression in LV systolic dysfunction?
Exercise intolerance
Prolonged _____ _____ restricts diastolic blood flow, contributing to sub-endocardial ischemia and further decreasing exercise tolerance
Prolonged coronary compression
What are common symptoms in HFpEF?
- Paroxysmal nocturnal dyspnea
- Pulmonary edema
- Dependent edema
What heart sound is more common in HFrEF?
S3 gallop
What establishes the diagnosis of HFrEF in addition to the definitions?
Reduced EF + Presence of HF symptoms
Which type of HF is harder to Dx due to little symptoms at rest?
HFpEF
What diagnostic tool defines elevated LV systolic and diastolic stiffness?
Cardiac catheterization using pressure-volume analysis
What indicates HFpEF is a predictor of mortality?
Mean pulmonary capillary wedge pressure > 15 mmHg at rest or 25 mmHg during exercise
What is an early sign of LV failure and pulmonary HTN seen on CXR?
Distention of the pulmonary veins in the upper lung lobes
_______ appears as a hilar haze with ill-defined margins
Perivascular edema
_____ produces a honeycomb pattern, reflecting interlobular edema
Kerley Lines
________ produces densities in the lung fields, in a butterfly pattern
Alveolar edema
Radiographic evidence of pulmonary edema can lag behind clinical evidence by up to ____ hrs
12 hours
What does the ACC/AHA diagnostic criteria for HFpEF include?
- HF symptoms
- EF > 50%
- Evidence of LVDD
In contrast to AHA diagnosis critera, the European society of cardiology includes _______ evidence as another dx measurement
Echocardiographic evidence
Which test (used alone) has a low predictive value for HF diagnosis/risk prediction?
Electrocardiogram
What role do brain natriuretic peptide (BNP) and N-terminal pro-BNP play in HF?
They are important biomarkers related to LV end-diastolic wall stress
LV end-diastolic wall stress is higher in which type of HF due to LV dilation and eccentric remodeling
HFrEF
HFpEF is associated with _______ hypertrophy, ______ LV chamber size, _______ LV end diastolic wall stress
Concentric hypertrophy
normal LV size
lower LV end diastolic wall stress
Are BNP and NT-ProBNP levels higher in HFpEF or HFrEF?
Higher in HFrEF
Myocardial damage increases which lab value?
Troponin (measures risk)
What 2 labs represent the inflammatory component of HF?
C-Reactive Protein & Growth differentiation factor-15
Which classification symptom focuses on degree of physical limiation?
NYHA
What classification system focuses on the presence and severity of HF?
ACC/AHA
Progression of HF is linked to a ______ ________ survival (the stages are progressive)
Reduced 5-year survival
Survival has increased in _____ with treatment, while survival is unchanged with _____ patients
Increased survival in HFrEF
No change in HFpEF
Which HF is medication ineffective for?
HFpEF
What is a common treatment for HFrEF?
- Beta-blockers
- ACE-inhibitors
This drug calss reduces LV filling pressures, decrease pulmonary venous congestion, and improve HF symptoms
Diuretics
What is the mainstay tx for HFrEF that only shows benefits in HFpEF patietns if they have HTN?
ACE-i and ARBs
This drug is useful in poorly controlled HTN pts to prevent HFpEF
Thiazide diuretics
What is recommended for the treatment of HFpEF?
- Mitigation of symptoms
- Treatment of associated conditions
- Exercise
- Weight loss
What diet is recommended to improve LV diastolic function, decrease arterial stiffness, and facilitate LV-arterial coupling in HFpEF patients?
DASH diet (Salt-restricted Dietary Approaches to Stop Hypertension)
The goal of surgical treatment for chronic HF is to ____________ and preserve the natural heart geometry
prevent ventricular remodeling
What is cardiac resynchronization therapy (CRT)?
A treatment for HF with a ventricular conduction delay (prolonged QRS) using biventricular pacing
-Stimulates the heart to contract more synchronously
-Goal: Improve CO
This surgical treatment is done via CABG or PCI and can reverse LV dysfunction after MI to prevent permanent EF reduction
Coronary Revascularization
What are the risks associated with CRT?
- Infection
- Misplacement
- Device failure
CRT is recommended for patients with EF < ______ and QRS duration ______ ms
EF < 35%
QRS 120-150 ms
CRT can produce these outcomes
- Better exercise tolerance
- Improved ventricular function
- Less hospitalization
- Decreased mortality
_______ allows for remote observation of intracardiac pressures to guide treatment
Implantable hemodynamic monitoring
What % of deaths are due to sudden cardiac dysrhythmias?
50%
What device is used for preventing sudden death in advanced heart failure?
Implantable cardioverting-defibrillators (ICDs)
Patients in the terminal stage of HF can benefit from mechanical circulatory support from a ______ that take over the function of the damaged ventricle and restore perfusion
LVAD
What is the purpose of LV assist devices?
- Temporary ventricular assistance while heart is recovering
- Patients awaiting cardiac transplant
- Patients on inotropes or balloon pump with reversible conditions
What characterizes acute heart failure?
Treatment?
Rapid onset, often presenting with life-threatening conditions
Treatment: Decrease volume & stabilize hemodynamics
Acute HF that refers to those with exacerbated preexisting HF
Acute decompensated HF (ADHF)
Initial onset HF is referred to
de novo Acute HF
_______ is characterized by sudden increase in filling pressures or acute myocardial dysfunction leading to decreased perfusion and pulmonary edema
Symptoms: (3)
de novo AHF
Sx: Fluid retention, Weight gain, Dyspnea
This is the leading cause of de novo HF; treatment focuses on restoring cardiac perfusion, improving contractility, and stabilizing HD
Cardiac ischemia
Non-ischemic causes of de-novo HF are (3)
- Viral
- Drug-induced
- Peripartum cardiomyopathy
Classic presentation of a ADHF patient presenting for urgent surgery have this HD profile
____ CO
____ Filling pressure
____ BP
Low CP
High Filling pressure
HTN or HoTN
What is the first line treatment for acute heart failure?
Diuretics (Furosemide, Bumetenide, Torsemide as bolus or continuous gtt)
If your AHF pt is hypotensive, what do you need to do before diuretic therapy?
Hemodynamic support
Drugs that reduce filling pressures and afterload
Vasodilators
Drug effective for rapidly decreasing afterload
Sodium nitroprusside
Drug commonly used as an adjunct to diuretic therapy
NTG
Drug is a potential adjunct to reduce the arterial constriction, hyponatremia and volume overload associated w/ AHF
Vasopressin receptor antagonists
What is the mainstay treatment for patients with acute reduced contractility or cardiogenic shock?
Positive inotropes (epinephrine, norepinephrine, dopamine, dobutamine)
Drug class inhibiting cAMP degredation increasing intracellular Ca++ and excitation/contraction coupling
PDE inhibitors (Milrinone)
What is a exogenous BNP drug, inhibiting RAAS to decrease LVEDP and improve dyspena
Nesiritide
What is the function of the intraaortic balloon pump?
Improves LV coronary perfusion by reducing LVEDP
The balloon pump inflates _____ aortic valve closure and _____ during systole
Inflates after aortic valve closure
Deflates during systole
IABP setting for full support?
Setting for tachycardic patients?
Full support: 1:1
Tachycardia: 1:2 (1 inflation/2 beats)
How much does the IABP improve COP?
0.5-1 L/min (modest)
What is the purpose of Impella?
Reduces LV strain and myocardial work
-Used up to 14 days as a bridge for cardiac procedure
This type of VAD is a support device providing ECMO
Downside: Generates heat, causes hemolysis and lower flows
Peripheral VAD
This VAD is an alternative to peripheral VAD but invasive and requires sternotomy/thoracotomy for placement
Benefits: Complete ventricular decompression, avoidance of limb impairments, avoidance of SVC syndrome
Central VAD/ECMO
Impella VAD draws blood from the ____ and ejects it into the ______
LV and ejects into the ascending aorta
What is ECMO used for?
Cardiorespiratory support or an alternative to peripheral VAD
Patients on ECMO have _____ lung perfusion as blood bypasses the lungs before returning to the aorta
Redcued lung perfusion
______ might be limited by functional shunting around the lungs
_____ is preferred in patients on ECMO
Inhaled anesthetics limited
TIVA is preferred
ECMO membrane is ______ causing drugs like ______ to be sequestered within the circuit
Lipophilic; Fentanyl
What does a biventricular assist device (BiVAD) do?
Once a patient on ECMO is stable, decoupling support of the ventricles facilitates weaning of the left- or right-sided support
-Percutaneous placement to support both sides
What are HF patients at increased risk for during surgery?
- Renal failure
- Sepsis
- Pneumonia
- Cardiac arrest
-Require longer periods of ventilation, increased 30-day mortality
Postpone surgery in patients who are experiencing: (3)
- decompensation
- Recent change in clinical status
- de novo acute HF
What is a Biventricular assist device (BiVAD)?
A device that supports both ventricles using separate circuits
It facilitates weaning of left- or right-sided support once a patient on central ECMO is stable.
What medications should generally be held on the day of surgery for heart failure patients?
What drug is essential to maintain?
Diuretics
Beta blockers
Beta-blocker maintenance is essential.
What test is indicated pre-op in a patient with worsening dyspena?
TTE (Transthroacic echocardiogram)
What labs are taken in pre-op for HF patients
What lab is not routinely recommended
CBC, electrolytes, liver function, coagulation studies
BNP is not recommended
What is cardiomyopathy?
Cardiac disease associated with mechanical and/or electrical dysfunction
-Often with ventricular hypertrophy or dilation
-Either confined to the heart or part of systemic disorders
Often includes ventricular hypertrophy or dilation.
What are the two groups of cardiomyopathies?
- Primary cardiomyopathies: confined to heart muscle
- Secondary cardiomyopathies: pathologic cardiac involvement associated with multiorgan disorder
What characterizes Hypertrophic Cardiomyopathy (HCM)?
Left ventricular hypertrophy (LVH) in absence of other diseases
-Presents with hypertrophy of the interventricular septum and anterolateral free wall
It is the most common genetic cardiovascular disease.
What is the most common genetic CV disease?
Hypertrophic Cardiomyopathy
Pathophyisology of HCM?
______ relaxtion time and _____ compliance
Patho: LVOT obstruction, mitral regurgitation, diastolic dysfunction, myocardial ischemia, dysrhythmia
-Prolonged relaxation time and decreased compliance
What is the cause of sudden death in young patients with HCM?
Dysrhythmias
Dysrhythmias are caused by: (3)
- Disorganized cell architecture
- Myocardial scarring
- expanded interstitial matrix
What are common EKG abnormalities seen in 75-90% of HCM?
- High QRS voltage
- ST-segment and T-wave alterations
- Abnormal Q waves
- Left atrial enlargement
In asymptomatic patients, unexplained ____ may be the only sign of HCM
Unexplained LVH
In HCM:
Echocardiogram may show myocardial wall thickness > ____ mm
EF is usually > ___%, reflecting hypercontractility
wall thickness > 15 mm
EF > 80%
What is the medical treatment for HCM?
- Beta-blockers (BBs)
- Calcium channel blockers (CCBs)
HF despite BB and CCB: - Diuretics for heart failure
- Disopyramide as add-on therapy
Negative inotrope improving LVPOT obstruction and HF symptoms
Disopyramide
This intervention allows direct measurement of increased LVEDP
cardiac catheterization
What rhythm often develops in HCM?
A-fib (associated with thromboembolism, HF, and sudden death)
What is the most effective antidysrhythmic in HCM patients
Amiodarone
What is the primary surgical treatment for patients at risk of sudden cardiac death due to dysrhythmias in HCM?
ICD placement
It is reserved for patients with large outflow tract gradients and severe symptoms.
HCM patients with large outflow tract gradients and severe symptoms are candidates for
surgery
What surgical options are there for HCM?
- Septal myomectomy
- Cath w/ injection to induce ischemia of the septal perforator arteries
- Echo guided percutaneous septal ablation
- prosthetic mitral valve
What characterizes Dilated Cardiomyopathy (DCM)?
- Atrial and ventricular dilation
- decreased wall thickness
- systolic dysfunction
It is the principal indication for cardiac transplant.
What is the initial symptoms of dilated cardiomyopathy?
HF and chest pain
Ventricular dilation can lead to
mitral/tricuspid regurgitation
What pathology is common in dilated CM patients?
Dysrhythmia, emboli, sudden death
What is Stress Cardiomyopathy also known as?
Coronary arteries are ______
Apical ballooning syndrome - LV hypokinesis with ischemic EKG changes
Coronary arteries are patent
-Temporary disruption of LV contractility with the rest of the heart having normal contractility
It features left ventricular hypokinesis with ischemic EKG changes.
Main cause and symptom of stress cardiomypoathy?
Chest pain, dyspnea
Main cause: Physical/emotional stress
Women>Men
What is seen on echo of dilated cardiomyopathy patient?
Dilation of all 4 chambers (predominantly the LV)
Global Hypokinesis
Treatment for dilated CM?
Similar to chronic HF
1. Anticoagulants
EKG often shows what for Dilated CM?
Common dysrthythmias?
EKG: ST and T wave abnormalities, LBBB
Dysrhythmia: PVC and Afib
What can decrease risk of sudden death for dilated CM?
prophylactic ICD placement
What is the principal indication for cardiac transplant?
Dilated cardiomyopathy
Peripartum cardiomyopathy arises during which time period?
3rd trimester - 5 months postpartum
What are the criteria for diagnosing Peripartum Cardiomyopathy?
- Development of peripartum heart failure
- Absence of another explainable cause
- Left ventricular systolic dysfunction with EF <45%
Cardiomyopathy caused by diseases leading to myocardial infiltration and diastolic dysfunction
Secondary Cardiomyopathy
Sx of secondary cardiomyopathy?
HF without cardiomegaly/systolic dysfunction
What does BP look like for secondary cardiomyopathy?
Low to normal BP + orthostatic hypotension
What is Cor Pulmonale?
Right ventricular enlargement that may progress to right heart failure
It is commonly caused by pulmonary hypertension.
What are the common causes of secondary cardiomyopathy?
- Amyloidosis (most common)
- Hemochromatosis
- Sarcoidosis
- Carcinoid tumors
Causes of cor Pulmonale?
Most common: COPD
Other: pulmonary hypertension, heart disease, or significant respiratory, connective tissue, or chronic thromboembolic disease
EKG changes of cor Pulmonale?
RA and RV hypertrophy
RA hypertrophy (Peaked P waves)
Right axis deviation and RBBB
What is the most important determinant of pulmonary hypertension and cor pulmonale in patients with chronic lung disease?
Alveolar hypoxia
It is a key factor in the development of cor pulmonale.
True or False: Hypertrophic cardiomyopathy is related to the development of left ventricular outflow tract (LVOT) obstruction.
True
Fill in the blank: The initial symptom of Dilated Cardiomyopathy is _______.
heart failure
What is the typical treatment for acute heart failure?
- Loop diuretics
- Vasodilators
- Positive inotropes
- Mechanical devices
commonly d/t obstructive ischemic heart disease
HFrEF
increasing in prevalence and primarily the result of poor lifestyle choices and comorbidities
HFpEF
the most common genetic cardiac disorder. Its pathophysiology is related to the development of LVOT obstruction and ventricular dysrhythmias that can cause sudden death
HCM
Factors that induce LVOT obstruction in HCM
hypovolemia, tachycardia,increased contractility, and decreased afterload
the most common form of cardiomyopathy and the second most common cause of heart failure
Dilated CM
The best treatment of alveolar hypoxia is
long-term oxygen therapy
