Heart failure Flashcards
What can cause acute heart failure?
- CAD, ACS
- Valvular disease - endocarditis and aortic dissection
- Myopathies - myocarditis and postpartum CMP
- HTN and arrhythmia
- Acutely decompensated CHF due to other causes, COPD, drugs toxicity, volume overload, renal failure, and infection.
- Non-cardiac origin - sepsis, anemia, tamponade PE, shunt, thyrotoxicosis
What can cause chronic heart failure?
- IHD/CAD
- DCM and other CMPs
- HTN
- Valvular disorders
- Congenital
- Alcohol/drugs
- RHF due to COPD, PE, or pulm. HTN
- Arrhythmia
- Amyloidosis
NYHA classification
I: Symptoms at level of exertion that would limit normal individuals
II: Symptoms at ordinary exertion
III: Symptoms at less-than ordinary exertion
IV: Symptoms at rest
AHA/ACC stages of heart failure
Stage A: High risk for HF, but without structural heart disease or symptoms (e.g HTN, DM, metabolic syndrome, obesity, cardiotoxic drugs)
Stage B: Structural disease without symptoms of HF (previous MI, LV remodels such as LVH, ↓ EF, or asymptomatic.valve disease)
Stage C: Structural disease with prior or current symptoms of HF
Stage D: Refractory HF requiring special intervention
Forrest classification
Depend on the cardiac index and pulmonary capillary wedge pressure.
Stage I -> Warm + dry (Well compensated, hemodynamic stable, optimise oral chronic therapy ACE + BB)
Stage II -> Warm + wet ( symptoms of volume overload, Diuretics + vasodilators)
Stage III -> Cold + dry (Symptoms of ↓ CO, but dont have volume overload. Vasodilators or ionotropes, in case of ↓ BP use inotropes first)
Stage IV -> Cold + wet (Diuretics, vasodilation, ionotropes)
Cardiac index - cold is when perfusion is less than 2,2L/min/m2 and warm is above. Is about the afterload. Symptoms: Cold clammy extremities or altered mental status or and liver enzymes or ↑ serum createnine.
Pulomary - fluid state. wet is above 18 mmHg and dry is below. Is about preload. Symptoms: shortness of breath, pulmonary congestion, peripheral edema, JVD
Dilative cardiomyopathy causes
Idiopathic Inherited (25%) (E.g duchenne) Myocarditis (e.g coxsakie B or Chagas) Metabolic - hemocrhomatosis, thyrotoxicosis Peristent tachycardia Nutritional - vitamins deficiency (B1) - wet beriberi Valve problems Alcohol abuse Drugs - chemotherapy, cocaine Peripartum DCM
Symptoms of Dilative cardiomyopathy
Fatigue, dyspnea, orthopnea and PND
Also other features of HF and/or pulmonary edema
Dilative cardiomyopathy diagnostics
Physical examination:
- Narrow PP (due to a drop in SV), ↓ BP, ↑ JVP
- Displaced and diffuse apex, S3 gallop, murmur (MR/TR)
- Possible signs of right sided HF - peripheral edema, ascites, and hepatomegaly.
ECG: LVH, arrhythmias, possible previous MI
Echo: Confirms diagnosis- assessing measurements of cardiac walls, EDV, ESV, EF. Can show MR, TR and LV mural thrombus.
Dilative cardiomyopathy treatment
Relieve symptoms and improve diagnosis Medical: - Inotropes - Digitalis - BB, ACEi - Diuretics - Vasodilators - Antiarrhythmic agents - Anticoagulants
Surgery: Valve replacement, aneurysm resection, remodelling, cardiac transplant
Device: Pacemaker, ICS, IABP, LVAD, transplantation
Causes of hypertrophic cardiomyopathy
Gene defect of the myocardial structural proteins (myosin, troponin) this causes:
- Myofibril disarray
- Myocardial fibrosis
- Myocardial hypertrophy
- LV outflow tract obstruction
- Systolic/diastolic dysfunction.
Mainly a AD inherited condition, but can be sporadic due to de novo mutations as well.
hypertrophic cardiomyopathy symptoms
Often asymptomatic
If symptoms: Fatigue, dyspnea, angina, syncope, arrhythmias
hypertrophic cardiomyopathy diagnostics
S4, mid-systolic ejection murmur and/or pan systolic regurgitation murmur
ECG: LVH, pre-excitation and WPW
Echo: confirms diagnosis.
hypertrophic cardiomyopathy treatment
Medical: BB, CCB, Disopyramide, anti arrhythmic
Non-pharma: Surgical septal myotomy-myectomy
Alcohol septal ablation (To reduce LV outflow tract obstruction)
Dual-chamber pacing
ICD
Symptoms of heart failure
Right HF
- Peripheral edema, and ascites
- Distention/pulsation of neck veins
- Portal HTN w/heptomegaly and GI congestion causing nausea and anorexia
- Facial engorement, epistaxis, nocturina and depression
Left HF
- Pulmonary congestion and edema
- Dyspnea (exertion), orthopnea, and PND
- ↓ Sp=2
- Cough and wheezing
- Blood in sputum
- Fatigue, muscle wasting and weight loss, and poor exercise tolerance
- Cold extremities
Killip classification of AHF in AMI
Class I : no congestive HF
Class II: Rales/crackles, S3, pulmonary venous HT
Class III: Pulmonary edema
Class IV: Cardiogenic shock
Treatment steps of AHF
- Restoration of oxygenation and tissue perfusion
- Monitore and insure IV access
- Position - sit/half sit (45 degree)
- Symptom guided treatment
- Etiology evaluation and casual treatment
- Evaluation and control of fluid
Diagnostics AHF and CHF
ECG - strain/hypertrophy, ischemia, arrhythmia, conduction disturbances
CXR - Pulm.congestion, fluids, cardiomegaly
Blood test - BNP, cardiac enzymes, electrolytes, renal and liver function, glucose, thyroid hormones
ABG
Echo
Exersice test
NYHA classification, Forrester’s hemodynamic stages
Drug treatment of AHF
Stable decompensated CHF
- Vasodilators, loop diuretics, positive inotropes (in case of hypo perfusion)
Cardiogenic shock
- Fluid
- Inotropes/vasopressors
- Intubation, mechanical ventilation
- IABP
Pulmonary edema
- Morphine
- Loop diuretics
- Vasodilators if HTN
- Inotropes if hypo perfusion
Isolated right HF
- Fluids and inotropes
Non-pharmacological treatment of heart failure
Acute bridge therapy
- IABP
- Impella recover - pumping assistance for LV
- ECMO
- Tandem heart
- LVAD, RVAD, BiVAD
Temporary pacemaker therapy
- Antibrady-/tachycardia
- Resynchonization - biventricular pacing
Mechanical ventilation
ICD
Cardiac transplantation - Indications NYHA class III and IV
Lifestyle changes
- Physical activity, diet and weight reduction
- Salt and fluid restriction
- Alcohol restriction
- Smoking cessation
Drug treatment of CHF
Lower mortality with: ACE BB Vasodilators Spironolactone
Digoxin Vasodilators (nitrates) Positive inotropes Anti-arrhythmic Anticoagulants and antiplatelet drugs
