Heart Failure Caused by Systolic Dysfunction Lecture Powerpoint

Question 1

Heart failure caused by systolic dysfunction is also known as…

Answer 1

….heart failure with reduced ejection fraction (HFREF)

Question 2

Heart failure occurs because of problems in these 2 components of heart function

Answer 2

• Decrease in preload (venous return and end diastolic volume in ventricles stretching myocytes
• Decrease in myocardial contractility

Question 3

Systolic dysfunction has a _____ and ___ventricle while diastolic has a ____ and ___ ventricle

Answer 3

dilated and floppy, stiff and inflexible

Question 4

Ejection fraction to diagnose left heart failure must be less than…

Answer 4

Less than 40%

Question 5

Heart failure

Answer 5

Clinical syndrome that results when abnormalities in structure or function of myocardium impair the ability of ventricle to fill with (diastolic) or eject blood (systolic)

Question 6

Most common cause of systolic heart failure

Answer 6

Ischemic cardiomyopathy following an acute MI

Question 7

Most common cause of diastolic heart failure

Answer 7

Longstanding uncontrolled hypertension leading to LV hypertrophy

Question 8

Diastolic heart failure has preserved _____. But the issue is ____ volume containing ability caused by abnormal heart adaptations (despite not appearing to) that have dropped cardiac output

Answer 8

Ejection fraction, decreased

Question 9

Heart failure diagnoses are becoming more prevalent because…

Answer 9

…patients are living longer post MI and other forms of heart disease

Question 10

Myocyte remodeling in systolic heart failure mech of action

Answer 10

• Portion of heart that lacks perfusion (ischemia) becomes thinned and dilated (floppy)
• decreased CO
• RAAS system compensates decreased CO by vasoconstricting, increasing contractility, and retaining sodium (and therefore water volume)
• This actually worsens the cardiac functioning by increasing load placed on heart which is already weaker to begin with
• Portions of heart muscle surrounding thicken to compensate but it ultimately cannot
• decreased CO
• system recycles

Question 11

Can we have both systolic and diastolic dysfunction and how do you tell?

Answer 11

yes and thru imaging studies such as echocardiogram of the heart muscle

Question 12

Pathways targeted in systolic dysfunction for drug therapy

Answer 12

• B receptors

- RAAS

Question 13

Natriuretic peptides normal functions and levels in systolic dysfunction heart failure (generally)

Answer 13

Counterbalance RAAS by causing vasodilation (BNP) and increase Na+ excretion (and therefore H2O volume as well), levels will be elevated in heart failure

Question 14

Cardiorenal syndrome

Answer 14

Comorbidity due to the low cardiac output associated with systolic dysfunction heart failure causing renal hypoperfusion resulting in renal failure (patients with heart failure often go into renal failure)

Question 15

2 types of cardiac remodeling

Answer 15

1) physiologic - compensatory change in dimension and function of heart in response to stimuli such as pregnancy and exercise (not necessarily chronic or a bad thing)
2) pathologic - permanent changes to the heart’s shape and function in response to stimuli such as seen in MI, cardiomyopathy, HTN, and valvular disease

Question 16

Risk factors for systolic dysfunction (4)

Answer 16

• CAD***
• previous MI
• diabetes
• HTN

Question 17

2 types of cardiomyopathy

Answer 17

Restricted - diastolic function impacted

Dilated - systolic function impacted

Question 18

1 risk factor for diastolic dysfunction

Answer 18

-HTN

Question 19

Symptoms of systolic dysfunction heart failure (5)

Answer 19

• Dyspnea
• Fatigue
• Peripheral edema
• weight gain early stage weight loss in advanced stage
• JVDs

Question 20

Hepatojugular reflex

Answer 20

Distension of neck veins precipitated by placing firm pressure over the liver, distension greater than 3cm is diagnostic for systolic heart failure

Question 21

Most common type of ventricular failure is found on what side?

Answer 21

Left sided

Question 22

Why do we see shortness of breath in left ventricular failure?

Answer 22

Back up of fluid into the lungs from the left ventricle and atrium

Question 23

Leading disease state cause of right ventricular failure

Answer 23

Left ventricular failure (fluid backs up from left ventricles to lungs to right ventricle causing increased pressure on it)

Question 24

Common cause of 2ndary** right sided only ventricular failure

Answer 24

pulmonary fibrosis from things such as COPD (cor pulmonale)

Question 25

Modified framingham diagnostic criteria for congestive heart failure

Answer 25

Presence of 2 major criteria or 1 major and 2 minor criteria

Question 26

3 ways to classify heart failure

Answer 26

- Functional classification - disease state and progression - echocardiogram (systolic vs diastolic)

Question 27

Functional classification of heart failure and the 4 classes

Answer 27

Relates to syptoms of everyday activities and QOL Class 1 - no limitation Class 2 - slight limitation of physical activity Class 3 - comfortable only at rest Class 4 - symptomatic even at rest

Question 28

Disease state and progression classification of heart failure and the 4 classes

Answer 28

Based on pre-disease to advanced symptoms evidenced by EKGs and echos Stage A - patient high risk of developing but no structural disease or symptoms currently Stage B - patient with structural heart disease but no signs or symptoms Stage C - Patient with structural heart disease and current signs of HF Stage D - Patient with marked symptoms at rest requiring special intervention

Question 29

Echocardiogram (Systolic vs diastolic) classification of heart failure

Answer 29

Determined via echocardiogram Systolic - LV ejection fraction <40%, eccentric, thin ventricle Diastolic - LV ejection fraction >40%, thick ventricle wall

Question 30

Heart failure diagnosis (2)

Answer 30

Clinical H&P based from Framingham criteria, confirmed via echocardiography primarily and EKG secondarily

Question 31

Labs for heart failure (7)

Answer 31

1) CBC - possible anemia or infection 2) CHEM 7 - possible abnormal electrolytes 3) Liver function test - hepatic congestion 4) lipid profile/fasting glucose - check for risk factors 5) TSH - hypo or hyperthyroidism 6) Cardiac biomarkers - may be elevated in suspected MI 7) ***BNP - may be elevated

Question 32

BNP testing can show false positive elevation indicative of heart failure in these 3 other conditions

Answer 32

- pulmonary disease - PE - renal impairment

Question 33

Medications that exacerbate heart failure (2)

Answer 33

- NSAIDS | - CCBs

Question 34

S3 cause and what type of heart failure is it heard with?

Answer 34

- Increased sloshing reverberating against dilated left ventricular wall, not always pathology - More common in a systolic heart failure

Question 35

S4 cause and what type of heart failure is it heard with?

Answer 35

- Blood being forced into a stiff non-compliant ventricle, almost always pathology - more common in a diastolic heart failure

Question 36

Chest Xray findings for LV heart failure and what view is best for seeing it?

Answer 36

- Cardiac silhoutte greater than .5 indicates cardiomegaly as well as pulmonary signs for effusions and edema - only on a PA view can see it

Question 37

Kerley B lines

Answer 37

Occur on a chest xray indicating fluid buildup in lower lobes of the lungs often in LV heart failure

Question 38

Best imaging study for heart failure and best alternative

Answer 38

Transthoracic echocardiogram, transesophageal echocardiogram is best alt (but requires sedation :( )

Question 39

If a patient has an ejection fraction between 40-50%, what do you do?

Answer 39

Treat them considering the clinical picture and use judgement (are they symptomatic? Are they high risk for progression?)

Question 40

Systolic heart failure treatment targets

Answer 40

- preload - afterload - improved inotropy

Question 41

4 choice therapies for systolic heart failure

Answer 41

- non pharm lifestyle mods - multiple drugs - surgical - electrophysiological

Question 42

Lifestyle modification therapies for heart failure (3)

Answer 42

- quit smoking - decrease alcohol - salt and fluid restriction

Question 43

Systolic dysfunction has what contraindicated drug class?

Answer 43

non dihydropyridine ca2+ channel blockers (potential to act on heart)

Question 44

Pharmacological treatment for chronic systolic dysfunction heart failure (3)

Answer 44

- ACE and ARB #1 - B blocker - Spironolactone supplementary

Question 45

Stage A-D pharm treatment protocol for chronic systolic dysfunction heart failure

Answer 45

- ACE - ACE and B blocker - ACE and B blocker, diuretics - mechanical assist devices, transplant?

Question 46

Systolic dysfunction indicates ___ in all patients and ___ in all patients without contraindications

Answer 46

ACE, B blocker

Question 47

Digoxin helps with symptoms of heart failure but is not typical to use because it does not...

Answer 47

....affect mortality rates

Question 48

Drug class often indicated for HF patients with atrial fibrillation or recent MI

Answer 48

Anticoagulants

Question 49

2 Devices indicated for patients with LV Ejection Fraction of <30%

Answer 49

- Implantable cardioverter defibrillator | - Biventricular pacemaker (cardiac resyncronization therapy)

Question 50

Patients with LV ejection fraction <30% are at high risk for these 2 conditions

Answer 50

- Ventricular tachycardia | - ventricular fibrillation

Question 51

Implantable left ventricular assist device

Answer 51

Helps patients awaiting transplant pump blood at the ventricle

Question 52

Swan Ganz catheter

Answer 52

Right ventricle catheterization from pulmonary artery to measure CVP, right sided heart pressure, and pulmonary artery pressure

Question 53

The frank starling curve shifts in what direction in response to systolic dysfunction

Answer 53

Down and to the right (stroke volume (y axis) is reduced and preload is increased (LV EDV x axis)

Question 54

End result of myocyte remodeling in systolic heart failure

Answer 54

-end result is hypoperfusion with hypervolemia, and cardiac remodeling of ventricle to be dilated and floppy