Heart Failure Caused by Systolic Dysfunction Lecture Powerpoint Flashcards
fuck
Heart failure caused by systolic dysfunction is also known as…
….heart failure with reduced ejection fraction (HFREF)
Heart failure occurs because of problems in these 2 components of heart function
- Decrease in preload (venous return and end diastolic volume in ventricles stretching myocytes
- Decrease in myocardial contractility
Systolic dysfunction has a _____ and ___ventricle while diastolic has a ____ and ___ ventricle
dilated and floppy, stiff and inflexible
Ejection fraction to diagnose left heart failure must be less than…
Less than 40%
Heart failure
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)
Most common cause of systolic heart failure
Ischemic cardiomyopathy following an acute MI
Most common cause of diastolic heart failure
Longstanding uncontrolled hypertension leading to LV hypertrophy
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
Ejection fraction, decreased
Heart failure diagnoses are becoming more prevalent because…
…patients are living longer post MI and other forms of heart disease
Myocyte remodeling in systolic heart failure mech of action
- 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
Can we have both systolic and diastolic dysfunction and how do you tell?
yes and thru imaging studies such as echocardiogram of the heart muscle
Pathways targeted in systolic dysfunction for drug therapy
- B receptors
- RAAS
Natriuretic peptides normal functions and levels in systolic dysfunction heart failure (generally)
Counterbalance RAAS by causing vasodilation (BNP) and increase Na+ excretion (and therefore H2O volume as well), levels will be elevated in heart failure
Cardiorenal syndrome
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)
2 types of cardiac remodeling
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
Risk factors for systolic dysfunction (4)
- CAD***
- previous MI
- diabetes
- HTN
2 types of cardiomyopathy
Restricted - diastolic function impacted
Dilated - systolic function impacted
1 risk factor for diastolic dysfunction
-HTN
Symptoms of systolic dysfunction heart failure (5)
- Dyspnea
- Fatigue
- Peripheral edema
- weight gain early stage weight loss in advanced stage
- JVDs
Hepatojugular reflex
Distension of neck veins precipitated by placing firm pressure over the liver, distension greater than 3cm is diagnostic for systolic heart failure
Most common type of ventricular failure is found on what side?
Left sided
Why do we see shortness of breath in left ventricular failure?
Back up of fluid into the lungs from the left ventricle and atrium
Leading disease state cause of right ventricular failure
Left ventricular failure (fluid backs up from left ventricles to lungs to right ventricle causing increased pressure on it)
Common cause of 2ndary** right sided only ventricular failure
pulmonary fibrosis from things such as COPD (cor pulmonale)
Modified framingham diagnostic criteria for congestive heart failure
Presence of 2 major criteria or 1 major and 2 minor criteria
3 ways to classify heart failure
- Functional classification
- disease state and progression
- echocardiogram (systolic vs diastolic)
Functional classification of heart failure and the 4 classes
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
Disease state and progression classification of heart failure and the 4 classes
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
Echocardiogram (Systolic vs diastolic) classification of heart failure
Determined via echocardiogram
Systolic - LV ejection fraction <40%, eccentric, thin ventricle
Diastolic - LV ejection fraction >40%, thick ventricle wall
Heart failure diagnosis (2)
Clinical H&P based from Framingham criteria, confirmed via echocardiography primarily and EKG secondarily
Labs for heart failure (7)
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
BNP testing can show false positive elevation indicative of heart failure in these 3 other conditions
- pulmonary disease
- PE
- renal impairment
Medications that exacerbate heart failure (2)
- NSAIDS
- CCBs
S3 cause and what type of heart failure is it heard with?
- Increased sloshing reverberating against dilated left ventricular wall, not always pathology
- More common in a systolic heart failure
S4 cause and what type of heart failure is it heard with?
- Blood being forced into a stiff non-compliant ventricle, almost always pathology
- more common in a diastolic heart failure
Chest Xray findings for LV heart failure and what view is best for seeing it?
- Cardiac silhoutte greater than .5 indicates cardiomegaly as well as pulmonary signs for effusions and edema
- only on a PA view can see it
Kerley B lines
Occur on a chest xray indicating fluid buildup in lower lobes of the lungs often in LV heart failure
Best imaging study for heart failure and best alternative
Transthoracic echocardiogram, transesophageal echocardiogram is best alt (but requires sedation :( )
If a patient has an ejection fraction between 40-50%, what do you do?
Treat them considering the clinical picture and use judgement (are they symptomatic? Are they high risk for progression?)
Systolic heart failure treatment targets
- preload
- afterload
- improved inotropy
4 choice therapies for systolic heart failure
- non pharm lifestyle mods
- multiple drugs
- surgical
- electrophysiological
Lifestyle modification therapies for heart failure (3)
- quit smoking
- decrease alcohol
- salt and fluid restriction
Systolic dysfunction has what contraindicated drug class?
non dihydropyridine ca2+ channel blockers (potential to act on heart)
Pharmacological treatment for chronic systolic dysfunction heart failure (3)
- ACE and ARB #1
- B blocker
- Spironolactone supplementary
Stage A-D pharm treatment protocol for chronic systolic dysfunction heart failure
- ACE
- ACE and B blocker
- ACE and B blocker, diuretics
- mechanical assist devices, transplant?
Systolic dysfunction indicates ___ in all patients and ___ in all patients without contraindications
ACE, B blocker
Digoxin helps with symptoms of heart failure but is not typical to use because it does not…
….affect mortality rates
Drug class often indicated for HF patients with atrial fibrillation or recent MI
Anticoagulants
2 Devices indicated for patients with LV Ejection Fraction of <30%
- Implantable cardioverter defibrillator
- Biventricular pacemaker (cardiac resyncronization therapy)
Patients with LV ejection fraction <30% are at high risk for these 2 conditions
- Ventricular tachycardia
- ventricular fibrillation
Implantable left ventricular assist device
Helps patients awaiting transplant pump blood at the ventricle
Swan Ganz catheter
Right ventricle catheterization from pulmonary artery to measure CVP, right sided heart pressure, and pulmonary artery pressure
The frank starling curve shifts in what direction in response to systolic dysfunction
Down and to the right (stroke volume (y axis) is reduced and preload is increased (LV EDV x axis)
End result of myocyte remodeling in systolic heart failure
-end result is hypoperfusion with hypervolemia, and cardiac remodeling of ventricle to be dilated and floppy
