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Health Assessment > Heart Failure - Exam 4 HA > Flashcards

Heart Failure - Exam 4 HA Flashcards

1
Q

Stages of HF: At Risk

A

Risk factors but no structural changes or symptoms

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2
Q

Stages of HF: Pre-Heart Failure

A

Structural changes but no symptoms

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3
Q

Stages of HF: Heart Failure

A

Symptoms like SOB & fatigue

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4
Q

Stages of HF: Advanced Heart Failure

A

Symptoms don’t respond to treatment

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5
Q

HF is defined as a complex syndrome that results from:

A

=any structural or functional impairment of ventricular filling or blood ejection

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6
Q

HF leads to ______.

What symptoms does this cause?

A

Tissue hypoperfusion

This causes fatigue, dyspnea, weakness, edema, & weight gain

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7
Q

HF may be caused by structural abnormalities of the:

A

Pericardium, myocardium, endocardium, heart valves, or great vessels

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8
Q

Classifications: HF with reduced EF

A
  • HFrEF
  • systolic HF
  • HF w/ EF < or = 40%
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9
Q

Classifications: HF w/ preserved EF

A
  • HFpEF
  • Diastolic HF
  • HF w/ EF > or = 50%
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10
Q

Classifcations: Borderline HFpEF

A
  • HF symptoms & EF b/w 40-49%
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11
Q

Is Diastolic Dysfunction present in HFrEF or HFpEF?

A

Trick Question. It is present in both.

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12
Q

What are the distinguishing factors b/w HFrEF & HFpEF?

A
  1. LV dilation patterns
  2. remodeling
  3. their different responses to medical treatment
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13
Q

Why does EF remain a useful tool?

What is it the main marker for?

A
  1. Easily measured on echo
  2. main marker for determining HF risk factors, treatment, & outcomes
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14
Q

The amount of pts w/ HFpEF is increasing due to its relationship with what conditions?

A
  • HTN
  • DM
  • A-fib
  • obesity
  • metabolic syndrome
  • COPD
  • renal insufficiency
  • anemia
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15
Q

HFrEF pts are more likely to have ____ risk factors, such as ____ & ____.

A

Modifiable

Smoking & Hyperlipidemia

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16
Q

HFrEF pts are also more likely to have a higher incidence of -

A
  • myocardial ischemia & infarction
  • previous coronary intervention
  • CABG
  • PVD
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17
Q

____ % of HF cases are HFpEF.
____ % of HF cases are HFrEF.
____ % of HF cases are borderline HFpEF.

A
  1. 52%
  2. 33%
  3. 16%
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18
Q

________ are more likely to be affected by HFrEF.
________ are more likely to be affected by HFpEF

A

Men

Women

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19
Q

LV diastolic dysfunction (LVDD) is the primary determinant of ____.

A

HFpEF

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20
Q

Contractile Dysfunction is the primary derminant for ____.

A

HFrEF

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21
Q

The LV’s ability to fill is determined by:

(5 things)

A
  1. pulmonary venous blood flow
  2. LA function
  3. Mitral valve dynamics
  4. Pericardial restraint
  5. Active and Passive elastic properties of the left ventricle
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22
Q

LV diastolic function is ____ (normal or abnormal) when these factors combine to provide a LVEDV (preload) that provides sufficient CO for ________ ________ w/o elevating pulmonary venous pressures and LA pressures.

A

Normal

Cellular Metabolism

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23
Q

The majority of LVDD measurements depend on these 3 things -

A
  1. HR
  2. loading conditions
  3. myocardial contractility
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24
Q

In HFpEF higher ____ ________ ________ are required to achieve normal end-diastole volume.

A

LV filling pressures

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25
Q

A steeper rise of the end-diastolic pressure-volume curve is indicative of:

What does this lead to?

A
  1. delayed LV relaxation & increased myocardial stiffness
  2. leads to - reduced LV compliance and precipitates:
    -LA HTN
    -LA systolic & diastolic dysfunction
    -pulmonary venous congestion
    -exercise intolerance
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26
Q

________ ________ is indicated by a decrease in the slope of the end-systolif pressure-volume relation.

Is this present in HFrEF or HFpEF?

A

Decreased contractility

HFrEF

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27
Q

Decreased ____ ________ is indicated by an increase in the end-diastolic pressure-volume relation slope.

Is this present in HFrEF or HFpEF?

A

LV compliance

HFpEF

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28
Q

What do these diagrams emphasize?

A

That HF may result from LV systolic or diastolic dysfunction indendently

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29
Q

Common Causes of LV Diastolic Dysfunction

A
  1. Age >60 yrs
  2. acute MI (supply or demand)
  3. myocardial stunning, hibernation, or infarction
  4. pericardial diseases (tamponade, constrictive pericarditis)
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30
Q

Hypertrophic causes of LV Diastolic Dysfunction

A
  1. pressure-overload hypertrophy (aortic valve stenosis or essential HTN)
  2. volume-overload hypertrophy (aortic or mitral regurg)
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31
Q

Cardiomyopathy causes of LV Diastolic Dysfunction

A
  1. hypertrophic obstructive cardiomyopathy
  2. dilated cardiomyopathy (viral, postpartum, idiopathic)
  3. Restrictive cardiomyopathy (amyloidosis, hemochromatosis)
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32
Q

True or False: Delays in relaxation related to LV End-Diastolic Dysfunction are a form of “active stiffening”

If true, what is this caused by?

A

True

Caused by failure of the actin-myosin dissassociation (from inadequate perfusion or dysfunctional intracellular Ca++ homeostasis)

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33
Q

What does LV relaxation depend on?

Who is it typically elevated in?

A

Afterload

HTN patients

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34
Q

________ exacerbates the failure of LV relaxation.

What is the mechanism behind this?

A

Tachycardia

less filling time available

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35
Q

profound ________ ________ is seen w/ HFpEF despite having only a modestly depressed ____ ________ ________.

A

Exercise intolerance

LV Systolic Function

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36
Q
  1. With LVDD - prolonged compression of the coronary arteries restricts ________ ________ blood flow.
  2. This contributes to ________ ______.
  3. And leads to a further reduction in _______ ______.
A
  1. Diastolic Coronary
  2. subendocardial ischemia
  3. excercise tolerance
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37
Q

What are the most common symptoms of HF?

A
  • fatigue
  • tachypnea, dyspnea, paroxysmal nocturnal dyspnea, orthopnea
  • S3 gallop, JVD, peripheral edema
  • exercise intolerance
  • reduced tissue perfusion
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38
Q

What symptoms are more common with HFpEF?

A
  • paroxysmal nocturnal dyspnea
  • pulmonary edema
  • dependent edema
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39
Q

What symptoms are more common with HFrEF?

A
  • S3 gallop
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40
Q

True or False: When EF is reduced the presence of HF symptoms establishes the diagnosis of HFpEF.

A

False.

This establishes the diagnosis of HFrEF.

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41
Q

The initial diagnosis of ____ is often more difficult.

Especially when –

A

HFpEF

the patient has little/no symptoms at rest

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42
Q

How does cardiac catheterization define elevated LV systolic & diastolic stiffness?

A

using pressure-volume analysis or provocative testing (exercise & rapid IV volume expansion)

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43
Q

Direct measurement of ____ filling pressures gives further information about the severity of ____.

A

RV

HFpEF

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44
Q

What measureable data provides strong evidence of HFpEF and is a predictor of mortality?

A
  • mean capillary wedge pressure >15mmHg at rest or 25mmHg during exercise
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45
Q

Formula for EF

A

EF = SV/EDV

  • for the love of Schmidt, we better remember this.
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46
Q

HF diagnosis: CXR may detect these things –

A
  • pulmonary disease
  • cardiomegaly
  • pulmonary venous congestion
  • interstitial or alveolar pulmonary edema
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47
Q

HF diagnosis

An early radiographic sign of LV failure & pulmonary venous HTN is –

A

distention of the pulmonary veins in the upper lobes

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48
Q

HF diagnosis

CXR: Perivascular edema appears as a ________ or ________ haze w/ ill-defined margins

A

Hilar or Perihilar

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49
Q

HF Diagnosis

______ ______ which produce a honeycomb pattern, reflect what?

A

Kerley lines reflect interlobular edema

  • may be present in HF
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50
Q

HF diagnosis

________ ________ produces homeogenous densities in the lung fields.
In a ________ pattern.

A

Alveolar edema

butterfly

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51
Q

HF diagnosis

What types of effusion may be present on CXR?

A

Pleural & pericardial effusions

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52
Q

HF diagnosis

Radiographic evidence of pulmonary edema may lag behind the clinical evidence of pulmonary edema by up to ____ ____.

A

12 hours

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53
Q

HF diagnosis: ECHO

ACC/AHA diagnostic criteria depends on these 3 symptoms:

Who is this approach useful for?
What may it be too simplistic for?

A
  1. HF symptoms
  2. EF > or = 50%
  3. evidence of LVDD
  • useful for: pts w/ clear symptomolagy
  • too simplistic for subclinical HFpEF
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54
Q

HF Diagnosis: ECHO

The European Society of Cardiology Criteria is –

This is not the actual criteria

A
  • more specific & incorporates several echocardiographic indexes based on 2-dimensional measurements
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55
Q

HF diagnosis: ECHO

What is included in the ESC criteria?

A
  1. HF symptoms
  2. LV EF > or = 50%
  3. LV end-diastolic volume < 97mL/m2
  4. evidence of LV diastolic dysfunction
    - mean e’ TDI < 9cm/sec
    - E/e’ > or = 13
    - LA volume index > 34mL/m2
    - LV mass index > or = 115g/m2 (men) or > or = 95g/m2 (women)
    - BNP > or = 35pg/mL or NT-proBNP > or = 125pg/mL (suggestive)
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56
Q

HF Diagnosis: ECHO

The ESC guidelines rely entirely on ______ ______.

They are limited b/c they do not incorporate –

A

resting echocardiogram

provocative testing

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57
Q

HF Diagnosis: EKG

True or False: EKG abnormalities are common in HF pts.

What are they typically r/t?

A

True

R/T underlying pathology:
* Left ventricular hypertrophy
* previous MI
* arrhythmias
* conduction abnormalities

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58
Q

HF Diagnosis: EKG

EKG alone has a ____ predictive value for diagnosis or risk-prediction of HF.

A

low

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59
Q

HF Diagnosis: Labs

What are important biomarkers?

A
  1. Brain Natriuretic Peptide (BNP)
  2. N-terminal pro-BNP
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60
Q

HF Diagnosis: Labs

Natriuretic peptide concentrations are r/t what?

What type of HF is this higher in and why?

A

r/t LV end-diastolic wall stress

higher in HFrEF d/t LV dilation & eccentric remodeling

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61
Q

HF Diagnosis: Labs

What type of HF is associated w/ lower BNP & NT-proBNP levels?

Why?

A

HFpEF

  • it is associated w/ concentric hypertrophy, normal LV chamber size, and lower LV end-diastolic wall stress
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62
Q

HF Diagnosis: Labs

Troponins are systemically released d/t ________ damage, and they serve as a measure of ____ ________.

A

myocardial

risk prediction

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63
Q

HF Diagnosis: Labs

Both C-reactive protein (CRP) and growth differentiation factor-15 (GDF15) represent the ________ component of HF.

A

inflammatory

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64
Q

What does the New York Heart Association (NYHA) system for HF classification focus on?

A

the degree of physical limitation

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65
Q

What does the ACC/AHA classification system for HF focus on?

A

presence & severity of HF

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66
Q
A
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67
Q

When using these classification systems for HF, the stages are ________. Which means –

Are patients classified using 1 system?

A

progressive - they only move in 1 direction & don’t get better.

  • no - pts are usually classified using a combo of both scoring systems
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68
Q

NYHA Classification of HF

Class I:

A

No limitation and no symptoms from ordinary activity

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69
Q

NYHA Classification of HF

Class II:

A

mild limitation w/ activity & comfortable at rest or w/ mild exertion

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70
Q

NYHA Classification of HF

Class III:

A

Significant limitation w/ any activity & comfortable only at rest

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71
Q

NYHA Classification of HF

Class IV:

A

Discomfort w/ any physical activity and symptoms occurring at rest

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72
Q

ACC/AHA Classification of HF

Class A:

A

High risk of developing HF but no functional or structural heart deficits

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73
Q

ACC/AHA Classification of HF

Class B:

A

Structural heart deficit but no symptoms

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74
Q

ACC/AHA Classification of HF

Class C:

A

Heart failure symptoms d/t underlying structural heart deficit w/ medical management

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75
Q

ACC/AHA Classification of HF

Class D:

A

Advanced disease requiring hospitilization, transplant, or palliative care

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76
Q

Chronic HF Treatment

Survival of pts w/ ____ has improved during the past 3 decades.

Mortality in those w/ HFpEF remains ________.

A

HFrEF

unchanged.

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77
Q

Chronic HF Treatment

Who are medication treatments effective for? (HFpEF or HFrEF)

A

HFrEF

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78
Q

Chronic HF Treatment

HFpEF Tx:

A
  • mitigation of symptoms
  • treat associated conditions
  • exercise
  • weight loss
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79
Q

Chronic HF Treatment

HFrEF Tx:

A
  • BBs and ACE-I’s
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80
Q

Chronic HF Treatment

Algorithm for HFpEF

just an image

A
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81
Q

Chronic HF Treatment

____ ________ are recommended per ACC & ESC Guidelines.

What do the reduce?
What do they improve?

A

Loop Diuretics

reduced LV filling pressures & pulmonary venous congestion

improved HF sxms.

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82
Q

Chronic HF Tx:

Who are thiazide diuretics useful in? And what do they prevent?

A
  • useful in pts w/ poorly controlled HTN
  • prevents onset of HFpEF
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83
Q

Chronic HF Tx

What HF is BB’s recommended for?

What other indications may the be used for?

A
  • BBs best for HFrEF pts
  • can be used in HFpEF pts w/ HTN, MI, HR control w/ A-fib
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84
Q

Chronic HF Tx

What are the 2 mainstay medication treatments for HFrEF?

Do these show benefit in HFpEF pts?

A
  • ACE inhibitors & ARBs
  • no - unless used for HTN tx
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85
Q

Chronic HF Tx

Lifestyle Modifications

A
  1. Aerobic Fitness - reduces symptoms (improved quality of life)
  2. Weight loss - reduces major risk factors for HF (HTN, DM)
  3. Salt-restricted Dietary Approaches to Stop HTN (DASH) diet - improves LV diastolic function, decreases arterial stiffness, facilitates LV arterial coupling (HFpEF)
  4. control of HTN & glucose important
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86
Q

Chronic HF Tx: Surgery

Goals of surgical Tx for Chronic HF

A

prevent ventricular remodeling & retain the natural geometry of the heart

87
Q

Chronic HF Tx: Surgery

Coronary revascularization via CABG or PCI can reverse ____ ________ following an MI.

Successful early revascularization may prevent ________ ____ ________.

A

LV Dysfunction

Permanent EF Reductions

88
Q

Chronic HF Tx: Surgery

____ has been shown to reduce 10-year mortality by 7%.

A

CABG

89
Q

Chronic HF Tx: Surgery

Cardiac Resynchronization therapy (CRT) aka ________ ________, is a tx ffor HF w/ what?

A

biventricular pacing

tx for HF w/ a ventricular conduction delay (prolonged QRS)

90
Q

Chronic HF Tx: Surgery

What does CRT consist of?

What do the leads do?

A
  1. placement of a dual chamber cardiac pacemkaer (w/ RA & RV leads)
  2. an additional lead introduced through the coronary sinus and advanced until it reaches the lateral wall of the LV
  3. The leads stimulate the heart to contract more synchrously and efficiently to improve CO
91
Q

Chronic HF Tx: Surgery

CRT is recommended for pts meeting what criteria?

A
  1. NYHA class III or IV w/ EF < 5% and a QRS duration 120-150ms
92
Q

Chronic HF Tx: Surgery

CRT outcomes

A
  1. fewer HF sx
  2. better exercise tolerance
  3. improved ventricular function
  4. less hospitalizations
  5. decreased mortality
93
Q

Chronic HF Tx: Surgery

CRT risks include:

A
  1. infection
  2. misplacement of the leads
  3. device failure - causing further cardiac complications
94
Q

Chronic HF Tx: Surgery

Implantable hemodynamic monitoring allows for remote observation of –

A

intracardiac pressures to guide tx and prevent decompensation

95
Q

Chronic HF Tx:

The CardioMEMS HF system allows for management of ____ ________ ________ based on daily measurement of non-invasive ____.

What is done with the results?

A

LV filling pressures

PAP

The test is done at home and the results are uploaded to the pts physician.

96
Q

Chronic HF Tx: Surgery

What are implantable cardioverter-defibrilators (ICDs) usef for?

What are 50% of HF deaths due to?

A
  • used for prevention of sudden death in pts w/ advanced HF
  • 50% HF deaths d/t sudden cardiac dysrhythmias
97
Q

Chronic HF Tx: Surgery

What may pts in the terminal stages of HF benefit from?

Studies show an ________ survival and ________ quality of life in HF pts tx w/ VADs.

A

Mechanical circulatory support by a ventricular assist device (VAD)

  • increased survival & improved quality of life
98
Q

Chronic HF Tx: LVAD

What do these mechanical pumps take over?

What do they facilitate?

A

Partial or total function of the damaged ventricle

Restoration of normal hemodynamics & perfusion

99
Q

Chronic HF Tx: LVAD

What is the LVAD used for?

A
  • temporary ventricular assistance while the heart is recovering its function
  • pts awaiting cardiac transplant
  • pts on on inotropes or balloon pump (IABP) w/ potentially reversible medical conditions
  • pts w/ advanced HF who aren’t transplant candidates
100
Q

LVAD Photo:

A
101
Q

Acute HF has ________ onset and presents w/ ____ - ________ conditions.

A

Rapid

life-threatening

102
Q

What is acute HF Tx aimed at?

A

decreasing volume & stabilizing hemodynamics

103
Q

Who does the term “acute HF” apply to?

A
  • pts who present w/ worsening pre-existing HF (Acute decompensated HF - ADHF)
  • pts who present for the first time w/ HF (de novo acute HF - de novo AHF)
104
Q

ADHF Symptoms:

What do they result from?

A
  • fluid retention
  • weight gain
  • dyspnea
  • ALL resulting from decompensation d/t inadequate compensation
105
Q

De novo HF is characterized by a sudden increase in –

What does this lead to?

A
  • intracardiac filling pressures or acute myocardial dysfunction
  • leads to decreased peripheral perfusion & pulmonary edema
106
Q

What is the leading cause of de novo HF?

What is the management of de novo HF focused on?

A
  • Cardiac ischemia from a coronary occlusion
  • stabilizing hemodynamics, restoring myocardial perfusion, improving myocardial contractility
107
Q

what are the nonischemic causes of de novo HF?

A
  • viral
  • drug induced (toxic)
  • peripartum cardiomyopathies
108
Q

What may de novo HF lead to?

A
  • long-term cardiac dysfunction
  • management may allow for complete restoration
109
Q

What does the hemodynamic profile of acute HF include?

A
  • low CO
  • high ventricular filling pressures
  • HTN or HoTN
110
Q

Acute HF Tx

What is the 1st line tx for AHF?

A
  • Diuretics: Furosemide, Bumetanide, Torsemide (bolus or cont. infusion)
111
Q

Acute HF Tx

What patients may require hemodynamic support prior to diuretic therapy?

A

AHF pts w/ HoTN or cardiogenic shock

112
Q

Acute HF Tx

Reducing intravascular volume leads to decreased:

A

Central venous pressure & pulmonary capillary wedge pressure – this reduces pulmonary congestion

113
Q

Acute HF Tx

________ are proven to correct elevated filling pressures and reduce ________.

Are they useful in pts w/ AHF?

A

Vasodilators - reduce afterload

  • not useful in AHF
114
Q

Acute HF Tx

________ (drug) is effective in decreasing afterload.

________ (drug) is commonly used as an adjunct to diuretic therapy.

A
  • sodium nitroprusside
  • nitroglycerine
115
Q

Acute HF Tx

What is an example drug of a Vasopressin Receptor Antagonist?

What can it reduce?

A
  • Tolvaptan
  • arterial constriction
  • hyponatremia
  • volume overload associated w/ AHF
116
Q

Acute HF Tx

What is the mainstay Tx for pts w/ acute reduced contractility, or cardiogenic shock?

What do they increase? (hint: in the cell)

A
  • positive inotropes
  • cAMP - increases intracellular Ca++ excitation-contraction coupling
117
Q

Acute HF Tx

Examples of Catecholamine Drugs:

What do the stimulate?

A
  • Epinephrine
  • NE
  • Dopamine
  • Dobutamine
  • stimulate Beta receptors on the myocardium - activate adenylyl cyclase - increased cAMP
118
Q

Acute HF Tx

PDE-inhibitors such as ________, indirectly increase what?

A

Milrinone

increase cAMP by inhibiting its degradation

119
Q

Inotropic Agents

Epinphrine
Mechanism:
CO:
MAP:
HR:

A

B1 = B2 > a

CO ↑↑
MAP ↑↑
HR ↑↑

120
Q

Inotropic Agents

Norepinephrine
Mechanism
CO:
MAP:
HR:

A

a > B1 > B2
CO ↑
MAP ↑
HR – or ↓

121
Q

Inotropic Agents

Dobutamine
Mechanism
CO:
MAP:
HR:

A

B1 > B2 > a
CO – or ↓
MAP ↑↑
HR ↑↑

122
Q

Inotropic Agents

Dopamine
Mechanism
CO:
MAP:
HR:

A

D > B (a w/ high doses)
CO ↑
MAP ↑
HR ↑↑↑

123
Q

Inotropic Agents

Milrinone
Mechanism:
CO:
MAP:
HR:

A

PDE Inhibition
CO ↑
MAP – or ↓
HR – or ↓

124
Q

Inotropic Agents

Levosimendan
Mechanism:
CO:
MAP:
HR:

A

Calcium Sensitization
CO ↑↑
MAP – or ↓
HR ↑↑

125
Q

AHF Tx

What drug is exogenous BNP?

What does it bind to?
What does it inhibit and promote?
What are the overall effects?

A

Nesiritide
* binds to A & B-type natriuretic receptors
* inhibits the RAAS and promotes arterial, venous, and coronary vasodilation

  • overall effects: decreased LVEDP and improved dyspnea
126
Q

Acute HF Tx

What other effects does Nesiritide have?

Does it show advantage over NTG or SNP?

A
  • induces diuresis and natriuresis
  • relaxes cardiac muscle
  • lacks dysrhythmic effects
  • NO advantage over other vasodilators
127
Q

Acute HF Tx

What is inidcated when medical management fails & organ dysfunction occurs w/ AHF?

A

urgent mechanical circulatory support

128
Q

Acute HF Tx

MCS decision-making tool developed by the Society of Thoracic Surgeons

This is a table

A
  • INTERMACS profile system (inter-agency Registry of Mechanically Assisted Circulatory Support)
129
Q

How does the IABP function?

What does it improve and how?

A
  • functions by cyclic helium balloon inflation after aortic valve closure, followed by deflation during systole
  • improves LV coronary perfusion by reducing LVEDP
130
Q

IABP degree of support varies based on what factors?

A
  • the set volume
  • the size of the balloon
  • the ratio of supported beats
131
Q

Support settings for the IABP:

A
  • full support 1:1 (one inflation for every heartbeat)
  • tachycardic pts - 2:1 setting ideal (one inflation per every 2 heartbeats)
132
Q

What limits the IABP’s long-term use?

A
  • only provides modest improvements in CO (0.5-1L/min)
  • renders pts immobile
133
Q

What is an impella?

A

a VAD that can be placed percutaneously to reduce LV strain and myocardial work in the setting of acute HF

134
Q

Impella Devices can be used for up to ____ days.
They serve as a transition to revover or bridge to ________ ________

A
  • 14 days
  • cardiac procedures (CABG, PCI, VAD, transplant)
135
Q

Description of the Impella

A
  • consists of a miniature rotary blood pump inserted through the femoral artery
  • advanced through the aortic valve and is situated in the LV
  • The pump draws blood continously through the distal port and ejects it into the ascending aorta through its proximal port
136
Q

AHF Surgical Tx

What are peripheral VADs?

A

support devices that can provide extracorporeal membrane oxygenation (ECMO)

137
Q

AHF surgical tx

Peripheral VAD consits of a ____ ____ & ________. This is helpful for transport, but generates heat and causes more ________ and lower ________.

A
  • consists of a small pump & controller
  • causes more hemolysis and lower flows
138
Q

AHF surgical Tx

If Peripheral VAD have an ________, they are considered ECMO.

Or they can be used to just ________ the right or left side of the heart.

A
  • oxygenator
  • support
139
Q

AHF surgical tx

What may Central ECMO be necessary for?

A
  • cardiorespiratory support
  • alternative to peripheral ECMO if adequate flow rates are not achievable
140
Q

Acute HF surgical tx

Central VAD/ECMO procedure

A
  • requires sternotomy or thoracotomy for placement
  • cannulas are placed in the right atrium and aorta
141
Q

Acute HF surgical tx

What are the benefits to Central VAD/ECMO?

A
  • complete ventricular decompression
  • avoidance of limb impairment
  • avoidance of SVC syndrome
142
Q

Acute HF surgical tx

What is likely reduced in pts on ECMO? Why?

A
  • reduced lung perfusion as blood bypasses the lungs before returning to the aorta
143
Q

Acute HF surgical tx (ECMO)

________ ________ may be significantly limited by functional shunting around the lungs

A

Inhaled Anesthetics

144
Q

Acute HF surgical tx

CRNAs need to recognize that the ECMO membrane is ________, which causes what?

A

membrane is lipophilic

  • causes agents (fentanyl) to become sequestered within the circuit
145
Q

Acute HF surgical tx

What is a biventricular assist device?

A
  • after pt is stabilized on central ECMO - may want to decouple support of the ventricles w/ 2 independent circuits
  • this allows for weaning of either left or right sided support
146
Q

BiVAD

How can the separate circuits be achieved?

A
  • percutaneous placement to support R and L sides separately
  • R & L sides can be centrally cannulated individually
147
Q

Pre-op management HF:

What do HF pts have an increased risk of developing?

What can these risks lead to?

A
  • renal failure, sepsis, pneumonia, cardiac arrest
  • may lead to longer periods of mechanical ventilation and ↑ 30 day mortality
148
Q

Pre-op management HF

What are the comorbidities that should be examined & optimized w/ HF pts?

A

HTN, DM, angina, A-fib, renal failure

149
Q

Pre-op management of HF

Surgery should be postponed in pts experiencing what?

A
  • acute decompensation
  • recent change in clinical status
  • de novo acute HF
150
Q

Pre-op management HF

What medications do HF pts take that may affect anesthetic management?
Which ones should be continued/discontinued?

A
  • Diuretics - held day of surgery
  • BB - continue, they reduce perioperative M&M
  • ACE-Inhibitors: risk of intra-op HoTN (guidelines recommend maintaining therapy in peri-op period)
151
Q

Pre-op management HF

12-lead EKG is recommended in who?

A
  • any pt w/ cardiovascular disease
  • AKA all our damn pts probs.
152
Q

Pre-op management HF

A TTE is indicated in what pts?

A

pts w/ worsening dyspnea during their pre-op eval

153
Q

Pre-op management HF

LABS

A
  • CBC, electrolytes, liver function, coag studies
  • BNP not routinely recommended
154
Q

Pre-op management HF

____ & ________ should be interrogated prior to surgery.

A

ICDs and pacemakers

155
Q

What are cardiomyopathies?

A
  • group of myocardial diseasesassociated with mechanical and/or electrical dysfunction
  • usually exhibit ventricular hypertrophy or dilation
156
Q

Are cardiomyopathies just confined to the heart?

What do they lead to?

A

No, they can also be part of systemic disorders

Lead to cardiovascular death/disability

157
Q

Primary Cardiomyopathies

A

confined to the heart muscle

158
Q

secondary cardiomyopathies

A

pathophysiologic cardiac involvement in the context of multiorgan disorder

159
Q

Is hypertrophic cardiomyopathy primary or secondary?

What is it characterized by?

A
  • complex primary cardiomyopathy
  • characterized by LVH in the absence of other diseases capable of inducing ventricular hypertrophy
160
Q

What is the most common genetic cardiovascular disease?

A

hypertrophic cardiomyopathy

161
Q

HCM usually presents w/ hypertrophy of the ________ ________ and the ________ ____ ____.

A

interventricular septum & anterolateral free wall

162
Q

What histologic features are associated w/ HCM?

A

hypertrophied myocardial cells & patchy myocardial scarring

163
Q

What pathophysiology is r/t HCM?

A
  • myocardial hypertrophy
  • dynamic LVOT obstruction
  • mitral regurgitation
  • diastolic dysfunction
  • myocardial ischemia
  • dysrhythmias
164
Q

Factors that induce LVOT obstruction in HCM

A
  • hypovolemia, tachycardia, increased myocardial contractility, decreased afterload
165
Q

Hypertrophied myocardium has a prolonged ________ and decreased ________.

A

relaxation and decreased compliance

166
Q

________ ________ is present in pts w/ HCM regardless of if they have CAD or not.

A

myocardial ischemia

167
Q

What is the sudden cause of death in young adults w/ HCM?

What is it caused by?

A

Dysrhythmias
* caused by: disorganized cellular architecture, myocardial scarring, expanded interstitial matrix

168
Q

In asymptomatic pts, what may be the only sign of HCM?

A

unexplained LVH

169
Q

EKG abnormalities are seen in ____ - ____ % of pts w/ HCM.

What are the EKG abnormalities?

A

75-90%
* high QRS voltage, ST-segment & T-wave alterations, abnormal Q waves, left atrial enlargement

170
Q

What will Echo show in pts w/ HCM?

A
  • myocardial wall thickness > 15mm
  • EF > 80% (hypercontractility)
  • EF severely depressed in terminal states
171
Q

HCM: Cardiac cath allows for direct measurement of –

A

the increased LVEDP

172
Q

HCM tx

Medical therapy for HCM

A
  • BBs & CCBs
  • if HF developed - may show improvement w/ diuretics
173
Q

HCM tx

________ can be considered as add-on therapy in pts remaining symptomatic w/ HCM.

What effect does this drug have and what does it improve?

A

Disopyramide
* negative inotropic effect
* improves LVOT obstruction & HF sxms.

174
Q

____ often develops in HCM.
This is associated w/ increased risk of –

A

A-fib
* increased risk of thromboembolism, HF, & sudden death

175
Q

HCM tx

What is the most effective anti-dysrhythmic in HCM pts?

What is indicated for recurrent or chronic A-fib?

A
  • Amiodarone
  • long-term anticoagulation
176
Q

HCM tx: surgical

Who is HCM surgery reserved for?

A
  • subgroup of pts w/ large outflow tract gradients & severe sxms despite medical tx
177
Q

HCM tx: surgical

What are the surgical strategies for pts w/ HCM?

A
  1. septal myomectomy
  2. cardiac cath w/ injection to induce ischemia of the septal perforator arteries
  3. echocardiogram-guided percutaneous septal ablation
178
Q

HCM tx: surgical

In pts remaining symptomatic - a ________ ________ ________ can be inserted to conteract the systolic anterior motion of the mitral leaflet.

A

prosthetic mitral valve

179
Q

HCM tx: surgical

What is the primary tx for pts at risk of sudden cardiac death d/t dyshrythmias?

A

ICD placement

180
Q

What is Dilated Cardiomyopathy?
What is it characterized by?

A

primary myocardial disease
* 2nd most common cause of HF & most common form of cardiomyopathy!!*
**characterized by: **
* LV or biventricular dilation
* biatrial dilation
* decreased ventricular wall thickness
* systolic dysfunction w/o abnormal loading conditions or CAD

181
Q

What is the initial Sxm of dilated cardiomyopathy?

What other sxm may occur?

A
  1. HF
  2. chest pain
182
Q

Dilated Cardiomyopathy

Ventricular dilatation may lead to ________ and/or ________ ________.

A

Mitral/Tricuspid Regurgitation

183
Q

What pathologic events are common w/ dilated cardiomyopathy?

A
  • dysrhythmias
  • conduction abnormalities
  • emboli
  • sudden death
184
Q

Dilated Cardiomyopathy

What does the ECHO usually show?

A
  • dilation of all 4 chambers
  • predominantly the LV
  • Global hypokinesis
185
Q

Dilated Cardiomyopathy

EKG results -

A

often show ST-segment & T-wave abnormalities
* LBBB
* common dysrhythmias: PVC, A-fib

186
Q

Dilated Cardiomyopathy Tx

A
  • similar to tx of chronic HF
  • anticoagulation often indicated
  • prophylactic ICD placement decreases risk of sudden death by 50%
187
Q

What is the principal indication for cardiac transplant?

A

Dilated Cardiomyopathy

188
Q

What is stress cardiomyopathy?

A

(what I have.)

  • “apical ballooning syndrome”
  • temporary cardiomyopathy characterized by LV apical hypokinesis w/ ischemic eKG changes
  • cornary arteries rmain patent
189
Q

Stress cardiomyopathy

There is a temporary disruption of contractility in the ____ ____ while the rest of the heart has ________ ________.

A

LV Apex

Normal contractility

190
Q

What is the most common cuase of stress cardiomyopathy?

Common Sxms?

More in men or women?

A

STRESS, aka CRNA school.
(physical & emotional)

Sxms: chest pain, dyspnea

  • more in women b/c men bury their emotions.
191
Q

What is peripartum cardiomyopathy?

A
  • a rare primary cardiomyopathy
  • dilated cardiomyopathy - unkown cause
  • arises during peripartum (3rd trimester-5mos PP)
192
Q

3 criteria for Dx of peripartum cardiomyopathy

A
  1. development of HF in the period surrounding delivery
  2. absence of other explainable cause
  3. LV systolic dysfunction w/ a LVEF < 45%
193
Q

Dx studies for peripartum cardiomyopathy

A
  • EKG
  • ECHO
  • CXR
  • cardiac MRI
  • cardiac cath
  • endomyocardial biopsy
  • BNP levels
194
Q

What are secondary cardiomyopathies d/t?

A

systemic diseases that produce myocardial infiltration & severe diastolic dysfunction

195
Q

Causes of secondary cardiomyopathies

A
  • most common cause: amyloidosis
  • other causes: hemochromatosis, sarcoidosis, carcinoid tumors
196
Q

Secondary Cardiomyopathy diagnosis should be considered in pts who have –

A

HF but no evidence of cardiomegaly or systolic dysfunction

197
Q

Sxms secondary cardiomyopathy

A

pts can have low to normal BP
* can develop orthostatic HoTN

198
Q

Classification of primary cardiomyopathies

Genetic

A
  • hypertrophic cardiomyopathy
  • dysrhythmogenic RV cardiomyopathy
  • LV noncompaction
  • glycogen storage disease
  • conduction system disease (Lenegre disease)
  • ion channelopathies (long QT syndrome, Brugada syndrome, short QT syndrome)
199
Q

Classification of Primary Cardiomyopathies

Mixed:

A
  • Dilated cardiomyopathy
  • primary restrictive nonhypertrophic cardiomyopathy
200
Q

Classification of Primary Cardiomyopathies

Acquired:

A
  • myocarditis (inflammatory cardiomyopathy)
  • viral
  • bacterial
  • fungal
  • rickettsial
  • parasitic (Chagas Disease)
201
Q

Classification of Primary Cardiomyopathies

Other:

A
  • peripartum cardiomyopathy
  • stress cardiomyopathy (Takotsubo cardiomyopathy)
202
Q

Classification of Secondary Cardiomyopathies

Infiltrative:

A
  • amyloidosis
  • Gaucher disease
  • Hunter syndrome
203
Q

Classification of secondary Cardiomyopathies

Storage:

A
  • hemochromatosis
  • glycogen storage disease
  • Niemann-Pick disease
204
Q

Classification of secondary cardiomyopathies

Toxic:

A
  • Drugs: cocaine, alcohol
  • Chemotherapy drugs: doxorubicin, daunorubicin, cyclophosphamide
  • Heavy metals: lead, mercury
  • Radiation therapy
205
Q

Classification of Secondary Cardiomyopathies

Inflammatory

A

Sarcoidosis

206
Q

Classification of Secondary Cardiomyopathies

Endomyocardial

A
  • hypereosinophilic (Loffler) syndrome
  • endomyocardial fibrosis
207
Q

Classification of secondary cardiomyopathies

Endocrine

A
  • DM
  • hyper/hypothyroid
  • pheochromocytoma
  • acromegaly
208
Q

Classification of secondary cardiomyopathies

Neuromuscular

A
  • Duchenne-Becker Dystrophy
  • neurofibromatosis
  • tuberuous sclerosis
209
Q

Classification of secondary cardiomyopathies

Autoimmune

A
  • Lupus Erythematosus
  • RA
  • Scleroderma
  • Dermatomyositis
  • polyarteritis nodosa
210
Q

What is Cor Pulmonale?

A

RV enlargement (hypertrophy and/or dilation) that may progress to right-sided HF

211
Q

Causes of Cor Pulmonale?

A
  • pulmonary HTN
  • myocardial disease
  • congential heart disease
  • any significant respiratory, connective tissue, or chronic thromboembolic disease

*** MOST COMMON CAUSE: COPD
* more prevalent in men > 50 y/o **

212
Q

Cor Pulmonale: EKG

A
  • signs of RA/RV hypertrophy
  • RA hypertrophy: peaked P waves in II, III, avF
  • Right axis deviation & RBBB
213
Q

Cor Pulmonale: other diagnostics

A

TEE, right heart cath, CXR

214
Q

What is the most important determinant of pulmonary HTN & Cor Pulmonale in pts w/ chronic lung disease?

What is the best treatment?

A
  • alveolar hypoxia
  • long-term oxygen therapy

Health Assessment (8 decks)

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