Heart Failure - Exam 4 HA Flashcards
Stages of HF: At Risk
Risk factors but no structural changes or symptoms
Stages of HF: Pre-Heart Failure
Structural changes but no symptoms
Stages of HF: Heart Failure
Symptoms like SOB & fatigue
Stages of HF: Advanced Heart Failure
Symptoms don’t respond to treatment
HF is defined as a complex syndrome that results from:
=any structural or functional impairment of ventricular filling or blood ejection
HF leads to ______.
What symptoms does this cause?
Tissue hypoperfusion
This causes fatigue, dyspnea, weakness, edema, & weight gain
HF may be caused by structural abnormalities of the:
Pericardium, myocardium, endocardium, heart valves, or great vessels
Classifications: HF with reduced EF
- HFrEF
- systolic HF
- HF w/ EF < or = 40%
Classifications: HF w/ preserved EF
- HFpEF
- Diastolic HF
- HF w/ EF > or = 50%
Classifcations: Borderline HFpEF
- HF symptoms & EF b/w 40-49%
Is Diastolic Dysfunction present in HFrEF or HFpEF?
Trick Question. It is present in both.
What are the distinguishing factors b/w HFrEF & HFpEF?
- LV dilation patterns
- remodeling
- their different responses to medical treatment
Why does EF remain a useful tool?
What is it the main marker for?
- Easily measured on echo
- main marker for determining HF risk factors, treatment, & outcomes
The amount of pts w/ HFpEF is increasing due to its relationship with what conditions?
- HTN
- DM
- A-fib
- obesity
- metabolic syndrome
- COPD
- renal insufficiency
- anemia
HFrEF pts are more likely to have ____ risk factors, such as ____ & ____.
Modifiable
Smoking & Hyperlipidemia
HFrEF pts are also more likely to have a higher incidence of -
- myocardial ischemia & infarction
- previous coronary intervention
- CABG
- PVD
____ % of HF cases are HFpEF.
____ % of HF cases are HFrEF.
____ % of HF cases are borderline HFpEF.
- 52%
- 33%
- 16%
________ are more likely to be affected by HFrEF.
________ are more likely to be affected by HFpEF
Men
Women
LV diastolic dysfunction (LVDD) is the primary determinant of ____.
HFpEF
Contractile Dysfunction is the primary derminant for ____.
HFrEF
The LV’s ability to fill is determined by:
(5 things)
- pulmonary venous blood flow
- LA function
- Mitral valve dynamics
- Pericardial restraint
- Active and Passive elastic properties of the left ventricle
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.
Normal
Cellular Metabolism
The majority of LVDD measurements depend on these 3 things -
- HR
- loading conditions
- myocardial contractility
In HFpEF higher ____ ________ ________ are required to achieve normal end-diastole volume.
LV filling pressures
A steeper rise of the end-diastolic pressure-volume curve is indicative of:
What does this lead to?
- delayed LV relaxation & increased myocardial stiffness
- leads to - reduced LV compliance and precipitates:
-LA HTN
-LA systolic & diastolic dysfunction
-pulmonary venous congestion
-exercise intolerance
________ ________ is indicated by a decrease in the slope of the end-systolif pressure-volume relation.
Is this present in HFrEF or HFpEF?
Decreased contractility
HFrEF
Decreased ____ ________ is indicated by an increase in the end-diastolic pressure-volume relation slope.
Is this present in HFrEF or HFpEF?
LV compliance
HFpEF
What do these diagrams emphasize?
That HF may result from LV systolic or diastolic dysfunction indendently
Common Causes of LV Diastolic Dysfunction
- Age >60 yrs
- acute MI (supply or demand)
- myocardial stunning, hibernation, or infarction
- pericardial diseases (tamponade, constrictive pericarditis)
Hypertrophic causes of LV Diastolic Dysfunction
- pressure-overload hypertrophy (aortic valve stenosis or essential HTN)
- volume-overload hypertrophy (aortic or mitral regurg)
Cardiomyopathy causes of LV Diastolic Dysfunction
- hypertrophic obstructive cardiomyopathy
- dilated cardiomyopathy (viral, postpartum, idiopathic)
- Restrictive cardiomyopathy (amyloidosis, hemochromatosis)
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?
True
Caused by failure of the actin-myosin dissassociation (from inadequate perfusion or dysfunctional intracellular Ca++ homeostasis)
What does LV relaxation depend on?
Who is it typically elevated in?
Afterload
HTN patients
________ exacerbates the failure of LV relaxation.
What is the mechanism behind this?
Tachycardia
less filling time available
profound ________ ________ is seen w/ HFpEF despite having only a modestly depressed ____ ________ ________.
Exercise intolerance
LV Systolic Function
- With LVDD - prolonged compression of the coronary arteries restricts ________ ________ blood flow.
- This contributes to ________ ______.
- And leads to a further reduction in _______ ______.
- Diastolic Coronary
- subendocardial ischemia
- excercise tolerance
What are the most common symptoms of HF?
- fatigue
- tachypnea, dyspnea, paroxysmal nocturnal dyspnea, orthopnea
- S3 gallop, JVD, peripheral edema
- exercise intolerance
- reduced tissue perfusion
What symptoms are more common with HFpEF?
- paroxysmal nocturnal dyspnea
- pulmonary edema
- dependent edema
What symptoms are more common with HFrEF?
- S3 gallop
True or False: When EF is reduced the presence of HF symptoms establishes the diagnosis of HFpEF.
False.
This establishes the diagnosis of HFrEF.
The initial diagnosis of ____ is often more difficult.
Especially when –
HFpEF
the patient has little/no symptoms at rest
How does cardiac catheterization define elevated LV systolic & diastolic stiffness?
using pressure-volume analysis or provocative testing (exercise & rapid IV volume expansion)
Direct measurement of ____ filling pressures gives further information about the severity of ____.
RV
HFpEF
What measureable data provides strong evidence of HFpEF and is a predictor of mortality?
- mean capillary wedge pressure >15mmHg at rest or 25mmHg during exercise
Formula for EF
EF = SV/EDV
- for the love of Schmidt, we better remember this.
HF diagnosis: CXR may detect these things –
- pulmonary disease
- cardiomegaly
- pulmonary venous congestion
- interstitial or alveolar pulmonary edema
HF diagnosis
An early radiographic sign of LV failure & pulmonary venous HTN is –
distention of the pulmonary veins in the upper lobes
HF diagnosis
CXR: Perivascular edema appears as a ________ or ________ haze w/ ill-defined margins
Hilar or Perihilar
HF Diagnosis
______ ______ which produce a honeycomb pattern, reflect what?
Kerley lines reflect interlobular edema
- may be present in HF
HF diagnosis
________ ________ produces homeogenous densities in the lung fields.
In a ________ pattern.
Alveolar edema
butterfly
HF diagnosis
What types of effusion may be present on CXR?
Pleural & pericardial effusions
HF diagnosis
Radiographic evidence of pulmonary edema may lag behind the clinical evidence of pulmonary edema by up to ____ ____.
12 hours
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?
- HF symptoms
- EF > or = 50%
- evidence of LVDD
- useful for: pts w/ clear symptomolagy
- too simplistic for subclinical HFpEF
HF Diagnosis: ECHO
The European Society of Cardiology Criteria is –
This is not the actual criteria
- more specific & incorporates several echocardiographic indexes based on 2-dimensional measurements
HF diagnosis: ECHO
What is included in the ESC criteria?
- HF symptoms
- LV EF > or = 50%
- LV end-diastolic volume < 97mL/m2
- 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)
HF Diagnosis: ECHO
The ESC guidelines rely entirely on ______ ______.
They are limited b/c they do not incorporate –
resting echocardiogram
provocative testing
HF Diagnosis: EKG
True or False: EKG abnormalities are common in HF pts.
What are they typically r/t?
True
R/T underlying pathology:
* Left ventricular hypertrophy
* previous MI
* arrhythmias
* conduction abnormalities
HF Diagnosis: EKG
EKG alone has a ____ predictive value for diagnosis or risk-prediction of HF.
low
HF Diagnosis: Labs
What are important biomarkers?
- Brain Natriuretic Peptide (BNP)
- N-terminal pro-BNP
HF Diagnosis: Labs
Natriuretic peptide concentrations are r/t what?
What type of HF is this higher in and why?
r/t LV end-diastolic wall stress
higher in HFrEF d/t LV dilation & eccentric remodeling
HF Diagnosis: Labs
What type of HF is associated w/ lower BNP & NT-proBNP levels?
Why?
HFpEF
- it is associated w/ concentric hypertrophy, normal LV chamber size, and lower LV end-diastolic wall stress
HF Diagnosis: Labs
Troponins are systemically released d/t ________ damage, and they serve as a measure of ____ ________.
myocardial
risk prediction
HF Diagnosis: Labs
Both C-reactive protein (CRP) and growth differentiation factor-15 (GDF15) represent the ________ component of HF.
inflammatory
What does the New York Heart Association (NYHA) system for HF classification focus on?
the degree of physical limitation
What does the ACC/AHA classification system for HF focus on?
presence & severity of HF
When using these classification systems for HF, the stages are ________. Which means –
Are patients classified using 1 system?
progressive - they only move in 1 direction & don’t get better.
- no - pts are usually classified using a combo of both scoring systems
NYHA Classification of HF
Class I:
No limitation and no symptoms from ordinary activity
NYHA Classification of HF
Class II:
mild limitation w/ activity & comfortable at rest or w/ mild exertion
NYHA Classification of HF
Class III:
Significant limitation w/ any activity & comfortable only at rest
NYHA Classification of HF
Class IV:
Discomfort w/ any physical activity and symptoms occurring at rest
ACC/AHA Classification of HF
Class A:
High risk of developing HF but no functional or structural heart deficits
ACC/AHA Classification of HF
Class B:
Structural heart deficit but no symptoms
ACC/AHA Classification of HF
Class C:
Heart failure symptoms d/t underlying structural heart deficit w/ medical management
ACC/AHA Classification of HF
Class D:
Advanced disease requiring hospitilization, transplant, or palliative care
Chronic HF Treatment
Survival of pts w/ ____ has improved during the past 3 decades.
Mortality in those w/ HFpEF remains ________.
HFrEF
unchanged.
Chronic HF Treatment
Who are medication treatments effective for? (HFpEF or HFrEF)
HFrEF
Chronic HF Treatment
HFpEF Tx:
- mitigation of symptoms
- treat associated conditions
- exercise
- weight loss
Chronic HF Treatment
HFrEF Tx:
- BBs and ACE-I’s
Chronic HF Treatment
Algorithm for HFpEF
just an image
Chronic HF Treatment
____ ________ are recommended per ACC & ESC Guidelines.
What do the reduce?
What do they improve?
Loop Diuretics
reduced LV filling pressures & pulmonary venous congestion
improved HF sxms.
Chronic HF Tx:
Who are thiazide diuretics useful in? And what do they prevent?
- useful in pts w/ poorly controlled HTN
- prevents onset of HFpEF
Chronic HF Tx
What HF is BB’s recommended for?
What other indications may the be used for?
- BBs best for HFrEF pts
- can be used in HFpEF pts w/ HTN, MI, HR control w/ A-fib
Chronic HF Tx
What are the 2 mainstay medication treatments for HFrEF?
Do these show benefit in HFpEF pts?
- ACE inhibitors & ARBs
- no - unless used for HTN tx
Chronic HF Tx
Lifestyle Modifications
- Aerobic Fitness - reduces symptoms (improved quality of life)
- Weight loss - reduces major risk factors for HF (HTN, DM)
- Salt-restricted Dietary Approaches to Stop HTN (DASH) diet - improves LV diastolic function, decreases arterial stiffness, facilitates LV arterial coupling (HFpEF)
- control of HTN & glucose important
Chronic HF Tx: Surgery
Goals of surgical Tx for Chronic HF
prevent ventricular remodeling & retain the natural geometry of the heart
Chronic HF Tx: Surgery
Coronary revascularization via CABG or PCI can reverse ____ ________ following an MI.
Successful early revascularization may prevent ________ ____ ________.
LV Dysfunction
Permanent EF Reductions
Chronic HF Tx: Surgery
____ has been shown to reduce 10-year mortality by 7%.
CABG
Chronic HF Tx: Surgery
Cardiac Resynchronization therapy (CRT) aka ________ ________, is a tx ffor HF w/ what?
biventricular pacing
tx for HF w/ a ventricular conduction delay (prolonged QRS)
Chronic HF Tx: Surgery
What does CRT consist of?
What do the leads do?
- placement of a dual chamber cardiac pacemkaer (w/ RA & RV leads)
- an additional lead introduced through the coronary sinus and advanced until it reaches the lateral wall of the LV
- The leads stimulate the heart to contract more synchrously and efficiently to improve CO
Chronic HF Tx: Surgery
CRT is recommended for pts meeting what criteria?
- NYHA class III or IV w/ EF < 5% and a QRS duration 120-150ms
Chronic HF Tx: Surgery
CRT outcomes
- fewer HF sx
- better exercise tolerance
- improved ventricular function
- less hospitalizations
- decreased mortality
Chronic HF Tx: Surgery
CRT risks include:
- infection
- misplacement of the leads
- device failure - causing further cardiac complications
Chronic HF Tx: Surgery
Implantable hemodynamic monitoring allows for remote observation of –
intracardiac pressures to guide tx and prevent decompensation
Chronic HF Tx:
The CardioMEMS HF system allows for management of ____ ________ ________ based on daily measurement of non-invasive ____.
What is done with the results?
LV filling pressures
PAP
The test is done at home and the results are uploaded to the pts physician.
Chronic HF Tx: Surgery
What are implantable cardioverter-defibrilators (ICDs) usef for?
What are 50% of HF deaths due to?
- used for prevention of sudden death in pts w/ advanced HF
- 50% HF deaths d/t sudden cardiac dysrhythmias
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.
Mechanical circulatory support by a ventricular assist device (VAD)
- increased survival & improved quality of life
Chronic HF Tx: LVAD
What do these mechanical pumps take over?
What do they facilitate?
Partial or total function of the damaged ventricle
Restoration of normal hemodynamics & perfusion
Chronic HF Tx: LVAD
What is the LVAD used for?
- 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
LVAD Photo:
Acute HF has ________ onset and presents w/ ____ - ________ conditions.
Rapid
life-threatening
What is acute HF Tx aimed at?
decreasing volume & stabilizing hemodynamics
Who does the term “acute HF” apply to?
- 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)
ADHF Symptoms:
What do they result from?
- fluid retention
- weight gain
- dyspnea
- ALL resulting from decompensation d/t inadequate compensation
De novo HF is characterized by a sudden increase in –
What does this lead to?
- intracardiac filling pressures or acute myocardial dysfunction
- leads to decreased peripheral perfusion & pulmonary edema
What is the leading cause of de novo HF?
What is the management of de novo HF focused on?
- Cardiac ischemia from a coronary occlusion
- stabilizing hemodynamics, restoring myocardial perfusion, improving myocardial contractility
what are the nonischemic causes of de novo HF?
- viral
- drug induced (toxic)
- peripartum cardiomyopathies
What may de novo HF lead to?
- long-term cardiac dysfunction
- management may allow for complete restoration
What does the hemodynamic profile of acute HF include?
- low CO
- high ventricular filling pressures
- HTN or HoTN
Acute HF Tx
What is the 1st line tx for AHF?
- Diuretics: Furosemide, Bumetanide, Torsemide (bolus or cont. infusion)
Acute HF Tx
What patients may require hemodynamic support prior to diuretic therapy?
AHF pts w/ HoTN or cardiogenic shock
Acute HF Tx
Reducing intravascular volume leads to decreased:
Central venous pressure & pulmonary capillary wedge pressure – this reduces pulmonary congestion
Acute HF Tx
________ are proven to correct elevated filling pressures and reduce ________.
Are they useful in pts w/ AHF?
Vasodilators - reduce afterload
- not useful in AHF
Acute HF Tx
________ (drug) is effective in decreasing afterload.
________ (drug) is commonly used as an adjunct to diuretic therapy.
- sodium nitroprusside
- nitroglycerine
Acute HF Tx
What is an example drug of a Vasopressin Receptor Antagonist?
What can it reduce?
- Tolvaptan
- arterial constriction
- hyponatremia
- volume overload associated w/ AHF
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)
- positive inotropes
- cAMP - increases intracellular Ca++ excitation-contraction coupling
Acute HF Tx
Examples of Catecholamine Drugs:
What do the stimulate?
- Epinephrine
- NE
- Dopamine
- Dobutamine
- stimulate Beta receptors on the myocardium - activate adenylyl cyclase - increased cAMP
Acute HF Tx
PDE-inhibitors such as ________, indirectly increase what?
Milrinone
increase cAMP by inhibiting its degradation
Inotropic Agents
Epinphrine
Mechanism:
CO:
MAP:
HR:
B1 = B2 > a
CO ↑↑
MAP ↑↑
HR ↑↑
Inotropic Agents
Norepinephrine
Mechanism
CO:
MAP:
HR:
a > B1 > B2
CO ↑
MAP ↑
HR – or ↓
Inotropic Agents
Dobutamine
Mechanism
CO:
MAP:
HR:
B1 > B2 > a
CO – or ↓
MAP ↑↑
HR ↑↑
Inotropic Agents
Dopamine
Mechanism
CO:
MAP:
HR:
D > B (a w/ high doses)
CO ↑
MAP ↑
HR ↑↑↑
Inotropic Agents
Milrinone
Mechanism:
CO:
MAP:
HR:
PDE Inhibition
CO ↑
MAP – or ↓
HR – or ↓
Inotropic Agents
Levosimendan
Mechanism:
CO:
MAP:
HR:
Calcium Sensitization
CO ↑↑
MAP – or ↓
HR ↑↑
AHF Tx
What drug is exogenous BNP?
What does it bind to?
What does it inhibit and promote?
What are the overall effects?
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
Acute HF Tx
What other effects does Nesiritide have?
Does it show advantage over NTG or SNP?
- induces diuresis and natriuresis
- relaxes cardiac muscle
- lacks dysrhythmic effects
- NO advantage over other vasodilators
Acute HF Tx
What is inidcated when medical management fails & organ dysfunction occurs w/ AHF?
urgent mechanical circulatory support
Acute HF Tx
MCS decision-making tool developed by the Society of Thoracic Surgeons
This is a table
- INTERMACS profile system (inter-agency Registry of Mechanically Assisted Circulatory Support)
How does the IABP function?
What does it improve and how?
- functions by cyclic helium balloon inflation after aortic valve closure, followed by deflation during systole
- improves LV coronary perfusion by reducing LVEDP
IABP degree of support varies based on what factors?
- the set volume
- the size of the balloon
- the ratio of supported beats
Support settings for the IABP:
- full support 1:1 (one inflation for every heartbeat)
- tachycardic pts - 2:1 setting ideal (one inflation per every 2 heartbeats)
What limits the IABP’s long-term use?
- only provides modest improvements in CO (0.5-1L/min)
- renders pts immobile
What is an impella?
a VAD that can be placed percutaneously to reduce LV strain and myocardial work in the setting of acute HF
Impella Devices can be used for up to ____ days.
They serve as a transition to revover or bridge to ________ ________
- 14 days
- cardiac procedures (CABG, PCI, VAD, transplant)
Description of the Impella
- 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
AHF Surgical Tx
What are peripheral VADs?
support devices that can provide extracorporeal membrane oxygenation (ECMO)
AHF surgical tx
Peripheral VAD consits of a ____ ____ & ________. This is helpful for transport, but generates heat and causes more ________ and lower ________.
- consists of a small pump & controller
- causes more hemolysis and lower flows
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.
- oxygenator
- support
AHF surgical tx
What may Central ECMO be necessary for?
- cardiorespiratory support
- alternative to peripheral ECMO if adequate flow rates are not achievable
Acute HF surgical tx
Central VAD/ECMO procedure
- requires sternotomy or thoracotomy for placement
- cannulas are placed in the right atrium and aorta
Acute HF surgical tx
What are the benefits to Central VAD/ECMO?
- complete ventricular decompression
- avoidance of limb impairment
- avoidance of SVC syndrome
Acute HF surgical tx
What is likely reduced in pts on ECMO? Why?
- reduced lung perfusion as blood bypasses the lungs before returning to the aorta
Acute HF surgical tx (ECMO)
________ ________ may be significantly limited by functional shunting around the lungs
Inhaled Anesthetics
Acute HF surgical tx
CRNAs need to recognize that the ECMO membrane is ________, which causes what?
membrane is lipophilic
- causes agents (fentanyl) to become sequestered within the circuit
Acute HF surgical tx
What is a biventricular assist device?
- 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
BiVAD
How can the separate circuits be achieved?
- percutaneous placement to support R and L sides separately
- R & L sides can be centrally cannulated individually
Pre-op management HF:
What do HF pts have an increased risk of developing?
What can these risks lead to?
- renal failure, sepsis, pneumonia, cardiac arrest
- may lead to longer periods of mechanical ventilation and ↑ 30 day mortality
Pre-op management HF
What are the comorbidities that should be examined & optimized w/ HF pts?
HTN, DM, angina, A-fib, renal failure
Pre-op management of HF
Surgery should be postponed in pts experiencing what?
- acute decompensation
- recent change in clinical status
- de novo acute HF
Pre-op management HF
What medications do HF pts take that may affect anesthetic management?
Which ones should be continued/discontinued?
- 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)
Pre-op management HF
12-lead EKG is recommended in who?
- any pt w/ cardiovascular disease
- AKA all our damn pts probs.
Pre-op management HF
A TTE is indicated in what pts?
pts w/ worsening dyspnea during their pre-op eval
Pre-op management HF
LABS
- CBC, electrolytes, liver function, coag studies
- BNP not routinely recommended
Pre-op management HF
____ & ________ should be interrogated prior to surgery.
ICDs and pacemakers
What are cardiomyopathies?
- group of myocardial diseasesassociated with mechanical and/or electrical dysfunction
- usually exhibit ventricular hypertrophy or dilation
Are cardiomyopathies just confined to the heart?
What do they lead to?
No, they can also be part of systemic disorders
Lead to cardiovascular death/disability
Primary Cardiomyopathies
confined to the heart muscle
secondary cardiomyopathies
pathophysiologic cardiac involvement in the context of multiorgan disorder
Is hypertrophic cardiomyopathy primary or secondary?
What is it characterized by?
- complex primary cardiomyopathy
- characterized by LVH in the absence of other diseases capable of inducing ventricular hypertrophy
What is the most common genetic cardiovascular disease?
hypertrophic cardiomyopathy
HCM usually presents w/ hypertrophy of the ________ ________ and the ________ ____ ____.
interventricular septum & anterolateral free wall
What histologic features are associated w/ HCM?
hypertrophied myocardial cells & patchy myocardial scarring
What pathophysiology is r/t HCM?
- myocardial hypertrophy
- dynamic LVOT obstruction
- mitral regurgitation
- diastolic dysfunction
- myocardial ischemia
- dysrhythmias
Factors that induce LVOT obstruction in HCM
- hypovolemia, tachycardia, increased myocardial contractility, decreased afterload
Hypertrophied myocardium has a prolonged ________ and decreased ________.
relaxation and decreased compliance
________ ________ is present in pts w/ HCM regardless of if they have CAD or not.
myocardial ischemia
What is the sudden cause of death in young adults w/ HCM?
What is it caused by?
Dysrhythmias
* caused by: disorganized cellular architecture, myocardial scarring, expanded interstitial matrix
In asymptomatic pts, what may be the only sign of HCM?
unexplained LVH
EKG abnormalities are seen in ____ - ____ % of pts w/ HCM.
What are the EKG abnormalities?
75-90%
* high QRS voltage, ST-segment & T-wave alterations, abnormal Q waves, left atrial enlargement
What will Echo show in pts w/ HCM?
- myocardial wall thickness > 15mm
- EF > 80% (hypercontractility)
- EF severely depressed in terminal states
HCM: Cardiac cath allows for direct measurement of –
the increased LVEDP
HCM tx
Medical therapy for HCM
- BBs & CCBs
- if HF developed - may show improvement w/ diuretics
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?
Disopyramide
* negative inotropic effect
* improves LVOT obstruction & HF sxms.
____ often develops in HCM.
This is associated w/ increased risk of –
A-fib
* increased risk of thromboembolism, HF, & sudden death
HCM tx
What is the most effective anti-dysrhythmic in HCM pts?
What is indicated for recurrent or chronic A-fib?
- Amiodarone
- long-term anticoagulation
HCM tx: surgical
Who is HCM surgery reserved for?
- subgroup of pts w/ large outflow tract gradients & severe sxms despite medical tx
HCM tx: surgical
What are the surgical strategies for pts w/ HCM?
- septal myomectomy
- cardiac cath w/ injection to induce ischemia of the septal perforator arteries
- echocardiogram-guided percutaneous septal ablation
HCM tx: surgical
In pts remaining symptomatic - a ________ ________ ________ can be inserted to conteract the systolic anterior motion of the mitral leaflet.
prosthetic mitral valve
HCM tx: surgical
What is the primary tx for pts at risk of sudden cardiac death d/t dyshrythmias?
ICD placement
What is Dilated Cardiomyopathy?
What is it characterized by?
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
What is the initial Sxm of dilated cardiomyopathy?
What other sxm may occur?
- HF
- chest pain
Dilated Cardiomyopathy
Ventricular dilatation may lead to ________ and/or ________ ________.
Mitral/Tricuspid Regurgitation
What pathologic events are common w/ dilated cardiomyopathy?
- dysrhythmias
- conduction abnormalities
- emboli
- sudden death
Dilated Cardiomyopathy
What does the ECHO usually show?
- dilation of all 4 chambers
- predominantly the LV
- Global hypokinesis
Dilated Cardiomyopathy
EKG results -
often show ST-segment & T-wave abnormalities
* LBBB
* common dysrhythmias: PVC, A-fib
Dilated Cardiomyopathy Tx
- similar to tx of chronic HF
- anticoagulation often indicated
- prophylactic ICD placement decreases risk of sudden death by 50%
What is the principal indication for cardiac transplant?
Dilated Cardiomyopathy
What is stress cardiomyopathy?
(what I have.)
- “apical ballooning syndrome”
- temporary cardiomyopathy characterized by LV apical hypokinesis w/ ischemic eKG changes
- cornary arteries rmain patent
Stress cardiomyopathy
There is a temporary disruption of contractility in the ____ ____ while the rest of the heart has ________ ________.
LV Apex
Normal contractility
What is the most common cuase of stress cardiomyopathy?
Common Sxms?
More in men or women?
STRESS, aka CRNA school.
(physical & emotional)
Sxms: chest pain, dyspnea
- more in women b/c men bury their emotions.
What is peripartum cardiomyopathy?
- a rare primary cardiomyopathy
- dilated cardiomyopathy - unkown cause
- arises during peripartum (3rd trimester-5mos PP)
3 criteria for Dx of peripartum cardiomyopathy
- development of HF in the period surrounding delivery
- absence of other explainable cause
- LV systolic dysfunction w/ a LVEF < 45%
Dx studies for peripartum cardiomyopathy
- EKG
- ECHO
- CXR
- cardiac MRI
- cardiac cath
- endomyocardial biopsy
- BNP levels
What are secondary cardiomyopathies d/t?
systemic diseases that produce myocardial infiltration & severe diastolic dysfunction
Causes of secondary cardiomyopathies
- most common cause: amyloidosis
- other causes: hemochromatosis, sarcoidosis, carcinoid tumors
Secondary Cardiomyopathy diagnosis should be considered in pts who have –
HF but no evidence of cardiomegaly or systolic dysfunction
Sxms secondary cardiomyopathy
pts can have low to normal BP
* can develop orthostatic HoTN
Classification of primary cardiomyopathies
Genetic
- 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)
Classification of Primary Cardiomyopathies
Mixed:
- Dilated cardiomyopathy
- primary restrictive nonhypertrophic cardiomyopathy
Classification of Primary Cardiomyopathies
Acquired:
- myocarditis (inflammatory cardiomyopathy)
- viral
- bacterial
- fungal
- rickettsial
- parasitic (Chagas Disease)
Classification of Primary Cardiomyopathies
Other:
- peripartum cardiomyopathy
- stress cardiomyopathy (Takotsubo cardiomyopathy)
Classification of Secondary Cardiomyopathies
Infiltrative:
- amyloidosis
- Gaucher disease
- Hunter syndrome
Classification of secondary Cardiomyopathies
Storage:
- hemochromatosis
- glycogen storage disease
- Niemann-Pick disease
Classification of secondary cardiomyopathies
Toxic:
- Drugs: cocaine, alcohol
- Chemotherapy drugs: doxorubicin, daunorubicin, cyclophosphamide
- Heavy metals: lead, mercury
- Radiation therapy
Classification of Secondary Cardiomyopathies
Inflammatory
Sarcoidosis
Classification of Secondary Cardiomyopathies
Endomyocardial
- hypereosinophilic (Loffler) syndrome
- endomyocardial fibrosis
Classification of secondary cardiomyopathies
Endocrine
- DM
- hyper/hypothyroid
- pheochromocytoma
- acromegaly
Classification of secondary cardiomyopathies
Neuromuscular
- Duchenne-Becker Dystrophy
- neurofibromatosis
- tuberuous sclerosis
Classification of secondary cardiomyopathies
Autoimmune
- Lupus Erythematosus
- RA
- Scleroderma
- Dermatomyositis
- polyarteritis nodosa
What is Cor Pulmonale?
RV enlargement (hypertrophy and/or dilation) that may progress to right-sided HF
Causes of Cor Pulmonale?
- 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 **
Cor Pulmonale: EKG
- signs of RA/RV hypertrophy
- RA hypertrophy: peaked P waves in II, III, avF
- Right axis deviation & RBBB
Cor Pulmonale: other diagnostics
TEE, right heart cath, CXR
What is the most important determinant of pulmonary HTN & Cor Pulmonale in pts w/ chronic lung disease?
What is the best treatment?
- alveolar hypoxia
- long-term oxygen therapy
