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health assessment > Heart Failure (Exam IV) > Flashcards

Heart Failure (Exam IV) Flashcards

1
Q

Heart failure is a complex clinical syndrome resulting from any _______ or ______ impairment of ventricular filling or ejection of blood. The heart cannot meet metabolic tissue requirements or fill completely.

A
  • Structural (Pericardium, myocardium, endocardium, heart valves, great vessels)
  • Functional (Systolic, Diastolic)
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2
Q

HF w/ reduced EF (HFrEF). EF is < or equal _______ %

A
  • 40%
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3
Q

HF w/ preserved EF (HFpEF). EF > or equal to _______%

A
  • 50%
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4
Q

Characteristics of LV Diastolic Dysfunction.

A
  • Increased myocardial stiffness
  • Reduction in LV compliance
  • Restricted LV filling
  • Delayed LV relaxation (LV weakens over time)
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5
Q

What is the difference b/w HFrEF vs HFpEF?

A
  • HFrEF is a systolic failure (pumping problem d/t eccentric remodeling)
  • HFpEf is a diastolic failure (filling problem d/t concentric hypertrophy)
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6
Q

LV systolic dysfunction effects on
Contractility
SV
ESV
EDV
LV End Diastolic Pressure

A
  • ↓ Contractility
  • ↓ SV
  • ↑ ESV
  • ↑ EDV
  • ↑ LV End Diastolic Pressure

LV Systolic dysfunction will lead to compensatory LV dilation → fluid back into LA → Pulmonary venous congestion.

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7
Q

Left atrial systolic and diastolic dysfunction effects on
LV compliance
LV pressure
LA pressure

A
  • ↓ LV compliance
  • ↑ LV pressures
  • ↑ LA pressure to preserve LV filling

Over time, this dysfunction will dilate the LA and reduce LA compliance reducing LA filling. → Atrial Fibrillation

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8
Q

What will be the results of LV diastolic dysfunction?

A
  • LA HTN
  • LA systolic and diastolic dysfunction
  • Pulmonary venous congestion
  • Exercise intolerance.
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9
Q

What is systolic heart failure?

A
  • Systolic dysfunction – decreased ventricular systolic wall motion
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10
Q

What are the causes of systolic heart failure?

A
  • CAD
  • Dilated cardiomyopathy
  • Chronic pressure overload from aortic stenosis or chronic HTN
  • Chronic volume overload from regurgitant valvular lesions or high-output cardiac failure
  • Ventricular Dysryhtmias - LBB

Systolic Heart Failure will decrease EF.

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11
Q

The hallmark of chronic LV systolic dysfunction.

A
  • Decrease EF, < 40%
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12
Q

What is diastolic HF?

A
  • Abnormal ventricular relaxation (ventricles don’t relax as much) and reduced compliance
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13
Q

Causes of Diastolic HF?

A
  • IHD
  • Long-standing systemic HTN
  • Progressive aortic stenosis
  • Age dependent
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14
Q

Classes of Diastolic HF

A
  • Class I - abnormal LV relaxation pattern with normal left atrial pressure
  • Classes II, III, and IV - abnormal relaxation and reduced LV compliance, increasing LV End Diastolic Pressure
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15
Q

What is Acute Decompensated HF

A
  • Worsening symptoms of a preexisting condition

Chronic HF that has gotten acutely worse.

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16
Q

What is de novo acute HF

A
  • A sudden increase in intracardiac filling pressures and/or acute myocardial dysfunction

Example: Giant MI. This is an Emergent situation

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17
Q

CHF is present in pts with long-standing cardiac disease.
CHF is often accompanied by __________, but BP is maintained d/t adaptive mechanisms of action.

A
  • Venous congestion
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18
Q

Frank-starling Relationship.
SV directly related to _______.

A
  • LVEDP
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19
Q

The magnitude of the increase in SV produced by changing the __________of ventricular muscle fibers depends on myocardial ________.

A
  • Tension; Contractility
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20
Q

How does SNS Activation maintain BP in CHF patients?

A
  • Promotes arteriolar and venous constriction
  • Arteriolar constriction
  • The increased venous tone shifts blood from peripheral sites to the central circulation: ↑ Venous Return to LA
  • ↓ Renal blood flow activates RAAS

↑ SNS activity contributes to the deterioration of HF in the long term

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21
Q

What is an Inotropic State?

A
  • Myocardial contractility is reflected by the velocity of contraction developed by cardiac muscle.
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22
Q

What is Afterload?

A
  • The tension the ventricular muscle must develop to open the aortic or pulmonic valve.
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23
Q

Systolic HF with a low CO will have a _________ SV.

A

Fixed

Systolic HF is a pumping problem. SV can’t increase to compensate for low CO. HR will need to increase CO.

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24
Q

Diastolic HF with tachycardia leads to decreased _______.

A

Cardiac Output

Diastolic HF is a filling issue. Tachycardia doesn’t allow the heart to fill adequately. Need to control HR in Diastolic HF.

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25
Q

In an attempt to counterbalance these mechanisms, the heart evolves into an “endocrine” organ. What hormones does the heart release?

A
  • ANP (release from atrial muscle) - released d/t ↑ atrial pressure.
  • BNP (release from atrial and ventricular myocardium)
  • In the failing heart, the ventricle becomes the principal site of BNP production.
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26
Q

Physiologic effects of natriuretic peptides

A
  • Diuresis
  • Natriuresis (Na+ excretion)
  • Vasodilation
  • Anti-inflammatory effect
  • Inhibition of the RAAS and SNS
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27
Q

ANP and BNP inhibit cardiac _______ and ________.

A
  • Hypertrophy
  • Fibrosis

This is the heart’s protective mechanism.

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28
Q

What are the various endogenous mechanisms the body uses to maintain CO?

A
  • Mechanical
  • Neurohormonal
  • Genetic

These factors change LV size, shape, and function

29
Q

_______ injury is the most common cause of myocardial remodeling and encompasses both hypertrophy and dilatation of the left ventricle.

A
  • Ischemic
30
Q

Myocardial hypertrophy represents the compensatory mechanism for chronic pressure overload. How are the effects of this mechanism limited?

A
  • Hypertrophied cardiac muscle functions at a lower inotropic state than normal cardiac muscle.
31
Q

Cardiac dilatation occurs in response to volume overload and increases cardiac output by the Frank-Starling relationship. However, the increased cardiac wall tension produced by an enlarged ventricular radius is associated with increased ________ requirement and decreased _________.

A
  • Increased Myocardial Oxygen Requirements
  • Decreased Pumping Efficiency
32
Q

Types of Myocardial Remodeling

A
  • Cardiac Dilatation - d/t chronic volume overload
  • Eccentric Hypertrophy- d/t chronic volume overload
  • Concentric Hypertrophy - d/t chronic pressure overload
33
Q

Signs and Symptoms of HF (long list)

What is your earliest finding?

A
  • Dyspnea (earliest finding)
  • Orthopnea (pt needs to sleep sitting up.)
  • Paroxysmal nocturnal dyspnea
  • Pulmonary edema
  • Peripheral edema (Assess Pitting Edema)
  • Fatigue and weakness at rest or with minimal exertion (This will indicate ↓Cardiac Reserve and ↓CO.)
  • Anorexia, nausea, or abdominal pain (Liver congestion)
  • Confusion, difficulty concentrating, insomnia, anxiety, or memory deficits (d/t ↓ cerebral blood flow).
  • S3 gallop (occurs in early diastole at the end of rapid diastolic filling- Ken-tuc-ky)
  • JVD (d/t weakened right ventricle)
  • Exercise intolerance (quantify with METs)
34
Q

What medical imagings are used for HF?

Which imaging has the lowest predictive value of CHF?

A
  • ECG (Lowest predictive valve of CHF)
  • CXR
  • ECHO
35
Q

What is used to dx HFpEF?

A
  • ECHO

An ECHO evaluate left and right ventricular structure and function in both systole and diastole, as well as valvular function, and can detect the presence of pericardial disease.

36
Q

What are HF findings in a CXR?

A
  • Distention of the pulmonary veins in the upper lobes
  • Kerley lines
  • Alveolar edema (butterfly patternn)
  • Pleural effusion and pericardial effusion
  • Cardiac enlargement (wide mediastinum)
37
Q

Where are each of Kerley’s lines located:
Kerley Line A
Kerley Line B
Kerley Line C

A
  • Kerley Line A - Upper lung fields
  • Kerley Line B - Lower lung fields (perpendicular to chest wall)
  • Kerley Line C - Basilar Regions of the lungs

Kerley Lines produce a honeycomb pattern on the CXR.

38
Q

What lab values will be obtained with HF patients?

A
  • BNP levels
  • Troponins
  • C-reactive proteins
  • Growth differentiation factor 15
39
Q

A BNP level above what number correlates with a 90% positive predictive value of HF.

A
  • 500 pg/mL
40
Q

What BNP level will detect dyspnea of cardiac origin?

A
  • 300 pg/mL
41
Q

Classification of heart failureNew York Heart Association

A
42
Q

Classification of heart failure2005 ACC/AHA Classification

A
43
Q

Acute Heart Failure is an emergent situation characterized by what?

A
  • High ventricular filling pressure
  • Low CO
  • Hypertension or Hypotension
44
Q

What meds are given to someone with Acute HF?

A
  • Diuretics (Loop diuretics improve symptoms rapidly)
  • Vasodilators (Nitroglycerin and nitroprusside)
  • Inotropic drugs (Epinephrine, norepinephrine, dopamine, dobutamine, PDE inhibitors)
  • Mechanical assist devices (IABP, VADs)
  • Emergency surgery
45
Q

What INTERMACS score will require some type of assistance immediately to sustain life?

A
  • 1 or 2
46
Q

Lifestyle modifications for HF.

A
  • Smoking cessation
  • Adherence to a healthy diet with moderate Na restriction
  • Weight control
  • Exercise
  • Moderation of alcohol consumption
  • Adequate glycemic control
47
Q

How do diuretics treat HF?

A
  • Reduces LV filling pressures
  • Decreases pulmonary venous congestion
48
Q

What diuretics are recommended for HF therapy?

A
  • Thiazides
  • Loop diuretics
49
Q

What is the first-line therapy for patients presenting with acute heart failure?

A

Diuretics

50
Q

Beta-Blockers for HF patients.
* What does it do to SNS?
* What does it do to morbidity and hospitalization?
* What does it do to the quality of life?
* What will it do to EF and ventricular remodeling?
* Is it beneficial for HFrEF or HFpEF?

A
  • Reverses the effects of SNS activation
  • Reduces morbidity and the number of hospitalizations
  • Improves both qualities of life and length of survival
  • Increases EF and decreases ventricular remodeling
  • Beneficial for the treatment of HFrEF
51
Q

ACE inhibitors and ARBs for HF.
* ACE inhibitors recommended for HFrEF or HFpEF?
* What do both drugs do to ventricular remodeling?
* What do both drugs do to morbidity and mortality?
* ACE inhibitors combined with what drug will have good long-term outcomes?
* ARBS is useful for the control of arterial pressure in patients with ______ and ______.

A
  • ACE-I recommended for HFrEF
  • Proven to decrease ventricular remodeling
  • Reduce morbidity and mortality at any stage of HF
  • Therapy with ACE-I and β-blockers favorably influences long-term outcome
  • ARBS is useful for the control of arterial pressure in patients with HTN and HFpEF
52
Q

Effects of Statins for HF.

A
  • Anti-inflammatory and lipid-lowering effects
  • Decrease morbidity and mortality in pts with systolic and diastolic HF
  • Recommended use of statins in all HF pt.
53
Q

Use of Vasodilators in HF therapy.

A
  • Relaxes vascular smooth muscle
  • Decreases resistance to LV ejection, reduce afterload
  • Results in increased SV and decreased ventricular filling pressures
54
Q

What will cardiac resynchronization therapy do?

A
  • Increases contractility
  • Increase CO
55
Q

Types of resynchronization therapy.

A
  • Dual-chamber cardiac pacemaker
  • Implantable cardioverter-defibrillator (ICDs)
56
Q

What NYHA Class qualifies for cardiac resynchronization therapy?

A
  • Class III or IV
57
Q

LVEF < _______ and QRS duration of ________ (range) warrants cardiac resynchronization therapy.

A

LVEF < 35%
QRS: 120-150 ms (ventricular conduction delay)

58
Q

Surgical Management of HF
What is the gold standard?

A
  • PCI or CABG
  • Repair/replace valves
  • Cardiac transplantation (gold standard)
59
Q

What are Ventricular Assist Devices, and what do they do?

A
  • Mechanical support of the circulation
  • Increased survival, improved quality of life > medical treatment
  • Mechanical pumps that take over the ventricle
60
Q

Using VAD for the bridge to recovery

A

Require temporary ventricular assistance to allow the heart to recover its function.

61
Q

Using VAD for the bridge to therapy

A

Awaiting cardiac transplantation

62
Q

Using VAD for the bridge to decision

A

Pts on inotropic drugs or IABP with potentially reversible medical conditions

63
Q

Using VAD for destination therapy

A

Advanced HF who are not transplant candidates

Destination to Heaven

64
Q

What are the types of VAD?

A

IABP
* Increases aortic diastolic blood pressure and coronary perfusion pressure
* Enhances LV ejection

Impella system
* Miniaturized axial-flow rotary blood pump that draws blood from LV to ascending aorta.
* Generate CO of up to 5 L/min

65
Q

Pre-operative evaluation (long list)

A
  • TX precipitating factors for HF aggressively before elective surgery
  • ID previously recognized HF and assess the current degree of compensation relative to baseline
  • Establish the underlying cause of HF
  • ID and address coexisting conditions that may precipitate HF during the peri-op period
  • Exclude or confirm a new HF diagnosis in patients with dyspnea, fatigue, edema, congestion, or arrhythmias
  • Document the level of activity that elicits HF symptoms
  • Determine the stability of HF
  • β-blockers reduce perioperative morbidity and mortality
  • Electrolytes, renal function, and liver function tests
  • ECG and echocardiogram
66
Q

What will be d/c for surgery in HF patients?

A
  • Diuretics (d/c on the day of surgery)
  • ACE inhibitors
67
Q

Anesthetic considerations

A
  • GA – adjust drug dosages
  • Avoid hypotension - use ephedrine, phenylephrine, or vasopressin to manage BP.
  • Monitor fluids
  • Neuraxial anesthesia can be beneficial (watch for ↓ SVR)
68
Q

How does the heart physically compensate for LV systolic dysfunction?

A
  • LV dilation
69
Q

First-line therapy in all patients with heart failure.

A
  • ACE-inhibitors
  • Aldosterone Antagonist
  • Diuretics

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