Heart failure - Final Flashcards
1
Q
____ is a complex syndromeleading to impaired ventricular filling or blood ejection
Leads to ____ ____
A
Heart failure
Systemic Hypoperfusion
2
Q
Heart failure may be caused by what?
A
structural abnormalities of the pericardium, myocardium, endocardium, heart valves, or great vessels
3
Q
Symptoms of HF
A
fatigue, dyspnea, weakness, edema, and weight gain, tachypnea, orthopnea, S3 gallop, JVD, exercise intolerance, reduced tissue perfusion
4
Q
Explain the different types of HF
A
HF with reduced EF (HFrEF, aka systolic HF): HF w/ EF ≤40%
HF with preserved EF (HFpEF, aka diastolic HF): HF w/ EF≥50%
Borderline HFpEF: Symptomatic HF w/ an EF btw 40-49%
5
Q
Diastolic dysfunction is present in both ___ and ____
A
HFrEF
HFpEF
6
Q
What are the distinguishing features between HFrEF and HFpEF?
A
LV dilation patterns, and remodeling
As well as different responses to medical treatment
7
Q
What is the main marker for determining HF risk factors, treatments, and outcomes?
A
Ejection fraction
8
Q
The proportion of pts with HFpEF is increasing d/t its relationship w/conditions such as:
A
HTN, DM, A-fib, obesity, metabolic syndrome, COPD, renal insufficiency, and anemia
9
Q
Pts with HFrEF are more likely to have ____ risk factors (smoking, hyperlipidemia) as well as a higher incidence of:
A
Modifiable
myocardial ischemia & infarction, previous coronary intervention, CABG, and PVD
10
Q
___% HF cases are HFpEF
___% are HFrEF
___% are borderline HFpEF (EF 40-49%)
A
52%
33%
16%
11
Q
_____ are more likely to be affected by HFpEF
_____ more likely to be affected by HFrEF
A
Women
Men
12
Q
LV ______ dysfunction is the primary determinant of HFpEF, whereas LV_____ dysfunctionis the primary determinant for HFrEF
A
Diastolic
Systolic
13
Q
The LV’s ability to fill is determined by:
A
pulmonary venous blood flow
LA function
mitral valve dynamics
pericardial restraint
the elastic properties of the left ventricle
14
Q
The majority ofLVDD measurements depend on:
A
HR, loading conditions, contractility
15
Q
In HFpEF, what is required to achieve normal EDV?
A
Higher LV filling pressures
16
Q
A steeper rise of the end-diastolic pressure-volume curve is indicative of:
A
delayed LV relaxation and increasedmyocardial stiffness
17
Q
What does reduced LV compliance lead to?
A
LA hypertension, LA dysfunction, pulmonary venous congestion, and exercise intolerance
18
Q
LV pressure volume loop picture
A
19
Q
Common causes of LV diastolic dysfunction picture
A
20
Q
In LV end-diastolic dysfunction, delays in relaxation are caused by what?
A
failure of actin-myosin disassociation, which occurs due to inadequate perfusion or dysfunctional intracellular Ca++ homeostasis
21
Q
____ exacerbates diastolic dysfunction
A
Tachycardia
22
Q
Exercise intoleranceoccurs w/ _____ despite having only a slightly depressed LV systolic function
A
HFpEF
23
Q
What HF symptoms are more common in HFpEF?
HFrEF?
A
paroxysmal nocturnal dyspnea, pulmonary edema, dependent edema
S3 gallop
24
Q
In contrast to _____, the initial diagnosis of_____is more difficult,especially when the pt has little/no symptoms at rest
A
HFrEF
HFpEF
25
__________ defines elevated LV systolic and diastolic stiffness using pressure-volume analysis
Cardiac catheterization
26
Measurement of ___ _____ _____ provide further information on the severity of HFpEF
RV filling pressures
27
How can a CXR help with diagnosis of HF?
may detect pulmonary dz, cardiomegaly, pulmonary venous congestion, and interstitial or alveolar pulmonary edema
## Footnote
Pleural effusion and pericardial effusion may be present
27
Mean pulmonary capillary wedge pressure _____mmHg at rest or ____mmHg during exercise indicates HFpEF and is a predictor of mortality
>15mmHg
25mmHg
28
An early sign of LV failure & pulmonary venous HTN on CXR is:
distention of the pulmonary veins in the upper lung lobes
29
Perivascular edema appears as what on CXR?
hilar haze with ill-defined margins
30
Kerley lines produce what on CXR?
honeycomb pattern, which reflect interlobular edema
31
Alveolar edema produces what on CXR?
densities in the lung fields, typically in a butterfly pattern
32
Radiographic evidence of ____ ____ may lag behind the clinical evidence by up to 12 hours
Pulmonary edema
33
Kerley lines in HF on CXR picture
34
Diagnosis of HFpEF
Echocardiogram
The ACC/AHA diagnostic criteria d/o 3 factors: HF sx, EF >50%, and evidence of LVDD
- This approach is useful for pts with clear sx, but may be too simplistic for subclinical HFpEF
The ESC criteria is more specific and incorporates echocardiographic indexes another measurements
35
EKG abnormalities are common in HF pts and are typically r/t underlying pathology s/a:
LVH, previous MI, arrhythmias and conduction abnormalities
36
Labs for HF
BNP
Troponin
CRP
Growth differentiation factor-15 (GDF15)
37
Describe BNP
Brain natriuretic peptide (BNP) & N-terminal pro-BNP are important biomarkers
- Natriuretic peptide concentrations are related to LV end-diastolic wall stress, which is higher in HFrEF d/t LV dilation & eccentric remodeling
## Footnote
In contrast, HFpEF is assoicated w/concentric hypertrophy, relatively normal LV chamber size, and lower LV end-diastolic wall stress, allowing for lower BNP or NT-proBNP levels
38
Troponins are elevated in HF d/t what?
myocardial damage and serve as a measure of risk prediction
39
C-reactive protein (CRP) and Growth differentiation factor-15 (GDF15) represent what?
the inflammatory component of HF
40
Classification of HF chart
41
Survival of pts w/_____ has improved with treatments, but survival with ____ remains unchanged
HFrEF
HFpEF
42
Medication treatments are ineffective for what type of HF?
HFpEF
43
HFpEF tx
Mitigation of sx’s, treat associated conditions, exercise, weight loss
44
HFrEF tx
ΒB's and ACE-inhibitors
45
Chronic HF treatment includes:
Diuretics
B-blockers
Ace-inhibitors
Arbs
Lifestyle changes
46
Loop diuretics are recommended to do what in HF?
reduce LV filling pressures, decrease pulmonary venous congestion, and improve HF sx
47
Thiazide diuretics may be useful in ____ ____ ___ pts to prevent the HFpEF
Poorly controlled HTN
48
For B-blockers, they are strongly recommended for ____; Benefit not clearly established for ____
HFrEF
HFpEF
49
ACE-inhibitors and ARBs are mainstay tx’s for _____; however, no benefit in ____ unless used for managing HTN
HFrEF
HFpEF
50
What does lifestyle changes include for tx of HF?
- Aerobic exercise reduces symptoms, and increases quality of life
- Weight loss reduces major risk factors for HF, including HTN & DM
- DASH diet (Salt-restricted Dietary Approaches to Stop Hypertension) improves LV diastolic function, decreases arterial stiffness, and facilitates LV-arterial coupling in pts w/ HFpEF
- BP and blood glucose mgmt are also important
51
The goal of surgical treatment for chronic HF is to prevent:
ventricular remodeling and preserve natural geometry of the heart
52
______ ______ via CABG or PCI can reverse LV dysfunction after MI
Coronary revascularization
## Footnote
Successful early revascularization may prevent permanent EF reductions
53
________ is a tx for HF w/a ventricular conduction delay (prolonged QRS)
Cardiac resynchronization therapy (CRT): Aka “biventricular pacing,”
54
Explain Cardiac resynchronization therapy (CRT):
- dual-chamber pacemaker stimulates heart to contract more synchronously
- CRT is recommended for pts w/EF < 35% and a QRS duration 120-150 ms
- CRT outcomes: better exercise tolerance, improved ventricular function, less hospitalizations, and decreased mortality
55
Risks for Cardiac resynchronization therapy (CRT):
infection, misplacement, and device failure
56
_______ allows remote observation of intracardiac pressures to guide tx
Implantable hemodynamic monitoring
57
What's an example of Implantable hemodynamic monitoring?
CardioMEMS Heart Failure system: daily measurements of noninvasive PAP are obtained at home and uploaded to the physician
58
_________ are used for prevention of sudden death in pts with advanced heart failure
Implantable cardioverting-defibrillators (ICDs)
## Footnote
̴ 50% HF deaths are d/t sudden cardiac dysrhythmias
59
Pts in the terminal stages of HF may benefit from what type of device?
LV assist devices
- mechanical circulatory support (MCS) by a ventricular assist device (VAD)
60
What is the point of a LV assist device?
These pumps can take over function of the damaged ventricle and restore hemodynamic function and perfusion
61
LVADs are used for?
- temporary ventricular assistance while heart is recovering its function
- Pts awaiting cardiac transplant
- Pts are on inotropes or balloon pump (IABP) with reversible medical conditions
- Pts with advanced HF who aren’t transplant candidates
62
LVAD picture
63
What is the difference in acute vs chronic HF?
Chronic heart failure is classified as long-standing HF disease
Acute heart failure: rapid onset, often presenting w/life-threatening conditions
## Footnote
tx for AHF is aimed at decreasing volume & stabilizing hemodynamics
64
Acute heart failure refers to those w/:
exacerbated preexisting HF (acute decompensated heart failure [ADHF]) and initial onset HF (de novo acute heart failure)
65
ADHF sx include:
fluid retention, weight gain & dyspnea
66
De novo AHF is characterized by:
a sudden increase in filling pressures or acute myocardial dysfunction, leading to decreased perfusion and pulmonary edema
67
______ ______ is the leading cause of de novo HF; therefore, tx focuses on what?
Cardiac ischemia
restoring cardiac perfusion, improving contractility, and stabilizing hemodynamics
68
Less common nonischemic causes of de novo HF include:
viral, drug-induced, and peripartum cardiomyopathy
69
The hemodynamic profile of ADHF includes:
low COP, high ventricular filling pressures, and HTN or HoTN
70
What is the 1st line tx for AHF? Why?
Exception?
Diuretics: Reducing in intravascular volume decreases CVP and pulmonary capillary wedge pressures (PCWP), reducing pulmonary congestion
If HoTN, pt may require hemodynamic support prior to diuretic therapy
## Footnote
Furosemide, Bumetanide, and Torsemide, given as bolus or continuous infusions
71
What is the point of used vasodilators in acute HF?
reduce filling pressures and afterload; however, evidence is lacking on their efficacy in AHF
## Footnote
- SNP is effective in rapidly decreasing afterload
- NTG is commonly used as an adjunct to diuretic therapy
- Overall, routine use of vasodilators is not shown to improve outcomes
72
What are vasopressin receptor antagonists used for in acute HF?
potential adjuncts, to reduce the arterial constriction, hyponatremia, and volume overload associated with AHF
73
_____ _____ are the mainstay tx for pts with acute reduced contractility, or cardiogenic shock
Positive inotropes
74
What do catecholamines do?
Examples?
stimulate β-receptors on the myocardium to activate adenylyl cyclase to increase cAMP
epinephrine, norepinephrine, dopamine, dobutamine
75
What do PDE inhibitors do?
inhibit cAMP degradation, cAMP increases intracellular calcium and excitation-contraction coupling
76
Commonly used inotropic agents in AHF chart
77
What is exogenous BNP used for in acute Hf?
Example?
inhibits the RAAS and promotes vasodilation, decreasing LVEDP and improving dyspnea; also induces diuresis & natriuresis and relaxes cardiac muscle
Nesiritide
## Footnote
However, Nesiritide has not shown advantage over traditional vasodilators such as NTG & SNP
78
What is an intraortic balloon pump used for?
functions by balloon inflation after aortic valve closure, followed by deflation during systole
- improve LV coronary perfusion by reducing LVEDP
79
Overall, IABP provides only modest improvements in COP (_____ L/min) and render pts:
0.5–1 L/min
immobile, limiting its long-term use
79
Explain the different levels of support from an IABP
degree of support varies b/o the set volume, size of balloon, and ratio of supported beats
- Full support would be 1:1 (one inflation for every heartbeat)
- In tachycardic pts, a setting of 1:2 (one inflation per every two heartbeats) is ideal
80
What is an impella used for?
a VAD, placed percutaneously to reduce LV strain and myocardial work
- Can be utilized for up to 14 days and serve as a transition to recovery or a bridge to cardiac procedure (CABG, PCI, VAD, transplant)
81
What does an impella consist of?
consists of a miniature rotary blood pump inserted through the femoral artery, advanced through the aortic valve and sits in the LV
- The pump draws blood continuously from the LV through the distal port and ejects it into the ascending aorta through its proximal port
82
What is a peripheral VAD used for?
support device that can provide extracorporeal membrane oxygenation (ECMO)
- Consists of a small pump & controller, which is helpful for transport, but generates heat, causing more hemolysis and lower flows
83
What is a central VAD/ECMO used for?
Explain these?
may be necessary for cardiorespiratory support or an alternative to peripheral VAD
Cannulas placed in the right atrium and aorta
- Invasive; require sternotomy or thoracotomy for placement
84
What are the benefits of central VAD/ECMO?
complete ventricular decompression, avoidance of limb impairment, and avoidance of SVC syndrome
85
Pts on ECMO likely have reduced ____ ______ as blood bypasses the lungs before returning to the aorta
lung perfusion
86
What type of anesthesia is preferred for pts on ECMO?
TIVA
87
ECMO membrane is _____, causing many agents, including fentanyl, to become what?
lipophilic
sequestered within the circuit
88
What is a BiVAD (Biventricular assist device) used for?
Once a pt on central ECMO is stabile, decoupling support of the ventricles with two circuits facilitates weaning of the left- or right-sided support
- Separate circuits can be achieved by percutaneous placement to support the right and left sides, separately
- Alternatively, the right and left sides can be centrally cannulated individually
89
HF pts have an increased risk of what?
renal failure, sepsis, pneumonia, and cardiac arrest
## Footnote
require longer periods of mechanical ventilation; and have an increased 30-day mortality
90
Surgery should be postponed in HF pts experiencing what?
decompensation, a recent change in clinical status, or in de novo acute heart failure
91
Preop management of HF pts
*Most of these are common sense but just so they are added to the cards*
- HF pts usually take several meds that may affect anesthetic mgmt
- Generally, diuretics be held on the day of surgery
- BB maintenance is essential
- ACE-inhibitors may put pts at risk of intraop HoTN
- 12-lead EKG is recommended in any pt w/cardiovascular dz
- A transthoracic echocardiogram (TTE) is indicated in pts w/worsening dyspnea
- Labs: CBC, electrolytes, liver function, and coagulation studies
- BNP is not routinely recommended
- ICDs and pacemakers should be interrogated prior to surgery
92
What is cardiomyopathy?
cardiac disease associated with mechanical and/or electrical dysfunction, often with ventricular hypertrophy or dilation
93
What are the two cardiomyopathy groups?
Primary cardiomyopathies: are confined to heart muscle
Secondary cardiomyopathies: pathologic cardiac involvement assoc w/multiorgan disorder
94
What is hypertrophic cardiomyopathy?
complex primary cardiomyopathy
- most common genetic cardiovascular disease
- characterized by LVH in the absence of other diseases capable of inducing ventricular hypertrophy
95
What does Hypertrophic Cardiomyopathy usually present with?
hypertrophy of the interventricular septum and the anterolateral free wall
96
Pathophysiology of HCM is related to what?
myocardial hypertrophy, LVOT obstruction, mitral regurgitation, diastolic dysfunction, myocardial ischemia, and dysrhythmias
97
The hypertrophied myocardium has a prolonged ______ time and decreased _____
relaxation
compliance
98
_____ are the cause of sudden death in young adults with HCM
Dysrhythmias
99
Dysrhythmias in HCM are c/b:
disorganized cellular architecture, myocardial scarring, and an expanded interstitial matrix
100
In asymptomatic pts, _______ may be the only sign of HCM
unexplained LVH
101
What are EKG abnormalities seen in HCM?
high QRS voltage, ST-segment and T-wave alterations, abnormal Q waves, and left atrial enlargement
## Footnote
EKG abnormalities seen in 75-90% of pts
102
Echocardiogram may show myocardial wall thickness ___ mm in HCM
Ejection fraction is usually ____%, reflecting the _______
>15 mm
>80%; hypercontractility
## Footnote
In severe cases, the EF becomes depressed
103
Medical therapy for HCM includes:
If these don't work, what are other therapies?
BBs & CCBs
Diuretics
Disopyramide: negative inotrope, improving LVOT obstruction and heart failure symptoms
104
______ often develops in HCM and is assoc w/ increased risk of thromboembolism, heart failure, and sudden death
What is the most effective antidysrhythmic in these pts?
A-fib
Amiodarone
105
For HCM pts, surgery is reserved for pts with what?
What are the surgical strategies?
large outflow tract gradients and severe sx
- Septal myomectomy
- Cardiac cath w/injection to induce ischemia of the septal perforator arteries
- Echocardiogram-guided percutaneous septal ablation
- Prosthetic mitral valve can also be inserted
106
_______ is the primary tx for pts at risk of sudden cardiac death d/t dysrhythmias in HCM
ICD placement
107
What is dilated cardiomyopathy?
characterized by atrial and ventricular dilation, decreased ventricular wall thickness, and systolic dysfunction
108
Initial symptoms of dilated cardiomyopathy?
heart failure, chest pain may also occur
- Ventricular dilatation may lead to mitral and/or tricuspid regurgitation
- Dysrhythmias, emboli and sudden death are common
109
Echocardiogram typically reveals dilation of all 4 chambers, predominantly the _____, as well as _______ in dilated cardiomyopathy
LV
global hypokinesis
110
Treated of dilated cardiomyopathy is similar to that of ______ ; ____ is often imitated
Chronic HF
Antiocoagulation
111
What do EKGs look like in dilated cardiomyopathy?
EKG often shows ST-segment and T-wave abnormalities and LBBB
- common dysrhythmias include PVC and Afib
## Footnote
prophylactic ICD placement decreases the risk of sudden death by 50%
112
________ is the principal indication for cardiac transplant
Dilated cardiomyopathy
113
What is stress cardiomyopathy?
AKA apical ballooning syndrome
a LV hypokinesis w/ischemic EKG changes, however the coronary arteries remain patent
- Temporary disruption of LV contractility, the rest of the heart has normal contractility
114
Common symptoms of stress cardiomyopathy?
Main causative factor?
Who does this occur more in?
chest pain and dyspnea
Stress (physical or emotional)
Women > men
115
What is peripartum cardiomyopathy?
form of dilated cardiomyopathy that arises during the peripartum period (3rd trimester-5 months postpartum)
116
Diagnosis of peripartum cardiomyopathy is based on what 3 criteria?
development of peripartum HF
absence of another explainable cause
LV systolic dysfunction with EF <45%
117
Symptoms of secondary cardiomyopathy
heart failure without cardiomegaly or systolic dysfunction
- Pts have low to normal BP and can develop orthostatic hypotension
118
What is secondary cardiomyopathy?
Causes of this?
c/b diseases that lead to myocardial infiltration and diastolic dysfunction
The most common cause is amyloidosis; hemochromatosis, sarcoidosis, and carcinoid tumors
119
Explain how EKGs look for cor pulmonale
EKG may show signs of RA & RV hypertrophy
- RA hypertrophy is indicated by peaked P waves
- Right axis deviation and RBBB are also often seen
119
What is Cor pulmonale?
Causes?
RV enlargement that may progress to right heart failure
COPD (most common), pulmonary hypertension, heart disease, or significant respiratory, connective tissue, or chronic thromboembolic disease
120
What are other diagnostics for Cor pulmonale?
TEE, right heart cath, CXR
