Heart Failure (Johnston) Flashcards
Heart failure definition
-Inability of the heart to meet the metabolic demands of the body
Etiology of Heart failure
- 60-75% is ischemic heart disease
- 18% idiopathic, dilated cardiomyopathy
- 12% valvular heart disease–has declined, except for calcific aortic stenosis
- 10% Hypertensive heart disease; major factor in 75%: Congenital, viral myocarditis (Coxsackie or influenza A.B), toxins (alcohol, adriamycin, cocaine), endocrine–hypo/hyperthyroid, nutritional
Most common cause of LV systolic dysfunction is from
-ischemic heart disease
Basic causes of heart failure
-Restriction/Obstruction to Ventricular filling:
RV infarct
Constrictive pericarditis
Mitral stenosis
Atrial myxoma
Others: Thyrotoxicosis–AV fistula, beri beri
ACC/AHA Stage A Heart Failure
- HF risk factors: hyperlipidemia, diabetic etc
- No heart disease
- No symptoms
ACC/AHA Stage B Heart Failure
- Heart disease but no symptoms
- Asymptomatic LV dysfunction
ACC/AHA Stage C
-Prior or current HF symptoms
ACC/AHA Stage D
- Refractory HF symptoms
- no drugs seem to work and need mechanical devices like pacemakers or heart transplant.
The goal of ACC/AHA stages is to identify patients at risk for developing HF. What are some of these risk factors associated with stage A?
- CAD (ischemic, atherosclerotic)
- HT
- DM
- obesity
- Metabolic syndrome
- Excess alcohol
- Cardio/toxins or family history of cardiomyopathy
ACC/AHA stage B–patient symptoms
- Asymptomatic
- But has LVH and/or impaired LV function (low EF), previous MI, valvular disease
- structural heart disease
- hemodynamically stable
- One year mortality is 15-30%
ACC/AHA Stage C classification and symptoms
- Patient with current or past symptoms of HF with STRUCTURAL HEART DISEASE
- SOB
- Fatigue
- Reduced exercise tolerance
- one year mortality is 15-30%
ACC/AHA Stage D
- Refractory HF
- Eligible for specialized treatment (mechanical support, transplants)
- One year mortality 50-60%
Patients at high risk for heart failure but without structural heart disease or symptoms of heart failure
-examples: hypertension, diabetes mellitus, obesity, CAD (post-MI or revascularization), peripheral vascular disease, CVA, family history, exposure to cardiac toxins
-Stage A
- Patients with structural heart disease but without signs and symptoms of heart failure
- Prior MI, LVH or reduced LVEF, asymptomatic valvular disease
-Stage B
Patients with structural heart disease with prior or current symptoms of heart failure
–known structural heart disease and dyspnea, fatigue, reduced exercise tolerance
Stage C NYHA class I-IV
Patients with refractory heart failure requiring specialized interventions
-Marked symptoms at rest despite maximal medical therapy, with recurrent hospitalizations NYHA class III-IV
NYHA functional classification clinical stages–classes focus on
-excercise capacity and symptomatic status of the disease (subjective)
NYHA Class I
- No limitation of physical activity
- No symptoms with ordinary exertion
- One year mortality 5-10%
NYHA Class II
- Slight limitation of physical activity
- Ordinary activity causes symptoms
- One year mortality 15-30%
NYHA Class III
- Marked limitation of physical activity
- Less than ordinary activity causes symptoms
- Asymptomatic at rest
- One year mortality 15-30%
NYHA Class IV
- Inability to carry out physical activity without discomfort
- Symptoms at rest
- One year mortality 50-60%
- symptoms include DYSPNEA, FATIGUE AND CHEST PAIN!!
Word associations: Class I=
-ASYMPTOMATIC
Word associations: Class II=
- NO SYMPTOMS AT REST
- EXERTIONAL SYMPTOMS WITH ORDINARY ACTIVITY
Word associations: Class III=
- NO SYMPTOMS AT REST
- SYMPTOMS WITH MINIMAL ACTIVITY (less than ordinary activity)
Word associations: Class IV
SYMPTOMS AT REST!!
What test is essential in evaluation of HD/HF
- Echocardiogram!!!
- is non-invasive, bed-side mobile, no prep needed
Specific causes of heart failure
- Hypertensive heart disease: concentric hypertrophic
- Ischemic heart disease: wall motion abnormality–doesnt move as it should
- Hypertrophic heart disease–small ventricular cavity, big muscle, big cardiac silhouette
- Infiltrative heart disease–amyloidosis, sarcoidosis, speckled pattern
- Primary valvular heart disease
Its important to distinguish what in heart failure
-systolic heart failure from diastolic heart failure
Classification (Types) of heart failure
- Systolic/Diastolic
- High/low
- Acute/chronic
- Right/Left
- Forward/backward
Causes of ACUTE HF
- Acute MI
- Ruptured papillary muscle
- Mitral regurgitation
- Aortic insufficiency
- Toxins
Causes and symptoms of CHRONIC HF
- Multivalvular disease of dilated cardiomyopathy
- Progresses slowly
- Edema, weight gain
Systolic HF characteristics
- At least 50% of the cases
- low SV
- Increased ventricular filling pressure
- EF is less than 40%, hypo perfusion with impaired ventricular emptying
- Weak, fatigued, reduced exercise tolerance
- Dyspnea on exertion, orthopnea, Paroxysmal nocturnal dyspnea
LVEF=
SV/EDV
Diastolic Heart Failure–Ejection fraction is
-NORMAL
Characteristics of Diastolic heart failure
- SOB
- DOE
- Pulmonary Edema
- Inability of LV to relax/fill; increased resistance to ventricular filling; decreased compliance or increased stiffness
- Decreased ventricular diastolic capacity
- Impaired ventricular relaxation–acute ischemia, myocardial fibrosis, amyloidosis
Example of diseases associated with diastolic heart failure
- Restrictive/constrictive pericarditis
- Hypertensive/hypertrophic cardiomyopathy
High output HF seen in
High output but LOW ejection fraction
- Hyperthyroidism
- Anemia
- Pregnancy
- AV fistula
- beriberi
- Pagets
Low output HF seen in
- Ischemic heart disease
- Hypertension
- Dilated cardiomyopathy
- valvular and pericardial disease
- MUCH MORE FREQUENT THAN HIGH OUTPUT FAILURE
Right sided HF
- Affects RV
- Pulmonary HTN due to pulmonary embolus
- Edema, hepatomegalia, venous distention
Left sided HF
- LV is overloaded
- AS, MI
- Dyspnea, orthopnea due to pulmonary congestion
Heart Failure syndrome–Compensatory
- Neurohormonal responses:
- SNs
- RAAS
- Cytokine Activation
- Altered renal physiology
- LV remodeling
Mechanisms of Heart failure–RAAS
- Decreased renal perfusion
- Increased renin, angiotensinogen, A1
- A1 is converted to A11 which increases BP by vasoconstriction which stimulates adrenal gland to release aldosterone
- Leads to Na and water retention (increase preload, congestive symptoms and volume (expansion)
- A11 is vasoconstrictor, increases PVR (increase after load)
Mechanisms of heart failure–Arginine vasopressin–AVP or ADH
- Stimulation of thirst leads to increase TBW and hyponatremia (dilutional)
- Increases preload (salt and water retention)
Precipitating causes of heart failure
- Decompensation of the heart relates to underlying progression of heart disease
- Non compliance with diet–25-50%–too much sodium, too many calories, too many stimulants (tea, coffee, colas)
- Non compliance with meds–25-50%–too costly, SEs
Meds that worsen HF
- CCB
- Beta blockers
- NSAID
- Antiarrhythmics
Conditions that can cause heart failure
- Infection–20%: fever, tachycardia, increased metabolic demands, hypoxia
- Anemia: increased oxygen needs of tissues, increased cardiac output
- Arrhythmias–20-30%: tachyarrhthmias–decrease diastolic filling time, leading to ischemia; bradycardia
Other causes of heart failure
- Physical over exertion
- Fluid excess–transfusion/volume overload
- Environmental–stress
- Hypertension worsening
- MI–ischemia/infarction
- PE
- Hypothyroid
- Alcohol
- Valvular heart disease worsening (MS, AS, MR, AI)
- Pericardial disease
S3 gallop associated with
- Heart failure!!
- HF risk increases 10-11x with diagnosis of S3 gallop murmur!
Signs and Symptoms of Heart Failure
- Decreased arterial perfusion to organs and venous congestion (liver, lungs) leads to: Dyspnea–most common symptoms of HF
- Excercise intolerance, orthopnea, PND, nocturnal angina–due to pulmonary congestion and increased LA pressure
- PND increases the likelihood of heart failure 2 fold
- Weakness, fatigue not specific for HF
- Pulmonary edema–crackles in lungs–transudation of fluid from pulmonary capillaries into alveolar spaces and interstitium. May wheeze or cough (frothy–pink fluid); possible cyanotic and acidotic
More signs and symptoms of heart failure
- Hepatomegalia–passive congestion with increased LFTs, altered coagulation studies, ascites, increased abdominal girth, peripheral and sacral edema
- JVD-CVP can be elevated in volume overload; prominent in cardiac tamponade and COPD (lung hyperinflation)
More signs and symptoms of heart failure
- S3, S4
- presence of S3 gallop increases likelihood of heart failure 11 fold
- LV failure
- Orthopnea, PND
- Tachypnea, wheezing, crackles, decreased breath sounds
- Dullness to percussion over pleural effusions
RV failure symptoms
- Peripheral/sacral edema
- Hepatomegalia
- Ascites
- Increased JVD, HJR
Unilateral vs bilateral edema in heart failure
- Typically heart failure is associated with BILATERAL edema
- It is never unilateral! So if its unilateral, something else is causing it
Imaging/Lab used to diagnose HF
- There is NO single diagnostic test for HF
- It is largely a clinical diagnosis checked on a careful H&P
Chest X ray findings of HF
- Cardiomegalia
- Pulmonary edema with central peripheral infiltrates
- Increased size of vessels in upper portion of lungs
- Pleural effusions
Transudates vs Exudate effusion
- Transudates associated with oncotic process including HF
- Exudates are usually infective process or malignant process
- SO HF is usually a transudate and is often blunting costophrenic angles
Echocardiogram characteristics and used to diagnose what kind of diseases
- Practical useful test
- Mobile, bedside/ICU/ED
- Chamber sizes, clots, tumors
- Wall motion (ischemic), muscle thickness
- Pericardial effisions
- Valvular disease
- Systolic/Diastolic heart failure–ejection fraction
ECG in heart failure
- may or may not be helpful
- May have ischemia, infarction, hypertrophy
- Rhythm disturbances (atrial, junctional, ventricular)
- Tachycardia, bradycardia, Blocks
Lab–Cardiac enzymes–troponins T and I
- Troponins T and I–released from myocyte when damaged
- Increase 2-12 hours from onset of chest pain
- Peak 24-48 hours; return to baseline 5-14 days
Lab–Cardiac enzymes–Creatine kinase–CK (MB)
- Increase 3-12 hours from onset of chest pain
- Peak 24 hours; baseline 1-3 days
- Sensitivity
Other labs associated with HF
- CBC–Anemia secondary to chronic disease, anemia may aggravate HF
- CMP–electrolyte imbalance–low Na, K
- Pre-renal azotemia–high BUN to creatinine
- UA–protein in urine
- ABG-may have hypoxia, metabolic acidosis from lactic acidosis
- Thyroid
If patient is in HF, greater than 65 years old with A. fib, must check what?!
THYROID!!
-Free T4, TSH
Lab–BNP in heart failure
- Brain natriuretic peptide
- Neurohormone, made in ventricles
- Sensitive to ventricle stretching and volume overload; preload/afterload are stimuli
- Lower EF, higher BNP
- If value is less than 100 pg/ml there is a 97% chance of no HF
-Increased BNP seen in what diseases?
in heart failure, AMI, PE, renal failure, old age
Hear failure most reliable signs
- S3 gallop!
- hyponatremia and decrease in hemoglobin–both due to dilution due to fluid overload
- Reduced ejection fraction
Differential Diagnosis of heart failure
- Pulmonary problems: PE, asthma, pneumonia
- Cirrhosis: ascites, edema
- Renal–edema
- Venous insufficiency–edema
