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Cardiovascular II Final Exam > Heart Failure (Johnston) > Flashcards

Heart Failure (Johnston) Flashcards

1
Q

Heart failure definition

A

-Inability of the heart to meet the metabolic demands of the body

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2
Q

Etiology of Heart failure

A
  • 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
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3
Q

Most common cause of LV systolic dysfunction is from

A

-ischemic heart disease

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4
Q

Basic causes of heart failure

A

-Restriction/Obstruction to Ventricular filling:
RV infarct
Constrictive pericarditis
Mitral stenosis
Atrial myxoma
Others: Thyrotoxicosis–AV fistula, beri beri

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5
Q

ACC/AHA Stage A Heart Failure

A
  • HF risk factors: hyperlipidemia, diabetic etc
  • No heart disease
  • No symptoms
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6
Q

ACC/AHA Stage B Heart Failure

A
  • Heart disease but no symptoms

- Asymptomatic LV dysfunction

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7
Q

ACC/AHA Stage C

A

-Prior or current HF symptoms

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8
Q

ACC/AHA Stage D

A
  • Refractory HF symptoms

- no drugs seem to work and need mechanical devices like pacemakers or heart transplant.

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9
Q

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?

A
  • CAD (ischemic, atherosclerotic)
  • HT
  • DM
  • obesity
  • Metabolic syndrome
  • Excess alcohol
  • Cardio/toxins or family history of cardiomyopathy
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10
Q

ACC/AHA stage B–patient symptoms

A
  • 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%
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11
Q

ACC/AHA Stage C classification and symptoms

A
  • Patient with current or past symptoms of HF with STRUCTURAL HEART DISEASE
  • SOB
  • Fatigue
  • Reduced exercise tolerance
  • one year mortality is 15-30%
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12
Q

ACC/AHA Stage D

A
  • Refractory HF
  • Eligible for specialized treatment (mechanical support, transplants)
  • One year mortality 50-60%
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13
Q

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

A

-Stage A

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14
Q
  • Patients with structural heart disease but without signs and symptoms of heart failure
  • Prior MI, LVH or reduced LVEF, asymptomatic valvular disease
A

-Stage B

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15
Q

Patients with structural heart disease with prior or current symptoms of heart failure
–known structural heart disease and dyspnea, fatigue, reduced exercise tolerance

A 
Stage C
NYHA class I-IV
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16
Q

Patients with refractory heart failure requiring specialized interventions

A 
-Marked symptoms at rest despite maximal medical therapy, with recurrent hospitalizations
NYHA class III-IV
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17
Q

NYHA functional classification clinical stages–classes focus on

A

-excercise capacity and symptomatic status of the disease (subjective)

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18
Q

NYHA Class I

A
  • No limitation of physical activity
  • No symptoms with ordinary exertion
  • One year mortality 5-10%
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19
Q

NYHA Class II

A
  • Slight limitation of physical activity
  • Ordinary activity causes symptoms
  • One year mortality 15-30%
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20
Q

NYHA Class III

A
  • Marked limitation of physical activity
  • Less than ordinary activity causes symptoms
  • Asymptomatic at rest
  • One year mortality 15-30%
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21
Q

NYHA Class IV

A
  • Inability to carry out physical activity without discomfort
  • Symptoms at rest
  • One year mortality 50-60%
  • symptoms include DYSPNEA, FATIGUE AND CHEST PAIN!!
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22
Q

Word associations: Class I=

A

-ASYMPTOMATIC

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23
Q

Word associations: Class II=

A
  • NO SYMPTOMS AT REST

- EXERTIONAL SYMPTOMS WITH ORDINARY ACTIVITY

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24
Q

Word associations: Class III=

A
  • NO SYMPTOMS AT REST

- SYMPTOMS WITH MINIMAL ACTIVITY (less than ordinary activity)

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25
Q

Word associations: Class IV

A

SYMPTOMS AT REST!!

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26
Q

What test is essential in evaluation of HD/HF

A
  • Echocardiogram!!!

- is non-invasive, bed-side mobile, no prep needed

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27
Q

Specific causes of heart failure

A
  • 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
28
Q

Its important to distinguish what in heart failure

A

-systolic heart failure from diastolic heart failure

29
Q

Classification (Types) of heart failure

A
  • Systolic/Diastolic
  • High/low
  • Acute/chronic
  • Right/Left
  • Forward/backward
30
Q

Causes of ACUTE HF

A
  • Acute MI
  • Ruptured papillary muscle
  • Mitral regurgitation
  • Aortic insufficiency
  • Toxins
31
Q

Causes and symptoms of CHRONIC HF

A
  • Multivalvular disease of dilated cardiomyopathy
  • Progresses slowly
  • Edema, weight gain
32
Q

Systolic HF characteristics

A
  • 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
33
Q

LVEF=

A

SV/EDV

34
Q

Diastolic Heart Failure–Ejection fraction is

A

-NORMAL

35
Q

Characteristics of Diastolic heart failure

A
  • 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
36
Q

Example of diseases associated with diastolic heart failure

A
  • Restrictive/constrictive pericarditis

- Hypertensive/hypertrophic cardiomyopathy

37
Q

High output HF seen in

High output but LOW ejection fraction

A
  • Hyperthyroidism
  • Anemia
  • Pregnancy
  • AV fistula
  • beriberi
  • Pagets
38
Q

Low output HF seen in

A
  • Ischemic heart disease
  • Hypertension
  • Dilated cardiomyopathy
  • valvular and pericardial disease
  • MUCH MORE FREQUENT THAN HIGH OUTPUT FAILURE
39
Q

Right sided HF

A
  • Affects RV
  • Pulmonary HTN due to pulmonary embolus
  • Edema, hepatomegalia, venous distention
40
Q

Left sided HF

A
  • LV is overloaded
  • AS, MI
  • Dyspnea, orthopnea due to pulmonary congestion
41
Q

Heart Failure syndrome–Compensatory

A
  • Neurohormonal responses:
  • SNs
  • RAAS
  • Cytokine Activation
  • Altered renal physiology
  • LV remodeling
42
Q

Mechanisms of Heart failure–RAAS

A
  • 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)
43
Q

Mechanisms of heart failure–Arginine vasopressin–AVP or ADH

A
  • Stimulation of thirst leads to increase TBW and hyponatremia (dilutional)
  • Increases preload (salt and water retention)
44
Q

Precipitating causes of heart failure

A
  • 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
45
Q

Meds that worsen HF

A
  • CCB
  • Beta blockers
  • NSAID
  • Antiarrhythmics
46
Q

Conditions that can cause heart failure

A
  • 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
47
Q

Other causes of heart failure

A
  • 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
48
Q

S3 gallop associated with

A
  • Heart failure!!

- HF risk increases 10-11x with diagnosis of S3 gallop murmur!

49
Q

Signs and Symptoms of Heart Failure

A
  • 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
50
Q

More signs and symptoms of heart failure

A
  • 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)
51
Q

More signs and symptoms of heart failure

A
  • 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
52
Q

RV failure symptoms

A
  • Peripheral/sacral edema
  • Hepatomegalia
  • Ascites
  • Increased JVD, HJR
53
Q

Unilateral vs bilateral edema in heart failure

A
  • Typically heart failure is associated with BILATERAL edema

- It is never unilateral! So if its unilateral, something else is causing it

54
Q

Imaging/Lab used to diagnose HF

A
  • There is NO single diagnostic test for HF

- It is largely a clinical diagnosis checked on a careful H&P

55
Q

Chest X ray findings of HF

A
  • Cardiomegalia
  • Pulmonary edema with central peripheral infiltrates
  • Increased size of vessels in upper portion of lungs
  • Pleural effusions
56
Q

Transudates vs Exudate effusion

A
  • 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
57
Q

Echocardiogram characteristics and used to diagnose what kind of diseases

A
  • 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
58
Q

ECG in heart failure

A
  • may or may not be helpful
  • May have ischemia, infarction, hypertrophy
  • Rhythm disturbances (atrial, junctional, ventricular)
  • Tachycardia, bradycardia, Blocks
59
Q

Lab–Cardiac enzymes–troponins T and I

A
  • 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
60
Q

Lab–Cardiac enzymes–Creatine kinase–CK (MB)

A
  • Increase 3-12 hours from onset of chest pain
  • Peak 24 hours; baseline 1-3 days
  • Sensitivity
61
Q

Other labs associated with HF

A
  • 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
62
Q

If patient is in HF, greater than 65 years old with A. fib, must check what?!

A

THYROID!!

-Free T4, TSH

63
Q

Lab–BNP in heart failure

A
  • 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
64
Q

-Increased BNP seen in what diseases?

A

in heart failure, AMI, PE, renal failure, old age

65
Q

Hear failure most reliable signs

A
  • S3 gallop!
  • hyponatremia and decrease in hemoglobin–both due to dilution due to fluid overload
  • Reduced ejection fraction
66
Q

Differential Diagnosis of heart failure

A
  • Pulmonary problems: PE, asthma, pneumonia
  • Cirrhosis: ascites, edema
  • Renal–edema
  • Venous insufficiency–edema

Cardiovascular II Final Exam (13 decks)

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