Heart Failure question Flashcards
What is the New York heart Association (NHYA classification)
NHYA I: no limitations of physical activity and no symptoms with ordinary activity
NHYA II: slight limitation of physical activity but comfortable at rest or mild exertion
NYHA III: marked limitation of physical activity and comfortable only at rest
NYHA IV: symptoms of heart failure at rest
What is pathophysiology of chronic heart failure
neuro-endocrine activation, including
a) activation of the sympathetic nervous system/renin-angiotensin system
c) release of endogenous noradrenaline, antidiuretic hormone (vasopressin) and endothelin
d) Results in fluid retention and inappropriately high afterload.
What are main causes of heart failure
Increased pre-load (volume)
Reduced contractility
Increased afterload (AS, HTN, coarctation)
Impaired cardiac rhythm
Impaired ventricular filing
High-output failure (secondary to anemia, sepsis, pregnancy, hyperthyroidism, AV fistual)
What are principles of treatment of heart failure
Treat the cause: CABG (CASS/STICH)
Reduced pre-load: diuretics; aldosterone antagonist (RALES)
Left ventricular volume reduction: (RESTORE, SAVER)–controversial
Improve contractility: a. Cardiac resynchronization therapy (MUSTIC)
b. Implantable cardioverter defibrilatory (MADIT)
c. Ventricular assist devices (REMATCH)
d. Cardiac transplantation (COCPIT)*
e. Cellular cariomyoplasty (MAGIC) *
f. dynamic cardiomyoplasty (C-SMART*
Reduce afterload: a. ACE inibiitors (SOLDV; CONSENSUS)
b. ARB (CHARM)
c. Betablockers (COPERNICUS)
d. Intra-aortic balloon pump short term
e. ventricular septal myectomy for HOCM
What are indications for CABG in patients with heart failure
Reasonable target vessels to graft
myocardial ischemia
myocardial viability (>20% of left ventricles demonstrating viability)
CASS study
5 year survival of patients with ischemic cardiomyopathy being 41% with pts treated medically and 62% with surgery
Relative contra-indications to CABG are a. poor targets b. pulmonary HTN c. impaired right ventricle
List principles for biventricular pacing
Ventricular dysynchrony often results from LBBB as earlier controcation of the right ventricle and paradoxical ventricular septal motion leads to impaired left ventricular filling and imparied left ventricular systolic function.
Biventricular pacing induces simultaneous left and right verntricular contraction, thereby increasing the efficacy of ventricular contractility without increasing myocardial oxygen consumption
When is biventricular pacing indicated
Heart failure for at least 6 weeks on maximal medical therapy
NYHA functional status III or IV
Left ventricular ejection fraction < 35%
QRS interval > 150ms
What are the indications for implantable cardiodeibrillator in heart failure
Primary prevention: pts who have sustained a previous MY with an ejection fraction of < 35% with a. non-sustained v.tach; or b) inducible ventricular tachycardia on electro-phyiological studies
secondary prevention in pts with hemodynamically significant tachyarrhythmias and an ejection fraction of < 35%
treat any underlying causes including drug toxicity, electrolyte disturbance, reversible ischemia, before implanting an ICD
What are the principles of the surgical ventricular restoration procedure
SVR excludes areas of non-functional LF, resulting in reduced left ventricular volume and wall stress (Laplace Law) and return of an elliptical shape to the left ventricle.
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What are the components of the heart failure survival score
Ischemic cardiomyopathy Heart rate LV ejection fraction mean arterial blood pressure interventricular conduction delay serum sodium peak myocardial oxygen consumption
those with medium or high-risk HFSS would benefit from transplantation as the 1 year survival of transplntatation is 85%
How does resynchronized therapy work
It allows the apex of the RV to be synchronous with lateral wall of the LV
Optimize the LA and LV timing
What is Non-ischemic dilated cardiomyopathy
Causes include viral, valvular, idiopathic
All muscle is viable to some degree
A variable degree of hypertrophy is also present
25% of patients have familial disease
the inheritance is x-linked
onset is early in men and late in women
Thromboembolism is a risk when LV is dilated and AF present
What medications can be used/useful for pregnant women with heart failure
Beta-blockers--- should be continued or inhaled during pregnany Digoxin Diuretics Hydralazine Nitrates
What are important hemodynamic changes in normal pregnancy
Increase in blood volume Increase Heart rate Increase cardiac output Decrease in peripheral vascular resistance and blood pressure Anemia
What is PPCM
Post partum cardiomyopathy dilated cardiomyopathy (LVEF < 45%) with the development of HF in the last montth of pregnancy or within five months after delivery, in the absence of a demonstrable cause for HF
What are risk factors for PPCM
Multiparity Multiple fetus gestations Older maternal age History of gestational hypertension Maternal cocaine use Long-term oral tocolytic
Potential reasons for PPCM
Viral infections
myocarditis
myocyte apoptosis
development of maternal cardiac autoantibodies
oxidative stress linked to proteolysis’ cleavage of prolactin into a potent cariotoxic subfragment
Indications for Cardiac transplant
Systolic Heart failure
Ischemic heart disease with intractable angina
intractable arrhytmia
congenital heart disease in which severe fixed pulmonary hypertension is not a complication
cardiac tumor
Hypertrophic cardimyopathy
What is UNOS (United network for organ sharing) criteria
Status 1A
- require mechanic circulatory support with one more of the following devices
- ECMO/IABP/LVAD/TAH
- Life expectancy < 7 days
- mechanical ventilation
- continuous infusion of high-dose inotropes
Status 1B
- LVAD or RVA implanted for > 30 days
- continuous infusion of inotropes;pt is home?
Status II
- all others who do not meet status Ia or Ib
What are INTERMACS patient profiles
STAGE 1: Critical cardiogenic shock STAGE 2: Progressive decline on inotrope support STAGE 3: Stable but on inotrope support STAGE 4: Resting symptoms but at home STAGE 5: Exertion intolerant STAGE 6: Exertion limited STAGE 7: Advanced NYHA III symptoms
Myocardial ischemia occurs in the context of HOCM because
Intramural coroanries (bridging)
increased oxygen demand due to increase in muscle mass
increased wall tensions due to diastolic dysfunction
associated epicardial coronary artery disease
Mechanism of LVOT obstruction in HOCM
Reduced LVOT dimension
Anterior basal spetal hypertrophy
anterior displacement of the mitral valve
increased size and height of both mitral leaflets
SAM
Papillary muscle anomalies–insertion too close to the mitral valve
3 subsets that benefit the most from atrial kick
Obstruction to atrial emptying (mitral stenosis) Non compliant left ventricle (AS with hypertrophy) Heart failure (atrial kick can contribute up to 20-30% EF)
What is HOCM pattern of inheritance and penetrance
Autosomal dominant 1:500: 70% familial and 30% sporadic
What are other heart failure surgery surgery options
Cardiomyoplasty
partial lef ventriculectomy (Batista procedure)
endoventricular circular patch plasty (Dor Procedure)
Surgical ventricular restoration procedure
What are pathological features of Heart Failure
Ventricular dilation
change from ellipsoidal to a more spherical chamber shape
cardiomyocyte hypertrophy
interstitial fibrosis
numberous alteration in biochemical and molecular functions
List steps of SVR
Operative procedure is performed for akinesia or dyskinesia of the anterior LV wall:
a. left ventriculotomy through scar tissue--2 cm lateral to the LAD b. subtotal endocardial resection over the septum and posterior wall and cryotherapy at the limits of the resection for patients with recurrent ventricular arrhythmias c. circumfrential endoventricular (Fotane) circular suture is passed 1-2cm outcomes the limit of healthy muscle and then tied around a balloon mannequin to reduce the size of the left ventricle to a diastolic volume of 50-60ml/M d. the residual apical defect is closed with a dacron patch to produce an elliptical-shaped left ventricle e. ventriculotomy is closed with two-layered teflon strips
List evidence for CRT in pts with heart failure
COMPANION trial demonstrated that CRT improved survival in individuals with NYHA class III or IV heart failure with a widened QRS complex on an electrocardiogram.
CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all cause mortality, and a reduction in cardiovascular-related hospitalization
List meds all heart failure pts should be taking
ACE or ARB
Beta-blocker
Aldosterone
Diuretic
Nitrates can be used
oral BNPnestertide
4 major types of Cardiomyopathy
Congestive/Dilated
Hypertrophic cardiomyopathy
Restrictive Cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy
List 3 types of restrictive cardiomyopathy
Sarcoidosis
Hemochromatosis
Amyloidosis
*other types Loffler endocarditis/Endocardial fibroelastosis/post radiation
How do you diagnosis Amyloidosis
Free immunoglobin Lambda chains in serum
What is Loeffler Endocarditis
Loeffler endocarditis is a form of restrictive cardiomyopathy which affects the endocardium and occurs with white blood cell proliferation, specifically of eosinophils
eosinophilia and eosinophilic penetration of the cardiac myocytes leads to a fibrotic thickening of portions of the heart, large mural thrombi develop, commonly contracted in temperate climates (due to the favorable conditions for parasites), and is rapidly fatal.
What is Endocardial fiibroelastosis
characterized by a thickening of the inmost lining of the heart chambers (the endocardium) due to an increase in the amount of supporting connective tissue and elastic fibers.
uncommon cause of unexplained heart failure in infants and children, and is one component of HEC syndrome Fibroelastosis is strongly seen as a primary cause of restricted cardiomyopathy seen in children
What is Dilated Cardiomyopathy
one of cardiomyopathies, a group of diseases that primarily affect the myocardium with different causes and affect the heart in different ways.
In DCM a portion of the myocardium is dilated, often without any obvious cause. Left or right ventricular systolic pump function of the heart is impaired, enlargement and hypertrophy
Most common form of non-ischemic cardiomyopathy.
What are more details of DCM
Although in many cases no cause (etiology) is apparent, it is probably the result of damage to the myocardium produced by a variety of toxic, metabolic, or infectious agents
When should you consider Pulmonary thrombecomtomy in a chronic situation
Unresolved (unchanged V/Q scans over 8 to 12 weeks despite anticoagulation) Thromboembolic and significant functional limitations (NYHA III or IV) with compromised vascular bed.
Proximal extent of the organized thrombotic material should at least at the level of the lobar pulmonary arteries and resting PA pressure should be greater then 30 mm Hg.
List signs of right heart failure
peripheral edema Ascities Hepatic congestion Distended varicose/JVP systemic veins Pleural effusions
