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
