Heart FailureClinical Cases

Question 1

How can we conceptualize heart failure as a “blood flow” issue? how about a pump failure how about hormonal?

Answer 1

• blood flow
  
  • forward flow issue-impaired pxygen delivery to vital organs
  • backward flow issue-venous congestion of lungs, liver, kidney, mesentery
• pump failure
  
  • impaired contractility-systolic failure or HFrEF
  • increased afterload- in pulmonary or systemic circulation
  • valvular incompetence leading to syndrome of heart failure
  • impaired relaxation- diatolic failure of myocardium, pericardial disease
• bad hormone
  
  • excessive adrenergic tone, ADH release, and RAA activation are initially productive but ultimately coutnerproductive

Question 2

What are the 2 questions to ask when assessing heart failure?

Answer 2

is the patient warm or cold? is the patient wet or dry?

**If you are warm then you have adequate perfusion

**If you are wet then you have congestion

Question 3

what does distended jugular vein signify?

Answer 3

back up of fluid. usually from ight sided- heart failure

Question 4

what does a warm and wet patient have?

side

blood flow

hormones

pump failure

Answer 4

left ventricular failure

blood flow- backward flow issue: venous congestion of lungs, liver, kidney, mesentery

bad hormones- excessive adrenergic tone and R-A-A activation

Pump failure- inpaired relaxation: diatolic failure of myocardium consequences: S4, LA enlargement

Question 5

How do you treat a warm and wet patient?

blood flow

bad hormones

pump failures

Answer 5

blood flow- promote venous decongestion with diuresis

bad hormones- block R-A-A activity to reduce LVH (reduce adrenergic tone to improve diastolic filing time possibly)

pump failure- impaired relaxation: improve myocardial oxygen supply (if possible), lengthen diastolic filling time (possibly)

Question 6

What do “wet” heart failures result from? how do we treat it?

Answer 6

“wet” conditions result from excessive salt and water retention which increases intravascular volume

treatment: furosemide (powerful loop diuretic) that promotes excretion of filtered Na through inhibition of the Na/ 2 Cl/ K cotransport system

Question 7

what is the pathophysiology of remodeling in HFpEF? what is the treatment

Answer 7

pathophysiology: relaxation is an active, energy dependent process. It is impaired in LVH, oxygen supply demand mismatch (ie CAD) nifiltrative disorder and fibrosis
treatment: manage underlying risk factors for LVH. Aldosterone antagonism is the most promising angle in R-A-A blockade

Question 8

warm wet patients need ________

patients with HFpEF have limited pharmacologic therapeutic options: _______, _____ and possibly ______

HFpEF management hinges on managing ______-

Answer 8

warm wet patients need diuresis

patients with HFpEF have limited pharmacologic therapeutic options: diuresis, R-A-A blockade, and possibly BB

HFpEF management hinges on managing risk factos for progression

Question 9

what does a cold and wet patient have?

blood flow

bad hormones

pump failure

Answer 9

bi-ventricular failure

blood failure- both aforward and backflow issue

bad hormones- excessive adrenergic tone and R-A-A activation

pump failure- most impaired contrction, but also some valvular incompetence and likely som eimpaired relaxation

Question 10

what is the pathophysiology of cold, wet HFpEF? treatment?

Answer 10

cold due to low cardiac output, wet due to counterproductive compensatory mechanisms

treatment: diuresis, intropy, arterial vasodilation