heart fialure Flashcards
the level of stretch in the relaxed muscle immediately before it contracts
preload
: volume of blood pumped out by the heart per minute
Cardiac Output
volume of blood returning to the heart via the veins per minute
Venous Return
volume of blood pumped out with each contraction of the heart
Stroke Volume:
volume of blood returning to the heart via the veins per minute
80% blood volume in veins when ambulatory.
Venous Return
volume of blood pumped out by the heart per minute
Cardiac Output
Three components of SV
= Contractillity, preload, and afterload.
franks sterling’s law
stroke volume is dependent on your venous return
rubberband analogy
% of blood that is pumped out of the hear to the body
ejection fraction
what is normal ejection fraction
50-75%
mild ejection fraction
wheN the LVEF falls before 50% and is above 40%
moderate ejection fracrion
LVEF 30-39%
progressive condition in which the heart has los the ability to pump to the tissues because of what two general physiological causes
poor contraction or poor relaxation
Inability of heart to contract enough to provide blood flow forward to the body.
Problem of Contraction and Ejection of Blood
systolic heart failure
Inability of left ventricle (LV) to Relax normally resulting in fluid backing up to the lungs.
Involves a thickened and stiff LV muscle
Problem with heart relaxation and filling with blood.
Diastolic Heart Failure (Filling Problem)
reasons for left sided systolic heart failure
ischemic heart disease
long standing hTN
dilated cardiomyopathy
when right ventricle looks bigger than the left
that is pulmonary HTN and right sided heart failure (usualy have 18months to live)
most common reasons for right sided heart failure
cor pulmonale or left sided heart failure
shunt
why would you see diastolic heart failure on the left side
hypertrophy causeing less room
can be cause by aortic stenosis and start as systolic
HErEF
heart failure reduced EF
<40% = systolic hF
HFpEF
> 50% will let you know it is diastolic HF
causes of ACUTE decompensation of HF
Noncompliance with diet or therapy
Sepsis, Acute Illness (coxsackie, HIV, Influenza).
New onset arrhythmias (A. Fib)
Pulmonary Embolus: everything this getting backed up
Anemia Pregnancy Hyper/hypothyroidism Acute Coronary Syndrome Uncontrolled hypertension Toxins: Alcohol, cocaine NSAIDS Holliday Heart Valvular dysfunction Idiopathic
most common shunt
atrial septal defect
foramen ovale
JVD would be a symptom of what type of HF
right sided heart failure
asceitis would be a symptom of
right sided heart failure
risk factors for HF
CAD Cigarette smoking/ Nicotine Use Hypertension Obesity Diabetes CKD Cardiotoxins Alcohol, Cocaine, Cancer chemotherapeutics. Valvular heart disease Rheumatic Fever Structural heart disease Dilated Cardiomyopathy Hypertrophic Cardiomyopathy
May develop over time i.e. HTN, Alcohol, cocaine, CKD.
what two structural changes do we see with heart failure
muscle wall stretches and thins
or muscle wall thickens and becomes ischemic
both lead to heart cells becoming irritated and arrhythmia
how many people will develop heart failure
1/5
how many people will die of heart failure
1/9
myocardial injury can be due to was dx
CAD HTN DM Cardiomyopathy valvular dz
symptoms of low ejection fraction
dyspnea, fatigue, and edema
angiotensinogen is found in the
liver and is the precursor to angiotensin I
angiotensin II is responsible for
ADH release at the cite of the pituitary
arteriole vasoconstriction
aldosterone secretion in the adrenals
tubular NA+ cl- reabsorption and K+ excretion, H20 retention
and increases SNS activity
ADH is responsible for
H20 absorption
how do you manage activation of SNS from RAAS
Beta blocker
how do you manage aldosterone release in RAAS
spironolactone
inotropy is synonymous w/
Contractility
Norepinephrine via ______recptors cause vasoconstriction
Norepinephrine via α1-adrenorecptors cause vasoconstriction
Arterial vasoconstriction maintains BP but, increases ______
Arterial vasoconstriction maintains BP but, increases Afterload.
Venous vasoconstriction increases______in an attempt to maintain SV.
Venous vasoconstriction increases venous return (Preload) in an attempt to maintain SV.
Increase venous pressure leads to _________
Increase venous pressure leads to pulmonary edema.
______ receptors increase HR
Nor Epi β1receptors increase HR
________receptors cause vasoconstriction
Nor Epi α1receptors cause vasoconstriction
clinical presentation
Orthopnea : Sleeping in a chair/ or on multiple pillows PND (paroxysmal nocturnal dyspnea) SOB / DOE Fatigue CP Palpitations Edema Insomnia Change in Exercise capacity Poor appetite or recent weight gain ? Abdominal distention/bloating? RUQ tenderness?
Sudden Cardiac Death
pulmonary HTN is seen as what pressure in the lungs
> 25 mmHg
pulses alterans
variable pulse
usually really strong and then not so strong
acute lung disorder that can lead to HF
cor pulmonale
resulting from pulmonary ebolism
what might you see in a pt with HF
Displaced PMI? Diffuse or focal? Lift? Heave? Double tap?
“Ken-tuc-ky” is used to distinguish what sound associated with HF
S3 gallop (“Ken-tuc-ky”),
anascara
full body edema
will present in flanks while lying down
pulmonary HTN can be caused by
damage to the lung tissue (COPD)
damage to vessels
something that affects spine or rib cage
what are some examples of damage to the pulmonary vessls that can result on pulmonary HTN and cor pulmonale
chronic thromboembolisms
recurrent blood clots
labs for suspected
cbc: rule out anemia (can’t add anything into the system)
chem panel : looking at renal function, electrolytes including Ca++, K, Mg. Hyponatremia common
Liver function tests: Liver damage from hepatic congestion
BMP
TSH
Biomarkers you would want to check in a pt suspected of HF
BNP, NT-proBNP, Can be useful in diagnosing, and tracking medical therapies, establishing prognosis or disease severity in chronic HF
however it may not be as specific in patients who are old or have COPD
Cardiac enzymes: Troponin, CK-MB – often elevated by HF itself.
What would you be looking for on an EKG
arrhythmias, LVH, LAE, widened QRS complex (if wide difficulty with electricity getting through the heart muscle).
besides EKG and lab work, what other diagnostic test would you want to order and what would you be looking for
Chest X-ray:
cardiomegaly, pulmonary edema
Kerley B Lines- short parallel lines at the lung periphery near the bases that indicate pulmonary congestion
Batwing or Butterfly shadow – enlarged hila and alveolar edema
Water bottle or boot shaped heart
echo image of a heart is seen as normal
with atrium on the bottom
how to diagnose HF
two major or two minor and one major
major criteria for modified framingham (7)
PND: relieved with walking for a minute with rule of OSA Orthopnea elevated JVP Rales S3 cardiomegaly on CXR PE on CXR
minor Framingham Criteria (6)
bilateral edema nocturnal cough dyspnea on ordinary exertion hepatomegaly pleural effusion tachycardia (HR>120)
management of diastolic HF
No consensus yet, ongoing studies
Systolic and diastolic BP should be controlled according to guidelines
Control their HR (Lower the better)
Diuretics should be used for relief of symptoms due to volume overload
Coronary revascularization is reasonable in patients with CAD that is symptomatic or demonstrable myocardial ischemia
Manage AF preferably rhythm control > rate control
Use of BB, ACE-I, ARB’s in those with hypertension is reasonable.
ARBs might be considered to reduce hospitalizations
HF and HTN waht tx
ACE or ARB (not both)
why, physiologically do ACE’s cause cough
above the lung
ARB below
biggest sx of HF
shortness of breath
Expands blood vessels which lowers blood pressure, neurohormonal blockade
ACE inhibitor (angiotensin-converting enzyme)
ACE inhibitor (angiotensin-converting enzyme)
ARB (angiotensin receptor blockers)
Reduces the action of stress hormones and slows the heart rate
Beta-blocker
Slows the heart rate and improves the heart’s pumping function (EF)
Digoxin
why would you use digoxin
on a little bit of a BB but still need more HR control
Filters sodium and excess fluid from the blood to reduce the heart’s workload
Diuretic
Blocks neurohormal activation and controls volume
Aldosterone blockade
spironolactone but this a potassium sparing blocade
when would you increase Lasixs (furosemide) in a pt who is gaining fluid
5lbs in a week or 3lbs in a day
what dies changes do you want to see in a pt with HF
low sodium low fat no alcohol or caffeine quit smoking lose weight
best tool for measuring HF
scale
Abbott device
pulmonary artery pressure reader
measuring pressure that is going into the lung
what is the time window you want to be mindful of following a MI
90 days
cna vest cardio defibrillator
Apical ballooning with NORMAL coronaries and wall motion abnormalities
Takotsubo / Broken Heart Syndrome:
most common ischemic cardiomyopathy
heart attack
most common non ischemic cardiomyopathy
alcohol
Hypertension Arrhythmias Myocarditis (viral) Alcohol – most common Non-Ischemic Chemotherapy Pregnancy Connective tissue disease Sepsis
all reasons for what type of cardiomyopathy
dialated
Infiltrative disease : Amyloidosis, Sarcoidosis
Non-dilated, non-hypertrophic, impaired filling
Familial
Hemochromatosis, Scleroderma
Cancer
are all associated with what type of cardiomyopathy
restrictive
Dilated CMP Sxs
Dyspnea : DOE / SOB Edema Orthopnea PND Fatigue S3 MV Murmur
Hypertrophic CMP (HOCM) sxs
Syncope Sudden Cardiac Death in Young Person light headed after typical workout routine Dyspnea Fatigue Angina Orthopnea Palpitations – Atrial Fib S4 on Physical Exam
Restrictive sxs
Dyspnea on Exertion Symptoms of Right Heart Failure Fatigue S3 or S4 Mitral Valve Regurg Murmur
dilated CMP diagnostics
EKG
NSSTC, AV Blocks, Ventricular Ectopy
Echo Dilated LV, Low CO Reduced or Preserved EF Enlarged Atria MV Regurg or Insufficiency? CXR Cardiomegaly Pulmonary Edema
Stress Echo/ Thallium
Angiogram
Labs – find the cause!
BNP?
HCOM diagnostics
EKG LVH, NSSTC, Septal Q waves Echo LVH! Asymmetric Septal Hypertrophy Small LV Volume Diastolic Dysfunction CXR Not remarkable Cardiac MRI
RESTRICTIVE diagnostic tests
EKG Low Voltage non specific changes Echo Large RV, Stage 4 Diastolic Dysfunction Endomysial Biopsy
TX of DILATED CMP
Tx Heart Failure
Tx Underlying Heart Disease/ Cause
Abstain from ETOH and Sodium
Severity of HF? – ?ICD/ LVAD/ Heart Transplant
RESTRICTIVE CMP tx
Diuretics – symptom control
PAH Drugs
( Sildenafil, Letairis, Tracleer, Flolan…etc)
Heart Transplant
HCOM tx
Beta Blockers or CCBs
Surgical Myomectomy or Ablation (cutting of the muscle)
ICD for prevention of SCD
Valve Replacement (MVR) if indicated
reversible cardiomyopathy with a clinical presentation that mimics an acute coronary syndrome (ACS).
Takotsubo / Broken Heart CMP
normal arteries in a pt with acs seen with transient ST elevation looks like an MI
Takotsubo / Broken Heart CMP
TX of Takotsubo / Broken Heart CMP
sx control and supportive care
HCOM is a 100% genetic disorder of what ventricle
left
AHA focuses on what for a sports physical
on medical history (family and personal) and physical examination
The European Society of Cardiology for sports physicals
recommends a pre participation screening strategy that comprises family and personal history, physical examination, and 12-lead ECG
Cardiovascular Screening History for Preparticipation Examinations: Critical Questions
Exertional chest pain or discomfort, or shortness of breath?
Exertional syncope or near-syncope, or unexpected fatigue?
Past detection of cardiac murmur or systemic hypertension?
Known family history of hypertrophic cardiomyopathy, other cardiomyopathies, long QT syndrome, Marfan syndrome, significant dysrhythmias?
Family history of premature death or known disabling cardiovascular disease in a first- or second-order relative younger than 50 years? (More concern if younger than 40 years.)
valsalva maneuver will do what to a murmur in Hypertrophic cardiomyopathy
intensity of the ejection systolic murmur promptly declines because of an increased left ventricular volume and arterial pressure, which increase the effective orifice size of the outflow tract; the carotid pulse upstroke remains sharp, and the volume may increase.
For the above patient, which test would be most helpful in assessing this patient’s murmur and risk for sudden cardiac death?
: Stress Echo
