HF Flashcards
HF is defined as a
complex syndrome that results from any structural or functional impairment of ventricular filling or blood ejection
HF leads to
to tissue hypoperfusion, fatigue, dyspnea, weakness, edema, and weight gain
HF may be caused by
structural abnormalities of the pericardium, myocardium, endocardium, heart valves, or great vessels
ejection fraction is the main marker for determining
HF risk factors, treatment, outcomes
the LV’s ability ot fill is determined by (5)
Pulmonary venous blood flow
LA function
mitral valve dynamics
pericardial restraint
active and passive elastic properties of the LV
LV diastolic function is normal when
factors combine to provide an LVEDV (preload) sufficient cardiac output for cellular metabolism without elevating pulmonary venous and LA pressures
in HFpEF, higher LV filling pressures are required to
to achieve normal end-diastole volume
A steeper rise of the end-diastolic pressure-volume curve indicates
delayed LV relaxation and increased myocardial stiffness
Reduced LV compliance and precipitates (5)
LA hypertension
LA systolic and diastolic dysfunction
pulmonary venous congestion
and exercise intolerance
Delays in relaxation are a form of “active stiffening” caused by
failure of the actin-myosin dissociation due to inadequate perfusion or dysfunctional intracellular Ca++ homeostasis.
LV relaxation depends on ________ , which is typically elevated in ______ patients.
afterload; HTN
t/f bradycardia exacerbates the failure of LV relaxation
false, tachycardia exacerbates the failure of LV relaxation
HFpEF or HFrEF
Profound exercise intolerance is seen with _______ despite only having a modest depression in LV systolic function
HFpEF
Prolonged compression of the coronary arteries restricts diastolic coronary blood flow, which contributes to
subendocardial ischemia and a further reduction in exercise tolerance
The most common signs of HF are
fatigue
tachypnea
dyspnea
paroxysmal nocturnal dyspnea
orthopnea
S3 gallop
JVD
peripheral edema
exercise intolerance
and reduced tissue perfusion.
where on CXR is an early indicator of LV failure and pulmonary venous HTN
distention of pulmonary veins in the upper lobes of the lung
kerley lines produce what pattern and reflect what?
honeycomb pattern and reflect interlobar edema
alveolar edema produces what in what kind of pattern
homogenous densities in the lung fields, typically butterfly pattern
T/f pulm edema in radiography may lag behind clincal evidence by up to 12 hours
true
what is the ACC/AHA diagnosis criteria for LVDD
HF symptoms, EF > 50% and evidence of LVDD
HFrEF or HFpEF
BNP elevation
HFrEF! due to LV dilation and eccentric remodeling
HFrEF or HFpEF
BNP lower
HFpEF! associated with concentric hypertrophic, relatively normal LV chamber size and lower end-diastolic wall stress allowing for lower BNP
what protein represents the inflammatory component of HF
C-reactive protein (CRP) and growth differentiation factor- 15 (GDF-15)
why check trops in HF patients
systemically released due to myocardial damage and serve as a measure of risk prediction
NYHA Class I
no limitations and no symptoms with ordinary activity
NYHA Class II vs Class III
Class II - limitations with minimal activity
Class III - limitations with any activity
both comfortable/asymptomatic at rest
NYHA Class IV
symptomatic at rest
also a INTERMAC 4
ACC/AHA Class A
high risk no funcitonal or structural deficitis
ACC/AHA Class B
structural deficit but asymptomatic
ACC/AHA Class C
heart failure symptoms due to underlying structure heart deficit with medical management
ACC/AHA Class D
advanced disease requiring hospitalization, transplant, or palliative care
lifestyle treatment for CHF
aerobic fitness, weight loss, salt-restricted diet (DASH), HTN and blood glucose manage, smoking cessation
kahoot Q
HFrEF
HF with EF < 40%
systolic HF
HFpEF
HF with EF > 50%
diastolic HF
borderline HFpEF
HF symptoms with an EF 40-49%
T/F diastolic dysfunction is only present in HFrEF
false, diastolic dysfunction is present in both HFpEF and HFrEF
LV hypertrophy pattern of HFpEF
concentric hypertrophy
LV dilation pattern of HFrEF
eccentric hypertrophy
which HF is related to conditions such as HTN, DM, Afib, obestiy, metabolic syndrome, COPD, and CKD/anemia
HFpEF
which HF is associated with modifiable risk factors such as smoking and HLD
HFrEF
which HF has a higher incidence of myocardial ischemia and infarction, previous PCI, CABG, PVD
HFrEF
women are more affected by _______
men are more effected by _______
women - HFpEF
men - HFrEF
prevalence of HFrEF, HFpEF, borderline in %
HFpEF - 52%
HFrEF - 33 %
boderline - 16%
what dysfunction is the primary determinant of HFpEF
LV diastolic dysfunction
what dysfunction is the primary determinant of HFrEF
contractile dysfunction
common causes of LV diastolic dysfunction
- age > 60
- acute myocardial ischemia
- myocardial stunnning/infarction
- ventricular remodeling after infarction
- pressure-volume overload hypertrophy (aortic valve stenosis/essential HTN)
- volume overload hypertrophy (aortic/mitral valve regurg)
- hypertrophic obstructive, dilated, restrictive cardiomyopathy
- pericardial disease
symptoms most common with HFpEF
paroxysmal nocturnal dyspnea, pulmonary edema, and dependent edema
symptoms most common with HFrEF
s3 gallop
mean pulmonary capillary wedge pressure > 15 mmHg at rest or >25 mmHg with exercise provides evidence of
HFpEF and is a predictor of mortality
EKG abnormalities in HF patients
LVH, previous MI, arrhythmias, and conduction abnormalities
chronic HF treatment consisting of treat associated conditions, exercise and weight loss is assoicated with which HF
HFpEF
chronic HF treatment with beta blocker and ACE-Inhibitor therapy is assoicated with which HF
HFrEF
according to ACC/ESC what medication can reduce LV filling pressures, decrease pulmonary venous congestion, and improve HF symptoms
loop diuretics
kahoot Q
when might thiazide diuretics be useful
poorly controlled HTN to prevent onset of HFpEF
beta blocker therapy is strongly recommended for
HFrEF!
in HFpEF BB are preseribed for other indications (HTN, Afib, MI)
kahoot Q
which HF uses ACE-Inhibitors as mainstay treatment
HFrEF
ACE-I show no benefit in HFpEF unless used for HTN
what can reverse LV dysfunction following an MI
coronary revascularization via CABG or PCI
early revascularization may prevent permenant EF reductions
cardiac resynchronized therapy is used for
biventricular pacing
HF with a ventricular conduction delay (prolonged QRS)
benefits of cardiac resynchonization therapy
more synchoronous heart contractions and improves Cardiac Output
when is CRT recommended
NYHA Class III or IV with EF < 5% and QRS duration 120-150 ms
risk of CRT
infection, misplacement, device failure
implantable hemodynamic monitoring allows remote observation of intracardiac pressures to
guide treatment and prevent decompensation
cardioMEMS - noninvasive PAP monitoring
implantable cardioverting-defibrillators used to prevent
sudden death in patients with advanced HF
50% HF deaths are due to sudden cardiac dysrhymias
kahoot Q
LVAD is used for
- temporary ventricular assistance while heart is recovering
- patients awaiting heart transplant
- patients on inotropes or IABP with potentially reversible medical conditions
- advanced HF not candidates for transplant
T/F LVAD mechanical pumps can take over total or partial function of the damaged ventricle and facilitate restoration of normal hemodynamcics and perfusion
true
acute heart failure is
rapid onset, present with life threating conditions
may require hospitalization
the term “acute heart failure” applies to
pts with worsening preexisting HF (acute decompensated HF) and first time with HF (de novo acute HF)
acute decompensated HF symptoms
fluid retention, weight gain, dyspnea
result of decompensation due to inadequate compensation
leading cause of de novo Hf
cardiac ischemia 2ndary to coronary occlusion
less common - nonischemic causes of de novo HF
viral, drug-induced (toxic) and peripartum cardiomyopathy
de novo AHF is characterized as
sudden increase in intracardiac filling pressures or acute myocardial dysfunction leading to decreased peripheral perfusion and pulmonary edema
T/F de novo HF leads to long term cardiac dysfunction, despite management
false, managament of the underlying cause may allow for complete restoration
hemodynamic profile of acute HF
low cardiac output, high ventricular filling pressures, and HTN or HTN
1st line treatment of acute HF
diuretics - should be given immediately in fluid over to mitigate symptoms and decrease mortality
patients w HypoTN/cardiogenic shock need HD support prior to diuretics
kahoot Q
what drugs can be used to reduce intravascular volume to decrease CVP and PCWP, and pulmonary congestion
furosemide, bumetanide, torsemide
GTT or bolus
vasodilators are used in acute HF bc they
correct elevated filling pressures and reduce afterload
careful considerations w vasodilators bc of the underlying hemodynamics
SNP is effective in rapidly decreasing
afterload
arterial vasodilator
NTG is commonly used as adjunct therapy with
diuretic therpay
why use tolvaptan in acute HF
vasopressin receptor antagonists
reduce arterial constriction, hyponatremia, and the volume overload assocaited with AHF
what is the mainstay drug for acute HF for patietns with reduced contractility or in cardiogenic shock
positive inotropes!!
inotropes increase cAMP which increases intracellular calcium and exicitation contraction coupling
kahoot Q
catecholamines MOA and examples
stimualate Beta receptors on myocardium to activate adenyl cyclase to increase cAMP
EPI, NE, dopamine, dobutamine
PDE-inhibitors MOA and example
indirectly increase cAMP by inhibiting the degradation of cAMP
milrinone
MOA, CO, MAP, HR with EPI
B1 = B2 > alpha
increased increased CO, MAP, HR
MOA, CO, MAP, HR with NE
A > B1 > B2
increased CO, MAP, HR stays same or decreases
MOA, CO, MAP, HR with dobutamine
B1 > B2 > a
cardiac ouput stays same or decreases
**increased increase ** MAP
**increased increase ** HR
MOA, CO, MAP, HR with dopamine
D > B (alpha with high doses)
icnreased CO, same/lower MAP, hella increased HR
what recombinant drug is used to inhibit RAAS and promote artial, venous, and coronary vasodilation, decreasing LVEDP and improve dyspnea
Nesiritide, exogenous BNP
binds to ANP and BNP receptors
kahoot Q
based on INTERMACS scoring, what would you score a patient whos critically ill and moribound with severe symptoms at rest, and crashing
1- crashing
based on INTERMACS scoring, what would you score a patient whos experiencing congestion while on inotropes
2- failing on inotropes
based on INTERMACS scoring, what would you score a patient whos at home with a continuous dobutamine infusion, with variable symptoms at rest and variable activity tolerence
3 - inotrope dependent
based on INTERMACS scoring, what would you score a patient whos at home with oral therapy
4 - symptoms at rest
IABP is a cyclic helium balloon that inflates duirng ____ and deflates during _____
inflation diastole
deflation systole
primary modes of IABP placement confirmation
TEE and Xray
IABP improve perfusion where by reducing what
improve LV coronary perfusion and reduce LVEDP
full support on IABP means
1:1 - one inflation for every Heartbeat
if the patient is tachycardiac while on IABP what setting is ideal (1:1) or (1:2)
kahoot Q
1:2 (one inflation per every 2 heartbeats)
T/F IABP provides great improvements in Cardiac output and is useful longterm
false, it improves CO (0.5-1 L/min) and renders patients immobile
the impella is a VAD that is placed percutaneously to reduce LV strain and myocardial work in the setting of acute HF - how long can it be utilized
up to 14 days
impella is used as a transiton to recovery or bridge to what cardiac procedures
CABG
PCI
VAD
transplant
what is the impella
mini rotary blood pump inserted in femoral artery, advanced into the aortic valve and is situated in the LV
the pump draws blood continuouly from the LV through distal port and ejects it into the ascending aorta
flows > 3.5L/min
peripheral VAD consists of a small pump and controller but generates heat and causes
hemolysis and low flow ratess
kahoot Q
if a peripheral VAD has an oxygenator it is considered
ECMO extracorpeal membrane oxygenation
central VAD/ECMO has cannulation where
in the right atrium and aorta
why central ECMO instead of peripheral
for cardiopulm support if adequate flow rates are not achievable
benefits of central ECMO
complete ventricular decompression, avoidance of limb impairment, avoidance of SVC syndrome
pts on ECMO likely have reduced ____ perfusion as blood bypasses the _____ before returning to the aorta
lung perfusion; lung
anesthetic considerations for ECMO patients
TIVA > inhaled anesthetics
INH anesthetics may be limited by functional shunting around the lung
T/F ECMO membrane is hydrophilic, causing many agents to be sequestered within the circuit
false, the circuit is lipophilic - causing agents to be sequestered within the circuit
HF patients have an increased risk of developing
renal failure, sepsis, PNE, and cardiac arrest
long mechanical vent hoursl overall increased 30 day mortality
when should surgery be postponed in HF patients
experiencing decompensation, recent change in clinical status, or de novo HF
all HF should have a comprehensive preop exam to determine if they are
compensated or require treatment
when are diuretics held
day of surgery
are BB continued
yes - they reduce perioperative M&M
are ACE-I continued
no - they put patients at risk for intraop Hypotension
when is a 12-lead warranted
any pt with CV disease
TTE is indicated when
patients with worsening dyspnea during preop eval
preop labs for HF patient
CBC, BMP, LFTs, COAGS
BNP not routinely ordered
patients with ICDs and pacemakers should have what before surgery
interogation of devices
cardiomyopathies are a group of myocardial diseases assocaited with _______ and/or _______ dysfunction that usually exhibits ventricular hypertrophy or dilation
mechanical and or electrical
cardiomyopathies are divided into 2 groups - primary and secondary (whats the difference)
primary - confined to the heart muscle
secondary - cardiac involvement in the context of a multiorgan disorder
most common genetic CV disease
Hypertrophic cardiomyopathy
hypertrophic cardiomyopathy is characterized by
LVH in the absence of other diseases capable of inducing ventricular hypertrophy
Hypertrophic cardiomyopathy presents with hypertrophy where in the heart
interventricular septum and the anterolateral free wall
histology shows hypertrophied myocardial cells & patchy myocardial scars
hypertrophied myocardium has a prolonged _______ time and decreased ________
relaxation time; decreased compliance
T/F myocardial ischemia is present in patients with hypertrophic cardiomyopathy whether or not they have CAD
true!
common cause of death in young adults with HCM
dysrhythmias - causing sudden death
In hypertrophic cardiomyopathy dysrhymias are caused by
disorganized cellular architecture, myocardial scarring, and expanded interstitial matrix
ECHO findings of a patient with hypertrophic cardiomyopathy
EF and wall thickness
> 80%
echo may show myocardial wall thickness > 15 mm
in terminal states EF may be severly depressed
EKG abnormalities in HCM include
high QRS voltage, ST- segment, T-wave alterations, abnormal Q waves, Left atrial enlargement
in asymptomatic patients, what may be the only sign of HCM
unexplained LVH
hypertrophic cardiomyopathy medical therapy
BB and CCB
pts who develop HF despite BB and CCB may show improvement with diuretics
whats a good adjucnt in patients with hypertrophic cardiomyopathy who reamin symptomatic
disopyramide - negative inotrope effect improving LVOT obstruction and heart failure symptoms
what arrythymia can develop with HCM
Afib
thrombembolism, HF, and sudden death
amiodorone most effective + long term anticoagulation is indicated chronic/recurrent afib
HCM surgical treatment options for symptomatic patients
a prosthetic mitral valve can be inserted to counteract the anterior motion of the mitral leaflet
surgical strategies for hypertrophic cardiomyopathy
septal myomectomy
cardiac cath with injection to induce ischemia of the septal perforator arteries
percutaneous septal ablation
dilated cardiomyopathy is characterized by
LV or biventricular dilation, biatrial dilation, decreased ventricular wall thickness, and systolic dysfunction without abnormal loading conditions
initial symptom of dilated cardiomyopathy
HF and CP
ventricular dilation from dilated cardiomyopathy can lead to
mitral and or tricuspid regurgiation
with dilated cardiomyopathy what are common things that can cause death
dysrhtymias, conduction abnormalities, emboli, and sudden death
ECHO results of dilated cardiomyopathy
dilation of all 4 chambers, predominately the LV as well as global hypokinesis
treatment for dilated cardiomyopathy
similar to that of chronic HF /anticoagulation
EKG of dilated cardiomyopathy
ST-segment and T wave abnormalities and LBBB
PVC and AFib
what is apical ballooning syndrome
stress cardiomyopathy
what is stress cardiomyopathy
apical ballooning syndrome
temporary primary cardiomyopathy characterized by LV apical hypokinesis with ischemic EKG changes, however the coronaries remain patent
where in the heart is there temporary dysfunction in stress cardiomyopathy
LV apex - while the rest of the heart has normal contractility
symptoms of stress cardiomyopathy
chest pain and dyspnea
causes of stress cardiomyopathy
stress (physical or emotional)
women > men
peripartum cardiomyopathy arises when
3rd trimester - 5 months postpartum
diagnosis of peripartum cardiomyopathy: 3 criteria
- development of HF in period surrounding delivery
- absence of another explainable cause
- LV systolic dysfunction with LVEF < 45%
diagnosis of peripartum cardiomyopathy
EKG, ECHO, CXR, cardiac MRI, cardiac cath, endomyocardial biopsy, BMP levels
what is secondary cardiomyopathy
due to systemic disease that produce myocardial infiltration and severe diastolic dysfunction
common cause of secondary cardiomyopathy
BONUS: Secondary causes
amyloidosis
secondary: hemochromatosis, sarcoidosis, carcinoid tumor
when should diagnosis of secondary cardiomyopathy be considered
pts with HF but no evidence of cardiomegaly or systolic dysfunction
secondary cardiomyopathy BP characteristics
low to normal BP
and can develop orthostatic hypotension
what is cor pulmonale
RV enlargement (hypertrophy or dilation) that may progress to HF
kahoot Q
causes of cor pulmonale
pulmonary HTN
myocardial disease
congential heart disease
respiratory, connective tissue, thromboembolic disease
most common cause of cor pulmonale
COPD
EKG changes with cor pulmonale (2)
RA and RV hypertrophy
peaked P waves in II, III, aVF (RA hypertrophy)
RBBB - right axis deviation
diagnostic test for cor pulmonale
TEE, CXR, right heart cath
