Module 3.2 : Congestive Heart Failure Flashcards
what is the hearts function
- to produce a cardiac output sufficient to meet all physiologic demands and to generate arterial pressures sufficient to perfuse the organs
what is cardiac failure
- a state in which the heart is unable to meet the oxygen and metabolic demands of the body
- may be present in resting state or exertion
- compensatory mechanisms end up making heart failure worse
two different classifications of CHF
- left heart failure
\+ disease of the myocardium
\+ valves
\+ coronary arteries
- right heart failure
\+ left heart failure
\+ disease of lung parenchyma
\+ lung vascularity
- emboli
- hypertension
- cor pulmonaletwo causes fo LHF
- decreased myocardial function
- increased myocardial workload
causes of decreased myocardial function
- CAD
- myocarditis
- cardiomyopathy
- infiltrative disease like hemochromatosis
- amyloidosis
- sarcoids
- medications
- radiation therapy
causes of increased myocardial workload
- hypertension
- valvular
+ severe regurgitation/ stenosis - increases preload/afterload
two different classifications of left heart failure
- forward systolic failure (reduced EF)
- backward diastolic failure (normal EF)
what is the most common cause of right heart failure
- left heart failure
systolic/forward/HFrEF = physiology
- Heart Failure reduced Ejection Fraction
- EF < 40%
- imparted ventricular contraction
- most common from ISCHEMIC HEART DISEASE
- 50-60% are this kind
diastolic/backward/ HFnEF
- Heart Failure normal EF
- EF > 55%
- impaired ventricular relaxation
- most common from HYPTENSION and LEFT VENTRICULAR HYPERTROPHY
- 40-50% this kind
systolic heart failure
- inability of the left ventricle to pump blood forward to meet metabolic demands of the body
- decrease cardiac output
- eventually filling pressure will rise leading to right heart failure as well
backwards heart failure
- related to reduced compliance and possibly hypertrophy of the LV
- seen with infiltrative myocardial disease, LVH caused by aortic stenosis, high blood pressure, advanced age
physiology of backwards heart failure
- reduced compliance in the LV myocardium leads to increased LV and LA filing pressures
- increased filling pressures translate the higher pressures backward into the pulmonary veins and into the lungs causing right heart failure
6 symptoms of left sided CHF - systolic and diastolic
- dyspnea = pulmonary congestion
- orthopnea = difficulty breathing when you’re laying down
- parxysmal nocturnal dyspnea = stop breathing at night
- acute pulmonary edema
- fatigue
- palpitations
7 signs of left sided CHF - systolic and diastolic
- cardiomegaly = dilatation
- ventricular heave = LV pushes against chest wall
- 3rd heart sound = early filling
- 4th heart sound = late filing decreased compliance
- rales or crackles = from fluid in lungs
- cheyne-stokes respiration = stop breathing
- tachycardia = as output reduces HR increases
right sided CHF
- MOST COMMON CAUSE IS LEFT SIDED HEART FAILURE
- cannot handle high afterload
- can also be caused by primary lung disease
+ pulmonary HTN
+ chronic obstructive pulmonary disease COPD
+ emphysema
7 signs right sided CHF- related to underlying disease
- RVH = the right ventricular may become hypertrophied
- murmur = pulmonary and tricuspid regurgitation
- wheezing SOB
- elevated jugular venous pulse
- pitting edema
- ascites
- cyanosis
4 symptoms of right sided CHF - main symptoms related to systemic venous congestion
- fatigue = when CO is reduced
- dependent edema = angles when upright. sacral and abdomen when supine
- liver engorgement = RUQ pain
- anorexia or bloating = from hepatic or visceral engorgement
what is the gold standard for measuring pulmonary pressure
- pulmonary capillary wedge pressure PCWP
- invasive
- echo can only estimate LAP
normal LAP
6-12
LAP > 18mmHg or 15mmHg
- means pulmonary hypertension
functional CHF categories
I = no symptoms or limitations in normal activity II = mild symptoms or some limitation with normal activity III = marked limitiaon in activity due to symptoms IV = severe limitations
what is venous return
- amount of blood returning to the heart
three things that affect venous return
- blood volume
- venous pressure
- intrathoracic pressure
what affects blood volume
- body volume (obesity)
- pregnancy
- blood loss
what affects venous pressure
- blood volume
- venous constriction
- temperature reduction
what affects intrathoracic pressure
- auto regulated in normal adult
what three things increase after load
- high BP = high after load
- aortic stenosis
- coarctation of the aorta
heart rate control - parasympathetic
- vagus nerve
- SA
- AV nodes
- slows things down
heart rate controls - sympathetic
- SA
- AV
- purkinjie fibers
- speeds things up
parasympathetic response with action potential
- slow heart rate by moving the resting membrane potential to a more negative state
- sympathetic does the opposite
sympathetic nervous system in CHF
- compensatory mechanism kick in when in CHF as the EF and BP drops
- fight or flight response
fight or flight response
- baroreceptors in the carotid bulb sense changes in pressure and respond with constriction or relaxation of the arterial system
three things that happen when BP (blood pressure) drops
- increased HR
- increased contractility
- systemic vasoconstriction
are compensatory mechanisms helpful or hurtful
- both
- helpful in short term but eventually detrimental to patient
ways to counteract the compensatory mechanisms
- release of hormones
+ atrial natriuretic peptide (ANP)
+ b-type natriuretic peptide (BNP) (tested to see if someone is in CHF) - effects
+ water excretion, vasodilation - unable to fully counteract the detrimental changes
the role of echo in CHF
- determination of underlying etiology
6 things to assess with echo for CHF
- cardiac chamber size and LV/RV mass
- systolic performance of LV and RV (EF, TAPSE, TDI, FAC)
- assessment of diastolic filling pressures
- determination of right sided heart pressures
- valvular function (stenosis, regurge)
- follow up for progression of known disease
what is an increase in cardiac mass called
- hypertrophy (eccentric)
- 141g/m^2
what is an increase in cardia size
- dilation
- ventricles and atria
what type of hypertrophy is seen more with backward and forward HF
- concentric LVH seen more in backward HF
+ walls thick but chamber normal - eccentric LVH seen more in forward HF
+ dilated chamber with normal walls
how to determine right heart pressures
- determine RAP with IVC sniff test
normal RAP IVC sniff test
- IVC = = 21 ; > 50% collapse
+ RAP = 3 mmHG
abnormal RAP IVC sniff test
- IVC = > 21 ; < 50% collapse
+ RAP = 15mmHg
what is the RAP if only one criteria is met
- 8 mmHg
valvular heart disease
- moderate or severe valvular regurge or stenosis can increase preload or afterload significantly
- can place an unfit or mildly diseased heart into failure
- assess the degree of stenosis or regurge for each value
what does treatment of CHF depend on
- underling cause and symptoms
what are the 3 options of treatment for CHF
- lifestyle \+ diet, smoking, exercise, weight reduction, stress reduction - medication - pacemakers \+ defibrillators, LV assist devices
medical options for treatment spend on what
- underlying etiology
- type of heart failure
goals of medical options
- mitigate symptoms to improve quality of life
- which would improve their classification
- BALANCE EFFECTS OF THE COMPENSATORY MECHANISMS
diuretics
- also known as water pills
- promotes urination to decrease intravascular volume
- decreases preload and after load
- relieves pulmonary congestion and or pedal edema
inotropic agents
- improve contractility
- for use in those with HFrEF
- increases contractility = increases stroke volume by stimulation viable wall segments to contract more
- digitalis digoxin
ACE inhibitors
- angiotensin converting enzyme BLOCKER
- arterial and venous vasodilation effects
- look for drugs ending in April
- decrease artery tension
beta blocker
- slows force of contraction and heart rate
- controversial in patient with low EF
- may decrease SV further
- though provides longer filling time
- end in olol
atrial arrhythmias
- afib = most common
- AF decreases stroke volume
- risk of clot formation
- ventricular arrhythmias
treatment for arrhythmia
- anti arrhythmics
- calcium channel blockers
- lidocaine
- beta blockers
- pacemakers
- implantable cardioverter/ defibrillators
- LV assist device
prophylactic anticoagulation for afib
- reduces risk of thrombus formation
- heparin
- warfarin
