Quiz #2 Flashcards
what is the most common cause of HF?
HTN
what are other causes of HF other than HTN?
MI, injury, or ischemia due to CAD
heart arrhythmias
renal insufficiency
cardiomyopathy
congenital heart disease
heart valve abnormalities
pulmonary embolus
pulmonary HTN
SCI
age-related changes
what are secondary causes of HF?
long-term significant alcohol abuse
infection
cigarette smoking
pregnancy
how does HTN lead to HF?
increased systemic pressure in arteries–> increased ventricular pressure–> hypertrophy–> stiff and thick–>can’t fill (diastolic dysfunction)
what is preload?
the volume of blood coming into the heart
what is afterload?
the pressure the ventricles have to overcome to get blood out of the heart
what is the Frank Starling mechanism?
a small amount of blood stays in the ventricles to keep it ready to contract
increased blood to the heart leads to ____ preload
increased
pulmonary disease changes what side of the heart?
the right side
what does L ventricular hypertrophy (LVH) lead to?
increased afterload, energy expenditure, and myocardial cell mass
how is LVH diagnosed?
echocardiogram (US)
ECG
what does an ECG show with LVH?
increased amplitude and width of the QRS complex
longer for depolarization signal bc of increased size of the myocardium
what is a common cause of HF?
CAD
how does CAD lead to HF?
ischemic injury leads to scarring and decreased contractility
how does cardiac arrhythmia lead to HF?
impairs the L/R ventricles
what can cause cardiac arrhythmias?
sick sinus syndrome/heart block (decreased HR)
a fib, a flutter, supraventricular tachycardia, vent tachycardia (increased HR)
how does renal insufficiency lead to HF?
fluid overload leads to increased blood volume
what is the goal of treatment in renal insufficiency?
to decreased reabsorption of fluid form the kidneys and increased fluid elimination
how does cardiomyopathy lead to HF?
impaired contraction and relaxation of the myocardium
what causes cardiomyopathy?
pathologic process w/in heart muscles
systemic disease process
what are the 3 types of cardiomyopathy?
- dilated
- hypertrophic
- restrictive
what is dilated cardiomyopathy?
dilation as a result of myocardial mitochondrial dysfunction from toxic, metabolic, or infectious agents
decreased pumping ability leading to increased LVEDP and LVEDV
increased pressure and volume dilate the LV
increased workload on the heart
LV can’t contract or relax
ineffective PUMPING/SYSTOLIC function
decreased pumping ability leads to ____ LVEDP and LVEDV
increased
which occurs first increased volume or increased pumping?
increased volume
is dilated cardiomyopathy ineffective pumping or filling?
pumping
what is hypertrophic cardiomyopathy?
results from malaligned muscles fibers
normal mitochondrial function
DIASTOLIC/FILLING dysfunction
increased LVEDP, LA pressure, pulmonary artery and capillaries pressure
hypercontractile LV
hypertrophy of myocardium
usually in middle age
high risk of sudden cardiac death/arrest from ventricular arrhythmias
what is restrictive cardiomyopathy?
stiff and less compliant LV
DIASTOLIC/FILLING dysfunction
decreased vent filling
decrease diastolic volume
increased diastolic pressure
how do valvular abnormalities and congenital acquired heart disease lead to HF?
stenosis
incompetence
or both
what is the most commonly affected valve in valvular abnormalities?
the aortic valve
what can lead to valvular abnormalities?
rheumatic disease, endocarditis, and congenital abnormalities
valve abnormalities cause the myocardium to _____ force of contraction to _____ CO
increase, increase
stenosis leads to…
hypertrophy and diastolic dysfunction
regurgitation leads to…
dilation and systolic dysfunction
regurgitation leads to ____ filling volume
increased
stenosis leads to ____ ventricular contractility
increased
mitral and tricuspid valve insufficiency leads to _____ dilation
atrial
how are valvular abnormalities diagnosed?
heart auscultation
echocardiogram/cardiac US
cardiac catheterization
what are the s/s of valvular abnormalities?
cardiac arrhythmias
murmurs on heart auscultation
angina
sncope
dyspnea
acute HF
how does pericardial effusion/myocarditis lead to HF?
injured pericardium
cardiac compression
increased intrapericardial pressure
cardiac tamponade (sudden fluid accumulation)
what are the s/s of pericardial effusion/myocarditis?
impaired diastolic filling
tachycardia and increased contractility
what is pleuritic chest pain?
chest pain w/inspiration/expiration
what does pleural friction sound like?
leather rubbing on leather from the inflammed pericardium
what is pulsus paradoxus?
a sign of development of cardiac tamponade where there is a fall in BP during inspiration greater than 10 mmHg
how is pleural effusion/myocarditis diagnosed?
echocardiography
chest x-ray
CT scan
how does pulmonary embolism (PE) lead to HF?
increased pulmonary artery pressure lead to increased work of the RV leading to R HF 1st
what is R sided HF due to?
high pulmonary artery pressure from damaged lung tissue (from ischemia) and decreased area for gas exchange
increased work of the RV
what is L sided HF due to?
decreased volume and coronary perfusion of the LV
impaired LV pumping due to decreased stroke volume and decreased CO
how is PE treated?
fibrinolytic agents such as Heparin to keep blood thin
TPA (tissue plasminogen activase) to destroy blood clots
anticoagulants for 6 months or longer
how does pulmonary HTN lead to HF?
increased pressure in the pulmonary circulation–> increased PA pressure–> increased pulmonary vascular resistance–> increased work of the RV to overcome increased pressure
enlarged RV causes R sided failure
blood flow through lungs slows down and BP in lung arteries rises
what are the causes of pulmonary HTN?
scarring, damaged alveoli, blood clots, thickened capillary walls, and congested and enlarged vessels
what is cor pulmonale?
increased pressure from lung disease
what are the s/s of pulmonary HTN?
dyspnea
fatigue
dizziness/syncope
chest pressure/pain
peripheral edema
ascites (abdominal edema)
syanosis of lips and skin
palpitations/pounding HR/fast pulse
how does SCI lead to HF?
sympathetic and parasympathetic imbalance causes decreased sympathetic response (no increased HR, contraction rate, or constriction of vasculature)
can lead to volume depletion (IV fluids needed)
what age-related change leads to HF?
cardiac muscle dysfunction (CMD) which causes decreased CO and ability of heart to relax/contraction
what are some age related heart changes?
increased systolic arterial pressure and decreased aortic distensibility–>LVH
delayed LV filling
increased NE leading to decreased catecholemine sensitivity
decreased baroreceptor sensitivity
decreased plasma renin concentrations
increased pericardial and myocardial stiffness
what are the most common congenital heart diseases?
congenital bicuspid aortic valve
mitral valve leaflet abnormality
what are the symptoms of HF?
dyspnea
paroxsysmal nocturnal dyspnea
orthopnea
tachypnea
decreased aerobic tolerance or aerobic capacity
what are the signs of HF?
altered breathing patterns
rales/crackles
peripheral edema
pulmonary edema
cold, pale, cynanotic extremities
weight gain
hepatomegaly
JVD
S3 heart sound
sinus tachycardia
what is dyspnea the result of?
poor gas exchange b/w the lungs and cells
what is the most common s/s of HF?
dyspnea
t/f: dyspnea results in increased RR and tidal volume to compensate
true
what is paroxysmal nocturnal dyspnea?
sudden, unexplained SOB during sleep that awakes the person
what helps the symptoms of paroxysmal nocturnal dyspnea?
standing or sitting
what is orthopnea?
dyspnea when lying flat or in recumbent position
pts with _____ _____ _____ demonstrate early onset anaerobic metabolism and abnormalities in the skeletal muscles
decreased exercise tolerance
what is a method of measuring decreased exercise tolerance?
NYHA classification system
how can a PT assess exercise tolerance?
symptoms
HR
BP
heart rhythm via ECG
O2 saturation via pulse ox
RR of specific workloads
exercise tests such as the 6MWT
what is tachypnea?
increased RR, decreased depth of breath
what is Cheyne-Stokes respiration?
looks like they’re not breathing
waxing and waning depth of breathing with periods of apnea in b/w
what is rales?
crackling lung sound associated with CHF heard on INSPIRATION with lung auscultation
sounds like hair being rubbed b/w 2 fingers
heard bilateral at the bases of the lungs
not cleared by coughing
what are the 2 normal heart sounds?
S1 and S2 (lub-dub)
what causes the S1 lub sound?
closing of the tricuspid and mitral valves
what causes the S2 dub sound?
closing of the aortic and pulmonary valves
what are the abnormal heart sounds?
S3 and S4
what is the Hallmark sign of CHF?
S3 heart sound
when is the S3 heart sound heard?
after S2 (lub-dub-DUB)
what does the S3 sound represent?
non-compliant LV
when is a S4 heart sound heard ?
presystolic sound heard b4 S1 (LUB-lub-dub)
what is atrial kick?
vibration of the ventricular wall in atrial contraction
exaggerated atrial contraction
when is S3 considered normal?
in young children and young adults
t/f: peripheral edema may be absent, despite significant CHF
true
what causes peripheral edema?
retained ECF that accumulated in dependent bilateral LE in HF
is peripheral edema caused by right or left HF?
right
is pulmonary edema caused by right or left HF?
left
what is the common area affected by peripheral edema?
ankles and pre-tibial region
t/f: as CHF worsens, peripheral edema can spread up to the thighs, sacral area, and abdomen
true
is peripheral edema pitting or non-pitting?
pitting
what causes pulmonary edema?
increased fluid in the vascular system and interstitial space
increased PCWP and flooded alveoli with fluid
what does pulmonary edema cause?
severe hypoxemia and hypercapnia from decreased gas exchange (ventilation/perfusion mismatch)
decreased lung volumes
respiratory acidosis
what is hepatomegaly?
enlarged liver and sign of of liver dysfunction
what causes hepatomegaly?
volume overload w/CHF causing hepatic venous congestion
what does hepatomegaly lead to?
hypoxemia and cardiac cirrhosis from low CO
cardiac cirrhosis
ascites (abdominal edema)
what is a (+) hepatojugular reflex?
press on the liver and turn head to the side and the jugular vein becomes distended from so much fluid in the venous system of the liver
what causes jugular vein distention?
fluid overload in the venous system from R sided HF
significant CHF will show JVD when?
in any position
what is the best position to measure JVD in?
45 deg semi recumbent
what is pulsus alternans?
mechanical alteration and variability of pulse strength
represents depressed myocardial function and CHF
feel alternating strong and weak pulses
what is pulsus alternans due to?
changing systolic pressure
what is abnormal weight gain for someone with CHF that would be an emergency?
more than 3 lbs in a day
what is systolic HF (HFrEF)?
impaired myocardial contractility/ventricular contraction
compromised ventricular function
decrease in SV, EF, and CO
increased ESV
what is diastolic HF (HFpEF)?
impaired ventricular relaxation and filling
decreased EDV
increased EDP
normal/high EF
lower than normal SV and CO
which has more research behind it: systolic or diastolic HF?
systolic HF
an ejection fraction of <__%=failure
40
what is ejection fraction?
ratio or % volume of blood ejected out of the ventricles relative to volume of blood received by the ventricles b4 contraction
systolic volume/ end diastolic volume OR
SV/LVEDV x 100
what is normal EF?
60-70%
why don’t you want a 100% EF?
bc according to the Frank-Starling mechanism there needs to be a little bit of blood left in the heart to maintain stretch of the myocardium
what is CO?
the volume blood ejected out of the ventricles into the system arterial circulation per minute
CO = HR x SV
what is normal CO?
4-6 L/min at rest
what is normal SV?
55-130 mL of blood
what is cardiac index (CI)?
CO per square meter of body surface area (takes body size into account)
what is normal CI?
about 3L/min/m^2
what is normal blood volume?
5.5 L
what is the best indicator we have of heart function?
CI
what is cardiogenic shock?
condition in which blood supply to the tissues is insufficient bc of inadequate CO
what level of CI is CHF diagnosed at?
<2.2L/min/m^2
what are the 2 types of pulmonary/L sided edema?
cardiogenic and noncardiogenic
what is cardiogenic edema?
edema caused by L sided HF
increased hydrostatic pressure in pulmonary capillaries
leads to increased LVEDV and PCWP and L arterial pressure
what helps distinguish b/w cardiogenic and noncardiogenic edema?
PCWP
what are the causes of cardiogenic edema?
mitral valve stenosis
atrial myoxoma
LV systolic/diastolic dysfunction
dysrhythmias
CMP (cardiomyopathy)
acute myocardial dysfunction
MI
post-op cardiac dysfunction
pulmonary HTN
what is non-cardiogenic edema?
edema caused by L HF
decreased alveolar pressure
elevated permeability
accumulation of fluid and protein in alveolar space
normal hydrostatic pressure
what are some causes of non-cardiogenic edema?
neurogenic
drowning
aspiration
inhalation injury
trauma
burns
acute kidney disease
allergic rxn
quick IV infusion of fluids
opiate OD
increased altitude
ARDS
what are the s/s of non-cardiogenic edema?
normal early physical exam
hypoxemia due to intrapulmonary shunting
PCWP<18mmHg (normal)
classic “batwing” pattern on chest x-ray
normal/increased lung volumes
what happens when CHF causes hypoxia?
it may stimulate RBC production, increasing blood volume and further increasing the volume overload
what happens with anemia and CHF?
decreased hemoglobin and hematocrit
decreased blood viscocity
decreased systemic vascular resisitance
may lower arterial O2 and O2 saturation levels and increased the work of the heart
is there a R or L shift on the oxyhemoglobin curve with anemia?
R shift
why should you be cautious of blood transfusions with CHF?
because it could increase the blood volume and therefore the work of the heart
increased preload as well
what should be done for patients with CHF who need a blood transfusion?
given additional diuretics to prevent an increase in blood volume
what 3 skeletal muscle abnormalities are often found with CHF?
selective atrophy of type 2 fibers
pronounced non-selective myopathy
hypertrophy of type 1 fibers
there can be a decrease in isometric muscles strength by __% in pts with CHF
50
does exercise capacity in pts with CHF increase or decrease?
decrease
t/f: severe LV failure can decrease flow to the pancreas
true
what are the consequences of decreased flow to the pancreas?
impaired insulin secretion leading to less energy for the heart from glucose metabolism
increased BS levels
what does renal function have to do with CHF?
there is sodium retention in HF due to inadequate CO which stimulates the RAAS
kidney try to retain fluid from stimulation from reduced blood flow which further contributes to fluid retention in HF and can lead to kidney damage
what lab values test renal function?
BUN and serum creatinine
serum creatinine below what would indicate serious impairment in renal function?
<4
what nutritional abnormalities are pts with CHF prone to?
GI abnormalities
anorexia
malnutrition
protein-calorie deficiency
vitamin deficiency
thiamine deficiency
carnitine and coenzyme Q10 decrease
why are their cognitive effects with CHF?
decrease in cerebral perfusion and oxygenation
structural changes in the brain (hippocampal damage)
loss of gray matter
atrophy
microemboli
t/f: cognitive function is a predictor of clinical outcomes, repeat hospitalizations and higher mortality rate
true
what is effective in preventing and reducing the effects and changes on brain function from CHF?
exercise/aerobic activity
what are some ways that HF can be managed?
nutritional supplementation
dietary changes (<2000mg sodium/day, decrease cholesterol and sat fat and fluid restricted to 2L or less/day)
pharmacologic treatment
self management techniques
what are common meds used for HF management?
ACE inhibitors
calcium channel blockers
diuretics
beta-blockers
potassium and magnesium repletion with diuretics
what lab values are used to diagnose HF?
BNP (blood naturetic peptide) increased in blood serum
troponin I
troponin T
magnesium
potassium
ABGs (arterial blood gas)
when is BNP released?
in response to stretch from high filling pressure
high arterial pressure
cardiac dilation
what are normal BNP levels?
<100 pg/mL
what are normal NT-pro-BNP levels?
<300 pg/mL
what level of BNP indicated that heart failure is likely?
> 400 pg/mL
what does BNP do?
lowers blood volume and venous dilation, and suppresses secretion of renin and aldosterone
what are normal troponin T levels?
<0.1 ng/mL^3
what are normal troponin I levels?
<0.03 ng/mL^3
what are normal adult magnesium levels?
1.3-2.1 ng/mL^3
what are possible critical values for magnesium?
<0.5 or >3 ng/mL^3
what is potassium important for?
function of excitable cells
what is the normal range for adult potassium levels?
3.5-5.0
what are possible critical values for adult potassium levels?
<2.5 or >6.5
what are ABGs used to evaluate?
pt’s ventilatory, acid-base, and oxygenation status
in CHF PaO2 levels are ____
reduced
in CHF PaCO2 levels are____
elevated
in CHF O2 saturation is ____
reduced
what is the normal pH range?
7.35-7.45
what is the normal range for PaCO2?
35-45 mmHg
what is the normal range for HCO3?
21-28 mEq/L
what is the normal range for PaO2?
80-100 mmHg
what are possible critical values for pH?
<7.25 or >7.55
what are possible critical values for PaCO2?
<20 or >60
what are possible critical values for HCO3?
<15 or > 40
what are possible critical values for PaO2?
<40
what can radiology tell us about CHF?
size and shape of cardiac silhoutte
presence of interstitial, perivascular, and alveolar edema
what is the Hallmark radiologic finding in CHF?
presence of interstitial, perivascular, and alveolar edema
how is HF diagnosed?
ECG, echocardiogram, or cardiac catheter
what is the most useful tool for diagnosing CHF?
echocardiogram
what can echocardiogram show us about CHF?
EF
vent wall dimensions and volume
wall thickness
chamber geometry
regional wall motion
what can be used for medical/surgical management of CHF?
implantable cardiac defibrillator
cardiac resynchronization therapy (CRT)/BiV PPM
valve surgeries
swan ganz catheter
pulmonary artery catheter
intraaortic balloon pump (IABP)
impella
ventricular assist device
transplant
how does a BiV PPM work?
leads in BOTH ventricles to provide stim in synchronized manner
is a TAVR valve procedure done for regurgitation or stenosis?
stenosis
what does the swan ganz catheter intermittently measure?
LA and LV EDP through the pulmonary artery
what is the prime indicator of LV performance?
LVEDP
what is the IABP used for?
to help the heart relax
counterpulsation device to decrease myocardial ischemia
what is an impella?
temporary ventricular support device inserted in the LV and across the aortic valve to support blood pumping from the LV to the aorta
for patients who don’t get enough fluids taken off with diuretics, what is done?
ultrafiltration
what is ultrafiltration?
mechanical removal of excess fluid through removal of plasma, water, and sodium from the blood via highly permeable membrane
what are the predictors for poor survival with CHF?
Decreasing LVEF
Worsening NYHA classification
Degree of hyponatremia
Decreasing peak exercise O2 uptake
Decreasing hematocrit
Widened QRS on ECG
Chronic hypotension
Resting tachycardia
Renal insufficiency
Refractory volume overload
what is the prognosis for CHF?
Risk of CHF following MI
Determined by BNP, higher the BNP, the higher risk
Marked elevation in serum BNP levels during hospitalization for CHF may predict rehospitalization and death.
