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Flashcards in 26 - Congestive Heart Failure Deck (39)
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What is heart failure?

Inadequate blood flow for metabolic needs


What are the primary and secondary causes of heart failure?

- This is what we will talk about in this course
- Cardiac origin, periphery affected

- Peripheral cause, cardiac affected
- Sepsis, anemia, toxins, etc.


Describe systolic heart failure

Remember systolic = contraction, so systolic heart failure is when the heart cannot contract enough (weakened contractility) and the heart can't empty
- Ejection fraction will be


Descrie diastolic heart failure

Remember diastolic = relaxation, so diastolic heart failure is when muscular hypertrophy prevents the heart from filling properly
- Ejection fraction will be >50%
- Hypertension will occur without ischemia


Describe the pathophysiology of heart failure

- Begins with decreased cardiac output
- Compensated by increased volume (retention of Na+ and water)
- Cardiac response


How does the heart respond to heart failure?

- Increased filling volume (LVEDV)
- Increased fiber length, which allows increased force of contraction
- Starling law


Describe the Starling law curves

- Up to a limit, stroke volume and LVEDV increase in tandem.
- In HF, the LVEDV is up but the stroke volume (LVEDV-LVESV) is down.
- Less is pumped out per cycle.


What does the body do in HF when senses a drop in tissue perfusion and interprets it as ischemia?

- Increases contractility, rate, peripheral resistance (Epinephrine, norepinephrine)

- Increases ischemia (systolic) or hypertrophy (diastolic) (Increased O2 demand, increased work load)

- Renin/angiotensin activated as if hypovolemic


What are the "upstream" consequences in HF?

- Left ventricular failure leads to pulmonary congestion and dyspnea

- Right ventricular failure leads to systemic congestion and edema


What are the "downstream" consequences in HF?

- Left ventricular failure leads to poor organ perfusion and therefore decreased function (renal, cerebral, cardiac --> Na+/H2O retention, confusion, ischemia)

- Right ventricular failure leads to lower filling pressures, creating diastolic failure (can't fill)


What is the most common cause of R ventricular failure?

Left ventricular failure
- Pulmonary vascular congestion from left ventricular failure increases the workload on the right ventricle
- Eventually the right ventricle will fail


What are symptoms of L ventricular failure?

- Dyspnea: exertion, recumbent, nocturnal, resting
- Diminished exercise capacity (output down)
- Nocturia (recumbent diuresis)
- CNS impairment (memory, insomnia, etc; end organ)


What are symptoms of R ventricular failure?

- Peripheral edema (Includes hepatosplenomegaly, legs up to back!)
- Edema of bowel wall can impair med absorption


What is the NYHA functional classification of HF?

Classes I-IV to determine level of heart failure


Describe class I

- No functional limitation
- Ordinary physical activity does not cause undue fatigue, dyspnea or palpitations
- Normal life expectancy for comorbidities
- At-risk population


Describe class II

- Slight limitation of activity
- Ordinary activity precipitates dyspnea, fatigue, palpitations or angina
- 25% risk in 1 year


Describe class III

- Market limitation
- Less than normal activity precipitates symptoms
- Marked limitation of physical activity
- Less than ordinary physical activity leads to symptoms
- 50% risk in 1 year


Describe class IV

- Symptoms at rest
- Unable to carry on any physical activity without discomfort
- 50% risk in 1 year


What would you see on physical examination in left HF?

- Pallor, cool extremities
- Anxiety, dyspnea at rest
- Pulses normal to rapid, weak
- Blood pressure varies
- Pulmonary rales, pleural effusion

Remember: usually not “pure” Left HF.


What would you see on physical examination in right HF?

- Hepatojugular reflux
- Kussmaul’s sign
--- Paradoxical JVD from increased R chest pressures
--- Inhalation normally increases blood return.
- Congestive hepatomegaly (Ascites)
- Edema – symmetrical, pitting, dependent


What would you see in a cardiac exam?

- Kussmaul’s sign
- Cardiomegaly
- S3 almost universal (LV or RV)
- S4 rare; absent in A fib.
- Pulsus alternans
- Murmurs
--- Systolic: MR, AS, TR
--- Diastolic: AI
- Cardiac cachexia (late)


What would you see in laboratory test?

- Electrolyte abnormalities (GFR, lytes)
- Liver enzyme elevations (stasis)
- Findings related to precipitating causes (e.g. TSH)


What would you see in an x-ray?

- Cardiomegaly
- Pulmonary congestion
- Pleural effusion
- Kerley lines


What is the prognosis of HF patients?

- Overall US mortality is 50% in 5 yr; one year 30-40%
- Most die of 1) pump failure or 2) tachyarrhythmias


What makes the prognosis worse?

Male gender
Low/narrow pulse pressure
High number NYHA functional class
Reduced exercise capacity


What are the therapy goals?

- Relieve symptoms – make the patient feel better
- Improve NYHA functional class (Challenging once patient has progressed to class 3 or 4)
- Decrease frequency and intensity of treatment (might reduce cost; inconsistent finding)
- Delay progression of myocardial dysfunction
- Reduce premature HF mortality


What does HF therapy depend on?

The stage of HF


What are the two most beneficial therapies of HF?

- ACEi
- Beta-blockers


Describe stage A therapy

Pre-symptoms, at risk but heart is okay

- ACE inhibitors are drug of choice
- Beta blockers may be beneficial
- Aim to prevent dysfunction and HF or any irreversible damage


Describe stage B therapy

Cardiac structure changes without symptoms

Drugs of choice
- ACEi
- Beta blockers
- Diuretics
- Digoxin (?)

Goal is to prevent worsening dysfunction, reduce hospitalizations, etc.