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AS - N932 Advanced Pathology > Cardiac > Flashcards

Flashcards in Cardiac Deck (30)
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1

Heart Failure Classification

New York Heart Association Functional Classification of Breathlessness (for heart failure patients)

2

NYHA Class I

No symptoms and no limitation in ordinary physical activity i.e. SOB when walking, climbing stairs, etc.

3

NYHA Class II

Mild symptoms (SOB and/or angina) and slight limitation during ordinary activity

4

NYHA Class III

Marked limitation in activity d/t symptoms even during less-than-ordinary activity i.e. walking short distances (20-100m)
Comfortable at rest

5

NYHA Class IV

Severe limitations
Experiences symptoms even while at rest
Mostly bedbound patients

6

Heart Failure Causes

Volume overload
Pressure overload
Myocardial contractile impairment d/t ischemia or infarct
Restrictive filling (constrictive pericarditis, cardiac tamponade, restrictive myocarditis)
Idiopathic remodeling - cardiomyopathy
Myocardial inflammation

7

Left-Sided HF Causes

↑LVEDP
Hypertension
CAD
Valvular disease
MI

8

Right-Sided HF Causes

↑RVEDP
Most common cause L-sided HF
Pulmonary arterial hypertension
R ventricle MI

9

Low Output HF Causes

Result from FILLING or EMPTYING problem
CAD
Chronic HTN
Cardiomyopathy
Valvular disease
Pericardial disease

10

High Output HF Causes

↑ metabolic demand
Anemia
Septicemia
Hyperthyroidism

11

Volume Overload

SHF
↓LVEF
↑LV chamber size
S3 gallop
Compliant
ECCENTRIC remodeling

12

Pressure Overload

DHF
Normal LVEF
↓LV chamber size
S4 gallop
↓ compliance
CONCENTRIC remodeling

13

Eccentric

New sarcomeres in series
Hypertrophy
↑radius (chamber size)
EMPTYING problem

14

Concentric

New sarcomeres in parallel
Hypertrophy
↓chamber radius
Cardiomyocyte thickening
FILLING problem

15

Heart Failure Physiological Compensations

↑SNS
Arterial VSMC vasoconstriction ↑SVR ↑afterload
↑venomotor tone ↑VR
Frank-Starling mechanism engagement
SA node ↑HR
Myocardium ↑inotropy ↓catecholamine sensitivity
Adrenal gland ↑circulating catecholamines
RAAS activation d/t ↓renal blood flow
Cardiac remodeling

16

Neural Compensations

Atrial & arterial baroreceptors trigger catecholamine release & ↑vasopressin
Catecholamines → cardiotoxicity (apoptosis & necrosis) promotes cardiac remodeling
Vasopressin ↑SVR ↑Na+/H2O retention

17

Local Compensations

↓renal blood flow → RAAS activation promotes remodeling
Ischemic cardiomyocytes release inflammatory mediations (cytokines) that trigger cardiac remodeling
Ischemic endothelial cells release endothelin
Stretched atrial & ventricular cells release ANP/BNP (cardioprotective)
ANP promoted diuresis, natriuresis, inhibits RAAS & SNS, anti-inflammatory, inhibits remodeling

18

Systolic Heart Failure

Emptying problem occurs in the L ventricle > R ventricle
Triggered by volume overload → eccentric remodeling

19

Diastolic Heart Failure

Filling problem occurs in the L ventricle > R ventricle
Triggered by pressure overload → concentric remodeling

20

Acute Heart Failure
Anesthetic Implications

Immediate goal ↑CO ↓LVEDP
End organ perfusion
Tools include inotropes, vasodilators, diuretics, Ca2+ sensitizers, BNP, NO inhibitors, & mechanical devices

21

Chronic Heart Failure
Anesthetic Implications

Goal to prevent acute heart failure episode
Hemodynamic stability
Full preop workup
Check medications, complete cardiac history, hepatic/renal/electrolyte panels, recent EKG or Echo

22

FILLING

DHF
Restrictive cardiomyopathy
Hypertrophic cardiomyopathy
Constrictive pericarditis
Cardiac tamponade
Hypotension
Mitral valve stenosis (L ventricle)
Tricuspid valve stenosis (R ventricle)

23

EMPTYING

SHF
Dilated cardiomyopathy
Hypertrophic cardiomyopathy w/ LVOTO
Myocardial infarction
Aortic valve stenosis (L ventricle)
Pulmonary valve stenosis (R ventricle)

24

Volume Overload

Aortic regurgitation (L ventricle)
Mitral regurgitation (L atrium)

25

SHF or DCM Considerations

EMPTYING problem
Heart rate - maintain NSR (atrial kick) ↓HR ↑filling time ↓CO
Preload - maximize Frank-Starling & prevent fluid volume overload or pulmonary congestion
Afterload - ↓SVR ↑CO (ΔP) w/o hypotension (maintain BP) ↓BP ↓CorrPP
Contractility/inotropy - admin inotropes to help improve forward flow
Ischemia - monitor to prevent

26

DHF or RCM
Considerations

FILLING problem
Heart rate - maintain NSR ↑HR ↓filling time SV limited
Preload - maximize Frank-Starling & prevent fluid volume overload
Afterload - maintain ↓SVR → SNS activation ↑HR
Contractility/inotropy - maintain (not an emptying problem) ↑contractility ↑MVO2
Ischemia - avoid ↑LVEDP

27

HCM w/ LVOTO
Considerations

FILLING & EMPTYING problem
Heart rate - avoid ↑HR ↓filling time
Preload - maintain w/o fluid volume overload
Afterload - do NOT ↓afterload (worsens LVOTO d/t Venturi effect)
Contractility/inotropy - ↑contractility worsens LVOTO
Ischemia - HIGH risk

28

Aortic Valve Stenosis
Considerations

L ventricle EMPTYING problem
Heart rate - maintain NSR (atrial kick) SV limited ↑HR ↑demand ↓supply ↓HR → L ventricle overdistension
Preload - maintain w/o fluid volume overload
Afterload - do NOT ↓afterload (unable to compensate to maintain BP)
Contractility/inotropy - maintain or ↑contractility ↑CO
Ischemia - HIGH risk

29

Pulmonic Valve Stenosis Considerations

R ventricle EMPTYING problem
Heart rate - maintain NSR ↓HR → volume overload
Preload - maintain w/o fluid volume overload
Afterload - minimal impact ↑SVR to maintain CO
Contractility/inotropy - maintain or ↑contractility
Ischemia - monitor ↑MVO2
Prevent ↑PVR → worsens R ventricle congestion & cardiac demand

30

Aortic & Mitral Valve Regurgitation Considerations

VOLUME overload
Heart rate - AVOID bradycardia >80bpm ↓filling time
Preload - maintain w/o fluid volume overload
Afterload - avoid ↑SVR ↓SVR as tolerated (ΔP) but maintain adequate perfusion
Contractility/inotropy - maintain & admin inotropes as needed to promote forward flow
Ischemia - ↑LVEDP ↓CorrPP