CHF 1 Flashcards
congestive heart failure (CHF) - physiologic definition
*the inability of the heart to maintain the circulatory demands of an organism without a rise in left ventricular filling pressure
*simply put, if you have a high filling pressure, you have heart failure
*translation: ELEVATED CARDIAC FILLING PRESSURES with normal/abnormal cardiac output and normal/abnormal LV ejection fraction
heart failure - first aid
*clinical syndrome of cardiac pump dysfunction → congestion and low perfusion
heart failure - clinical definition
*clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to either fill with or eject blood
high-output vs. low-output CHF
*causes of low-output CHF: aortic stenosis, hypertension, myocardial infarction
*causes of high-output CHF: anemia, thyrotoxicosis (thyroid storm), AVM, pregnancy
note: the vast majority of CHF is LOW output
cardiogenic shock vs. acute heart failure
*cardiogenic shock and acute heart failure are not different entities, but rather, CARDIOGENIC SHOCK IS ACUTE HEART FAILURE WITH HYPOTENSION
*acute heart failure: increased PCWP, high SVR
*cardiogenic shock: decreased CO, increased PCWP, high SVR, HYPOTENSION
common signs of CHF
*jugular venous distention
*S3 gallop [most specific sign on physical exam]
*pulmonary edema (crackles/rales)
*leg edema
*ascites
*hepatomegaly
recall: signs are objective features of an illness, detected by a practitioner
common symptoms of CHF
*dyspnea
*dyspnea on exertion
*orthopnea
*paroxysmal nocturnal dyspnea [most specific symptom]
*fatigue
*weakness
recall: symptoms are subjective features of an illness as related by a patient
signs/symptoms of left-sided heart failure
*signs: S3 gallop, pulmonary edema
*symptoms: dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, weakness
signs/symptoms of right-sided heart failure
*jugular venous distention
*leg edema
*ascites
*hepatomegaly
note: usually these are in addition to the s/s of left CHF (pulmonary edema, S3 gallop, dyspnea/orthopnea) b/c left CHF usually precedes right CHF
number 1 leading cause of right-sided CHF is?
LEFT-sided CHF
*meaning: right HF most often results from left HF
left-sided CHF pathogenesis: increased LV filling pressure
*increased LV end-diastolic pressure → increased left atrial pressure → increased pulmonary venous pressure → increased pulmonary capillary pressure → pulmonary edema
*increased left atrial pressure is translated back to the lungs where it produces shortness of breath (dyspnea)
*initially, it primarily affects the base of the lungs (due to gravity), but as the pressure increases, it can affect all the way to the lung apices
orthopnea in CHF
*shortness of breath when supine (when a patient lies down, venous return increases from the legs)
*increased venous return form redistribution of blood (immediate gravity effect) exacerbates pulmonary vascular congestion
*commonly associated with left-sided CHF
paroxysmal nocturnal dyspnea in CHF
*breathless awakening from sleep (sensation of shortness of breath that awakens the patient; usually relieved in an upright position)
*increased venous return from redistribution of blood, reabsorption of peripheral edema, etc
*commonly associated with left-sided CHF
pulmonary edema in CHF
*increased pulmonary venous pressure → pulmonary venous distention and transudation of fluid
*presence of hemosiderin-laden macrophages (“HF cells”) in lungs
*commonly associated with left-sided CHF
congestive hepatomegaly in CHF
*increased central venous pressure → increased resistance to portal flow
*rarely, leads to “cardiac cirrhosis”
*associated with NUTMEG LIVER (mottled appearance) on gross exam
*commonly associated with right-sided CHF
jugular venous distention in CHF
*increased venous pressure → distention of jugular veins in the neck
*commonly associated with right-sided CHF
peripheral edema in CHF
*increased venous pressure → fluid transudation
*commonly associated with right-sided CHF
S3 heart sound in CHF
*occurs in EARLY DIASTOLE (heard shortly after S2)
*“caused” by oscillation of blood back and forth between the walls of the ventricles initiated by blood rushing in from atria
*in CHF, it is because of increased left atrial pressure filling against a stiff left ventricle
right-sided CHF pathogenesis: increased RV filling pressure
*increased RV end-diastolic pressure → increased right atrial pressure → increased systemic venous pressure → increased systemic capillary pressure → jugular venous distention, ascites, and lower extremity edema
CHF signs & symptoms related to decreased cardiac output vs. increased ventricular filling pressures
*s/s due to decreased cardiac output: fatigue, weakness
*s/s due to increased ventricular filling pressures:
-JVD, S3, pulmonary edema, leg edema, ascites, hepatomegaly
-dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea
clinical profiles in acute heart failure (cold vs. warm; wet vs. dry)
*congestion at rest = WET (s/s: orthopnea/PND, S3/rales, JV distention, hepatomegaly, edema)
*low perfusion at rest = COLD (s/s: narrow pulse pressure, cool extremities, sleepy/obtunded, low serum sodium, renal dysfunction, hypotension with ACE inhibitor)
*warm & wet: congestion at rest, but normal perfusion
*cold & wet: congestion AND low perfusion at rest
*cold & dry: low perfusion at rest, but no congestion
*warm & dry (normal)
types of heart failure (based on ejection fraction)
- HFpEF: normal (preserved) LV ejection fraction (LVEF 50%+)
- HFmrEF: mildly reduced LV ejection fraction (LVEF 41-49%)
- HFrEF: reduced LV ejection fraction (LVEF 40% or less)
heart failure with preserved ejection fraction (HFpEF) - overview
*defined by LV ejection fraction of 50% or more
*DIASTOLIC dysfunction [associated with inability of LV to adequately relax & fill with blood due to decresaed compliance]
*normal EDV, decreased compliance (increased EDP)
*CONCENTRIC hypertrophy with preserved systolic function
*often secondary to myocardial hypertrophy
heart failure with reduced ejection fraction (HFrEF) - overview
*defined by LV ejection fraction of 40% or less
*SYSTOLIC dysfunction [ventricles unable to adequately pump blood out]
*increased EDV, decreased contractility
*ECCENTRIC hypertrophy with reduced systolic and diastolic function
*often secondary to ischemia/MI or dilated cardiomyopathy
