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Flashcards in CHF Deck (38):
1

heart failure mostly caused by

fluid backing up into lungs-->pulmonary edema/congestion

2

LV failure: systolic or diastolic

symptoms due to ??


management ??

what is the EF? (not CO, can have EF of 10% or 70% in HF)

Symptoms due to low CO and congestion, including dyspnea

Optimal management includes: ACE-I/ARB, BB, aldosterone inhibitors

3

RV failure

most likely due to LV failure

primary RV failure: cor pulmonale

Peripheral congestion, acites, edema

4

Hi-output failure

beri beri: vit def (thiamine)
hyperthyroid

5

Causes of systolic CHF

Ischemic cardiomyopathy (HA caused dead heart muscle)
HTN (stiffness inc. as afterload inc.)
hypo/hyperthyroid
HIV
ETOH
viral
dilated
cardiotoxins (herceptin, adriamycin?, doxirubicin)
infectious (Chagas)
hemochromatosis
sarcoid (both)
amyloid (both)
valvular
tachycardia-mediated
peri-partum

*important to know bc some causes are reversible

6

Systolic/Diastolic CHF

50/50

originally though HF was just systolic

7

Causes of diastolic CHF

*HTN*-hypertrophic (dilated and burned out)
restrictive (amyloidosis)
DM
pericardial disease
aging

8

Neurohormonal activation

Partially responsible for the mechanical changes in HF

Vasopressin (ADH) secretion – promotes water absorption by the kidney

(RAAA): Renin-angiotensin-aldosterone axis: maintains cardiac output (CO) and tissue perfusion

*now use B-blockers, used to be contraindicated

9

RAAA does what ??

stimulates arterial vasoconstriction with angII
expands intravascular volume with Na+ and water retention

10

important pressure to know

LVEDP: left ventr. end diastolic pressure
(preload)

dry or wet?

use surrogate endpoints

if too high will have backup into lungs

about equal to LA pressure (and wedge pressure, same as pulmonary artery diastolic pressure), and further back....jugular pulsations (JVP)

11

dec. CO

inc. SNS-->inc HR, contractility, vasoconstriction-->raise BP-->inc. CO

inc. RAAS-->vasoconstr, inc. circ volume-->inc. venous return (preload)-->inc. CO

inc. ADH-->inc. circ volume-->inc. venous return (preload)-->inc. CO

12

CHF classification

Stages A-D (Duke staging)
A: predisposed (poorly controlled HTN)
B: have LVEDP elev. (EF (more in recording)

13

Signs/Symptoms/Physical Exam/labs

Palpation: diffuse PMI may imply cardiomyopathy

S3/S4: (S3 systolic dysfunction, S4 diastolic dysfunction)

murmurs: mitral regurg-functional MR

HJR: press on liver area, see inc. in JP (hep jug reflex)

JVP
edema

BNP: heart damage from inc. LV wall stress, release naturitic peptide (NP) from atrium helps with diuresis

14

Assessment of LV function

*Echo* easiest, no radiation

MUGA (chemo pts) best way to grade EF, but don't do much

angiogram

15

Pressure-Volume Loops

Frank-Starling curve
preload vs. CO

*lasix will reduce preload

16

Treatment options

Target any potentially reversible causes (CAD, tachycardia, ETOH, etc..)

17

When to biopsy

acute fulminant myocarditis:

Acute presentation
hemodynamic compromise at initial presentation
new AVB, VT
(don't biopsy 95%, benign)

18

worst myocarditis

giant cell myocarditis

treatable with chemo
needs to be biopsied

19

px CHF: 5-year mortality

50%

20

s/s

tachycardia

venous congestion:
right-sided: hepatomeg, ascites, pleural effusion, edema, JVD
left-sided: tachypnea, nasal flaring/grunting, retractions, pulmonary edema

low CO: fatigue, pallor, sweating, cool extremities, poor growth, dizziness, alt. consciousness, syncope

21

CHF etiologies

Infectious Myocarditis

Dilated cardiomyopathy
-ARVD (arrhythmogenic RV dysplasia-->can lead to VT/sudden death)
-non-compaction (massive trabeculation)- *Uals* (tx: defibrillator)

Tako-Tsubo (apical ballooning)
-Stress cardiomyopathy
-typ. older females, emotional stress-->symp. surge, hyper contrac. of LV base
-most reversible

Hypertrophic
-CHF and risk of sudden death (arrhyth, put in defib)
-obstruc. of blood getting out of LV
-myomectomy to relieve

Restrictive (amyloid, biopsy, MRI)

Drug-induced and toxic

22

amyloid

apple green birefringence on electron microscopy

23

slide 14-16

names and classes of meds

24

CHF pt comes into HR: cool/clammy, respiratory distress, edema
what to do:

physical assessment most important
EKG: no STEMI
IV lasix
give O2

BP: 200/100
on no meds

get CXR
see cardiomeg, pulm vasc congestion
tachypnic, crackly

to lower BP: amlodipine (CCB), nitro, or metoprolol??
*will not use amlodipine, for long-term prevention
**cannot use B-blocker 1st time in acute compensated heart failure (unless they are on it), once stabilized can use
use nitro drip: venodilator, reduces pulmonary pressure, preload reduction, some drop in afterload

BIPAP
possible foley cath to measure output
troponin, Cr may be elevated

25

stabilized pt goes up to heart unit, how tx??

need more info

26

little old lady heart

low volume, high pressure
*diastolic heart*
EF>45%

27

floppy-baggy heart (dilated)

high volume, low pressure
*systolic heart*
EF

28

both hearts will have

SOB (pulmonary congestion)
elevated LVEDP
JVD
edema (elevated central vein pressures)
BNP elevated (stretch, volume tension, inc. work)

29

how to tell difference btw hearts?

get an ECHO! determine EF
if hear S3: systolic

30

FB heart, systolic

ACE inhibs
ARBs
B-blockers: carbetolol, metoprolol XL/succinate
Aldosterone antagonists
*reduce mortality*

symptomatic relief:
*diuretic, large doses lasix
digoxin (reduces hospitalization, does not reduce mortality)
Afr. American: hydralizine combo (reduces mortality)

if EF 120ms: cardiac synchronization therapy

ionotropes: dobutamine (stim. EF), noronone (PDE inhibitors, relax pulm congestion, helps pump)
(do not improve mortality, to get out of acute trouble

31

LOL heart, diastolic failure

*nothing reduces mortality!*

tx BP, DM
some lasix

(remember to determine etiology)

32

ICD

under pec, dual-channel device screwed into RV apex, if detects VT will shock

33

Bi-ventricular ICD (CRT)

LBBB
right atrial and ventricular lead, LV coronary sinus lead
pacing 100% of the time

34

can't get pt off balloon pump

LVAD implantation
takes place of LV, sucks blood out of LV and pumps to aorta-bridge to transplantation

35

OMM in CHF

Lymphatic Pump: fluid mobilization
Diaphragmatic Techniques: abdominal and thoracic
Effluerage: mobilize peripheral fluid
Clavicular releases: promote thoracic duct drainage
CV4: fluid homeostasis and decrease stress
of course: OA, thoracics, lumbar, Chapman pts, fascia

36

Dilated cardiomyopathies

Systolic dysfunction
Eccentric hypertrophy (sarcomeres added in series)

ETOH, beri-beri, coxsackie, chronic cocaine, chagas, doxorubicin, hemachromotosis, sarcoid, peripartum

CHF, S3, systolic regurgitant murmur, cardiomegaly on CXR

Tx: Na+ restriction, ACE-I/ARB, BB, diuretics, digoxin, ICD, OHT
(more)

37

Hypertrophic Cardiomyopathy

60-70% inherited as AD (Beta-myosin heavy-chain mutation)
Can be a/w friedrich ataxia
Syncope during exercise and sudden death in athletes due to VT

Tx: cessation of high-intensity athletics
BB, CCB, ICD if high risk
(more)

38

Restrictive/infiltrative cardiomyopathy

Sarcoid, amyloid, postradiation fibrosis, Loffler (endocardial fibroelastosis a/w eosinophilic infiltrate), and hemochromotosis (dilated can also occur)

(more)