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Flashcards in CHF lecture Deck (89):
1

Explain the CHF - RAAS loop.

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2

Congestive Heart Failure (CHF) is a _____.

Syndrome, not a disease

3

Syndrome is a______.

constellation of signs and symptoms occurring together and characterizing  a particular abnormality or condition

The same syndrome may occur with different diseases, which may have distinctly different etiologies and pathogenesis

4

CHF Clinical Syndrome in which

an abnormality of cardiac structure or function is responsible for the inability of the heart to eject or fill with blood at a rate sufficient to meet the demands of the metabolizing tissues.

Pump failure

5

CHF Epidemiology.

Prevalence is 5,000,000 patients

Incidence is 500,000 patients per year

1 million of hospital admissions a year

50,000  death a year

6

Systolic Heart failure results from

inadequate cardiac output (C.O.)/Ejection Fraction (E.F.)

C.O. = S.V. x H.R.

S.V. = E.D.V. – E.S.V.

E.F. = S.V./E.D.V.

7

Diastolic Heart Failure results from

 inability of the ventricles to relax and fill normally with blood during diastole. 

8

Forward vs. Backward Heart Failure. Explain?

Forward failure is decrease in perfusion of the organs/tissues down-stream from the heart

Backward failure is “backing up” of the blood into the organs upstream, increasing hydrostatic pressure, which leads to congestion/edema

9

Left ventricle CHF caused by?

Caused by conditions primarily affecting left ventricle

CAD/MI

Aortic/Mitral valves problems

HTN

Cardiomyopathies

10

Forward failure symptoms in left ventriclular CHF 

Forward failure symptoms are primarily in systemic circulation (downstream)

11

Backward failure symptoms in left ventricular CHF?

symptoms/congestion in the lungs (upstream)

12

Right ventricle CHF caused by?

Caused by conditions primarily affecting right ventricle

Pulmonary diseases/cor pulmonale

Tricuspid/pulmonary valves

Pulmonary Hypertension

Pulmonary emboli

13

Right ventricle CHF primary effects

Backward failure symptoms/congestion in the systemic venous circulation (upstream)

14

Biventricular Failure is?

End result of left and right failure

15

Acute HF is caused by 

due to a sudden and severe event

Massive MI

Chorda tendinae rupture

Large PE

16

Acute HF symptoms?

Predominantly forward failure

Flash Pulmonary Edema

17

Compared to Acute HF, Chronic HF does what?

Progresses slowly

Has exacerbation

Predominantly backward failure

18

Dilated Cardiomyopathy is due to?

Due to death or functional ischemic dysfunction of myocardial tissue due to complete or partial blockage of coronary arteries

19

In Dilated Cardiomyopathy the Degree of dysfunction depends on

the percent of myocardium affected

20

Describe the path of effects in Dilated Cardiomyopathy due to HTN.

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21

Describe the path of effects in Dilated Cardiomyopathy due to valvular heart disease.

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22

One of the main causes of dilated cardiomyopathy?

Infective Myocarditis

23

etiological agents of Infective Myocarditis

Viral 

Bacterial  

Fungal  

Helminthic

24

In Infective Myocarditis ______ or _______ frequently precedes cardiac symptoms by few weeks.

Febrile illness or URI

25

Non-infective toxic Myocarditis can be caused by?

Chemotherapy 

      Doxorubicin (Adriamycin)

Heavy metals (copper, iron, lead)

Lithium

Malaria drugs

Radiation causing inflammation and fibrosis

26

Autoimmune/ CTD associated Myocarditis can be caused by?

Giant Cell Myocarditis

PM/DM

SLE/RA

27

Cocaine can cause CHF through which mechanisms?

May cause vasospasm leading to MI

May cause arrhythmia

May cause drug-induced myocarditis/cardiomyopathy due to released catecholamines

28

How can ETOH cause CHF?

Alcoholic Cardiomyopathy

From prolonged chronic alcohol use (at least 10 years of chronic exposure)

Due to direct toxic effect of alcohol on myocardium

29

When is Peripartum Cardiomyopathy most common?

Between last month of pregnancy and first 5 months after delivery

30

Do patient recover from Peripartum Cardiomyopathy?

More than ½ of patients improve within 6 months

31

Peripartum Cardiomyopathy is due to? 

Likely due to immune-mediated process

32

Takotsubo Cardiomyopathy's other names? 

A.K.A. Stress cardiomyopathy

A.K.A. Apical Ballooning Syndrome

A.K.A. Broken Heart Syndrome

33

Takotsubo Cardiomyopathy is caused by? 

Triggered by an acute medical illness or by intense emotional or physical stress 

34

Takotsubo Cardiomyopathy symptoms?

Symptoms are similar to an acute MI

CP, SOB, Syncope, 

35

What is Hypertrophic Cardiomyopathy

Myocardial hypertrophy unrelated to any pressure or volume overload

36

Hypertrophic Cardiomyopathy is due to?

Due to different genes mutations

Myosin heavy chains

Proteins regulating Calcium handling

Most are autosomal dominant

37

Which portion of the heart is unproportionally effected in Hypertrophic Cardiomyopathy?

Inter-ventricular septum often disproportionally involved

causing sub-aortic stenosis

38

Hypertrophic Cardiomyopathy mostly causes what type of dysfunction?

Mostly causes diastolic, not a systolic dysfunction

39

Symptoms/signs of HOCM

SOB

Chest Pain

Syncope (often after exercise)

Arrhythmias

Atrial Fibrillation

Ventricular arrhythmias

Sudden death

Systolic murmur along the left sternal border 

increases with Valsalva maneuver/upright position

decreases with squatting

40

What differences are present in non-genetic, or HTN HOCM?

Similar to HOCM except for more generalized thickening with no disproportional involvement of the septum

Aortic stenosis-related hypertrophy

41

Symptoms of HTN HOCM d/t diastolic dysfunction? Obstructive dysfunction? (2 each)

Related to diastolic dysfunction

SOB

Edema

Related to Obstruction

Syncope

Chest Pain

42

Restrictive Cardiomyopathy Characterized by?

impaired filling causing predominantly diastolic dysfunction

43

Restrictive Cardiomyopathy is due to?  

  • Infiltrative disease
    • Amyloidosis 
    • Sarcoidosis
  • Systemic storage diseases
    • Hemochromatosis
    • Glycogen Storage Diseases
  • Metabolic disorders
  • Fibrotic
    • Radiation
    • Scleroderma
  • Endomyocardiac
    • Loffler’s endocarditis
    • Endomyocardial Fibrosis

44

Typical pulmonary pressures?

20/10mmHg

45

Idiopathic Pulmonary Hypertension characteristics

Uncommon (2 cases per million)

Females>males

30-50 is predominant age of onset

12-20% is autosomal dominant genetic disorders with incomplete penentrance

Mean survival is 2-3 years from diagnosis

46

Left to right shunting results in PHTN due to which defects?

Ventricular septal defect

Patent ductus arteriosus 

Atrial septal defect

Atrioventricular septal defect

47

Drugs-associated Pulmonary HTN

Fenfluramine (weight loss pill)

Direct effect on pulmonary vasculature

Secondary effect via right sided valvular heart disease

Amphetamines

Cocaine

48

What is Cor Pulmonale

Heart disease due to lung disease

49

Most common cause of PHTN?

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50

Typical origin of pulmonary embolism?

Usually originates from lower extremities

51

Pulmonary Embolism results in?

Results in increase in pulmonary artery pressure therefore increasing after-load for right  ventricle

May lead to right ventricular failure

52

High Output Failure is?

Increase metabolic demand doesn’t match with cardiac output

53

High Output Failure caused by?

Thyrotoxicosis

Anemia

AV fistula

 Conditions decreasing peripheral vascular resistance (Beriberi, sepsis etc)

54

Symptoms of CHF from Backward Left heart failure?

Pulmonary edema

SOB, cough (frosty)

PND

Orthopnea

Pleural effusions

55

Symptoms of CHF from Backward right heart failure?

Lower extremity swelling/edema

Anasarca/ascitis/pleural and pericardial effusion

Could affect lungs as well

End organ damage

Congestive hepatopathy/nutmeg liver

Splenomegaly with hypersplenism

Intestinal congestion leading to GI symptoms

56

Symptoms of Forward failure CHF

Mostly in left heart failure

Hypotension

Weakness

Exercise intolerance

End organ damage

Cardiac ischemia

Watershed infarcts

Renal failure

Bowel ischemia

Shock liver

57

New York Heart Association (NYHA)
Functional Classification?

Class I: Symptoms with more than ordinary activity 

Class II: Symptoms with ordinary activity 

Class III: Symptoms with minimal activity 

Class IIIa: No dyspnea at rest 

Class IIIb: Recent dyspnea at rest 

Class IV: Symptoms at rest 

58

Stages of Heart Failure
ACC/AHA 2005 Guidelines

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59

CHF typical VS

BP may be low in advanced CHF

Tachycardia is often present

Tachypnea and hypoxia in severe cases

60

CHF. Physical findings.
Neck?

Jugular Vein Distention

Hepato-jugular (Abdominal-jugular) reflux

Thyroid enlargement in toxic goiter may be present

61

CHF. Physical findings.
Lungs

Crackles/rales.

  • Usually bilateral
  • Bi-basilar

The higher you can hear them, the worse CHF is

Sometimes decrease breath sounds on bases

Dullness on percussion

Tactile Fremitus 

  • Decreased in case of bilateral pleural effusion
  • Increased in case of alveolar/interstitial edema

62

CHF. Physical findings.
Heart Palpation

PMI is displaced if LV is enlarged

Parasternal lift (heave) if RV is enlarged

Arrhythmia is common

63

CHF. Physical findings.
Heart Auscultation

S1 may be diminished if LV function is very poor

P2  (Pulmonic component of S2 ) may be accentuated when pulmonary hypertension is present. 

An apical third heart sound (S3) with low EF 

S4 is usually present with diastolic dysfunction

Murmurs may indicate the presence of significant valvular disease as the cause of heart failure or the result of it.

64

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Signs of Left Ventricular Hypertrophy

65

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Signs of Right Ventricular Hypertrophy

66

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Signs of Biventricular Hypertrophy

67

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Cor Pulmonale (R.A. hypertrophy + R.V. Hypertrophy)

68

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Atrial Fibrillation

69

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Ventricular ectopy

70

Brain Natriuretic peptide BNP produced by?

heart cells (ventricles)

71

BNP with ANP (atrial natriuretic peptide, which is produced by atrial cells) released in response to?

increased ventricular/atrial filling pressures

72

Both BNP and ANP have ____, ______and ______effect (compensatory effect in response to increase in ventricular filling pressures)

diuretic

natriuretic

hypotensive

73

Problems with using BNP?

High false positive rates

Increased in other conditions

Old age

Renal failure

Cor pulmonale

Pulmonary hypertension

Pulmonary embolism

Doesn’t rule out other causes of dyspnea

Chronic elevation in cardiomyopathy doesn’t help with diagnosing exacerbations

74

Heart Failure. CXR findings.

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75

Kerley B lines

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76

Echocardiogram looks at?

Size of the heart chambers

Thickness of the walls

Contractility 

Ejection fraction

Wall motion abnormality

Septal defects

Valvular structures and their integrity

Intracardiac structures (clots, tumors)

Diastolic dysfunction

Pulmonary pressures

77

CHF treatment, meds.

Diuretics

ACE inhibitors

ARBs
Digoxin

β − Blockers

Aldosterone antagonists

Nitrates

Hydralazine

78

Which diuretics are used in CHF?

Loop diuretics

79

How do diuretics help in CHF?

Help with “congestion” part of CHF

Improvement of symptoms, but not mortality

80

What to watch for when using diuretics in CHF?

May worsen renal function and cause electrolytes abnormalities

81

Why are ACE inhibitors used in CHF?

Decrease after-load    ►   increase ventricular function

Improves symptoms and mortality.

82

Why are ARBs used in CHF?

Decrease after-load

Improve symptoms and mortality

83

Why is digoxin used in CHF?

Increases contractility

Improves symptoms, decrease hospitalizations

84

What to watch out for with digoxin use?

No effect on mortality

May cause arrhythmia

Narrow therapeutic index

85

Why are ß blocker used in CHF?

Which three are shown to reduce mortality?

Used only with low EF

Improves symptoms

Prolongs life

Started only in stable patients

Counter-intuitive treatment

Usually  decrease contractility and C.O.

Only 3 beta-blockers have a proven effect on mortality

Metoprolol Succinate

Carvedilol

Bisoprolol

86

ß blockers in CHF. That doesn't make since. How does it work?

Upregulate beta receptors improving inotropic and chronotropic responsiveness of the myocardium   ►      improvement in contractile function. 

Reduce the level of vasoconstrictors ►  decreased after-load. 

Have a beneficial effect on LV remodeling  ►                improvement in LV geometry ►    ^    contractility.

Reduce myocardial consumption of oxygen.

Decrease the frequency of ventricular premature beats and the incidence of sudden cardiac death (SCD), especially after a myocardial infarction

87

Why are Aldosterone antagonists used in CHF?

Diuretic and a final piece of the renin-angiotensin-aldosterone axis

Decreases mortality in severe heart failure

88

Why are nitrates used in CHF?

Decrease preload and somewhat after-load

Improve symptoms of acute CHF

In combination with hydralasine improve mortality in African-Americans

89

Why is hydralizine used in CHF?

Decrease after-load, because dilates arterioles only.