Exam 2: Ch 20 Heart Failure

Question 1

to meet the body’s needs, the heart adjusts its…

Answer 1

cardiac output

increased with exercise

decreased with sleep

Question 2

calculate CO (cardiac output)

Answer 2

SV x HR

SNS can increase both SV and HR

Question 3

calculate SV (stroke volume)

Answer 3

EDV - ESV

end diastolic volume - end systolic volume

Question 4

calculate EF (ejection fraction)

Answer 4

SV/EDV

Question 5

preload

Answer 5

EDV: increased EDV –> increased SV within limits

in HF EDV is very high and SV is low

Question 6

afterload

Answer 6

SVR (systemic vascular resistance): high SVR –> increased work and/or low SV

Question 7

contractility

Answer 7

ability of the heart to eject (SV at any EDV): low EF in HF

calcium from SR and ECF

L-type calcium channels opened by catecholamine binding to receptor

cardiac glycocides inhibit Na/K pump

Question 8

athletes have a higher __ and lower __

Answer 8

SV, HR

Question 9

heart failure definition

Answer 9

heart fails to pump the blood that it receives

veins of lungs and peripheral organs become congested

Question 10

systolic HF

Answer 10

reduced EF: heart contracts poorly

often caused by ischemic heart disease, HBP, aortic stenosis

high EDV

low SV

EF less than 40%

Peripheral venous congestion

Question 11

disatolic HF

Answer 11

preserved EF: heart relaxes and fills poorly

aggravated by tachycardia

low EDV, ESV, SV, CO

hypertrophic cardiomyopathy

Pulmonary congestion

Question 12

right sided HF

Answer 12

high RVEDP –> high RAP –> high peripheral venous pressure

extremities and viscera become conjested –> peripheral edema & ascites

Question 13

causes of right sided HF

Answer 13

Rt sided valve problems or MI

severe pulmonary disease

severe pulmonary HTN

Question 14

left sided HF

Answer 14

low CO

high LVEDP –> high LAP –> high pulmonary venous pressure

lungs become congested and body tissues are inadequately perfused

Question 15

causes of left sided HF

Answer 15

MI

HTN

left sided valve dysfunction

Question 16

high output HF vs. low output HF

Answer 16

high output: CO is elevated but still inadequate

low output: pumping ability of the heart is decreased

Question 17

Frank-Starling mechanism

Answer 17

low CO triggers Na + H2O retention to increase EDV & SV

HF –> high EDV at rest, nearly normal SV

compensatory mechanism partially exhausted so ability to exercise is limited

high LVEDP –> pulmonary congestion

Question 18

______ are commonly helpful in HF

Answer 18

diuretics

Question 19

SNS activity in HF

Answer 19

SNS nerve activity and catecholemine levels high in early HF

maintains CO and vital organ perfusion

downside is increased afterload –> low SV or increased work

down regulates beta receptors

more arrythmias

Question 20

RAA system

Answer 20

stimulated by low renal blood flow or pressure

kidney secretes renin

renin turns renin substrate into angiotensin I

A I –> A II by ACE in lung capillaries

A II increases ADH/Aldo release

Question 21

ADH/Aldo/A II

Answer 21

ADH: increases H2O retention

Aldo: increases Na retention

A II: vasoconstrictor, helps tissue remodeling

Question 22

naturetic peptides

Answer 22

increased in HF

ANP (atrial natriuretic peptide), brain NP

ANP released when atria overstretched

BNP (brain) released from ventricles when stretched

both –> natriuresis (Na excretion by kidneys)

Question 23

endothelins

Answer 23

vasoconstrictors released by endothelial cells

cause cardiac tissue hypertrophy and remodeling

Question 24

is hypertrophy an initially helpful compensation for HF?

Answer 24

yes

eventually decreases cardiac pump function though

Question 25

stimuli for hypertrophy

Answer 25

mechanical stress A II, ANP, endothelin ACEI

Question 26

3 types of hypertrophy

Answer 26

symmetric concentric eccentric

Question 27

symmetric hypertrophy

Answer 27

muscle length and wall thickness is increased (athletes)

Question 28

concentric hypertrophy

Answer 28

wall thickens too much due to HTN increased afterload systolic function initially preserved, then leads to ischemia

Question 29

eccentric hypertrophy

Answer 29

muscle length is increased (dilated cardiomyopathy) decreased wall thickness increased preload

Question 30

6 manifestations of HF

Answer 30

edema and fluid retention respiratory symptoms fatigue and confusion cachexia cyanosis arrhythmias and sudden death

Question 31

edema and fluid retention

Answer 31

high capillary hydrostatic pressure causes edema right sided failure --> peripheral edema left sided failure --> pulmonary edema nocturia oliguria

Question 32

nocturia

Answer 32

early in HF laying down high venous return low urine output

Question 33

oliguria

Answer 33

late in HF low CO and renal perfusion low urine output

Question 34

respiratory symptoms of HF

Answer 34

pulmonary congestion causes dyspnea worst on exertion, when flat (orthopnea), and at night cardiac asthma: stimulation of stretch receptors

Question 35

fatigue and confusion is due to

Answer 35

decreased organ perfusion

Question 36

cachexia (loss of weight)

Answer 36

GI involvement and general fatigue

Question 37

cyanosis

Answer 37

arterial desaturation pulmonary edema or O2 removal

Question 38

arrhythmias and sudden death

Answer 38

AF (atrial fibrilation) VT/VF (ventricular tachycardia/ventricular fibrillation)

Question 39

acute HF syndromes

Answer 39

gradual or rapid change in HF signs and symptoms worsening of chronic HF that responds to Rx new onset HF from MI worsening of end-stage HF that is refractory to Rx

Question 40

acute pulmonary edema

Answer 40

dramatic and life-threatening symptom of AHFS and complication of left sided HF severe dyspnea, cyanosis, confusion, frothy blood-tinged sputum Rx: lower preload and afterload, increase contractility, give O2

Question 41

case of a 51 yro male with SOB: PA chest radiograph demonstrates bilateral parahilar infiltrates resembling batswing o butterfly in which the hilum or medulla of the lungs are mainly involved with sparing of the periphery or cortex

Answer 41

pulmonary edema "bats-wing" pattern

Question 42

2 classification systems for diagnosing HF

Answer 42

functional classification of severity by NYHA or ACC-AHA staging

Question 43

Dx of HF: H&P, Labs, Echo, CXR

Answer 43

H&P: ask about dyspnea, nocturia, fatigue, cough, edema Labs: BNP levels, electrolytes echo: look at EF, hypertrophy, valve action, distinguish between systolic vs. diastolic failure CXR: shows cardiac enlargement

Question 44

functional classification system by NYHA

Answer 44

class 1 is best, no limitation of physical activity class 4 is worst, can't perform any physical activity without discomfort; symptoms present at rest

Question 45

ACC-AHA staging

Answer 45

stage A: high risk for HF, no abnormalities yet Stage B: no symptoms but developed structural heart disease that may lead to HF Stage C: symptomatic HF associated with structural disease Stage D: advanced structural heart disease, signs of HF at reset despite max therapy

Question 46

pharmacologic treatment of HF goals

Answer 46

treat causes, reduce risk factors slow or reverse dysfunction, relieve symptoms, improve quality of life lower edema with Na restriction and diuretics surgical repair of cardiac defects

Question 47

pharmacology of HF treatment

Answer 47

diuretics: improve position of Starling curve digitalis: poison Na/K pump, lower HR and up contractility ACEI: lower afterload and aldosterone, slow remodeling A II receptor blockers: similar as above beta blockers: lower SNS activation to decrease mortality vasodilators: isosorbide, hydralazine

Question 48

Swan-Ganz catheter (invasive monitoring)

Answer 48

inserted in large vein (goes with flow) when wedged (PCWP) ~ LVEDP prolonged inflation causes pulmonary infarct measures CO: thermodilution measures MV O2

Question 49

non pharmacologic treatments of HF

Answer 49

exercise program Na/H2O restriction O2 therapy cardiac resynchronization mechanical support heart transplantation

Question 50

O2 therapy

Answer 50

increases O2 saturation CPAP - constant positive airway pressure

Question 51

cardiac resynchronization

Answer 51

use of pacing leads in Rt and Lt ventricles coordinates activity

Question 52

mechanical support VAD

Answer 52

ventricular assist device implanted percutaneously or open augment pumping action of LV

Question 53

heart transplantation

Answer 53

orthotopic technique: donor heart attached to retained posterior atrial walls of recipient required continued immunosuppressants 5-yr survival rate is 2/3 --> 3/4