Failure Flashcards

Question

Discuss NYHA functional classes of CCF

Answer 1

1) asymptomatic on ordinary physical activity 2) symptomatic on ordinary physical activity 3) symptomatic on less than ordinary physical activiy 4) symptomatic at rest

Answer 2

Three tenants 1) determining the underlying cardiac pathology 2) identify the precipitant 3) mitgate decompensation Primary treatment goals are to improve respiratory gas exchange, maintain adequate arterial saturation and decrease LV diastolic pressure while maintaining adequate cardaic and systemic perfusion Acute congestive state can be managed by 1) reducing cardiac workload through decreased preload and afterload 2) reducing excessive retention of salt and water 3) improving cardiac contractility

Answer 3

Many patient with failure demonstrate adequate systemic perfusion with elevated BP and this indicates presence of considerable mycoardail reserve and is associated with lower mortality in both acute and chornic HF. Treatment should involve reduction in both preload and afterload. Therapy should being with upright positioning of the patient, supplemental oxygen, nitrates, morphine and loop diuretics Ventilation and oxygenation - Most patient will have hypoxemia and need high flow oxygen if o2 below 90%- hyperoxemia is detrimental as it may significantly increase afterload and worsen cardiac function in decompensated failure. - NIV increases functional residual capacity, improves o2, reduces work of breathing and resutls in decreased LV preload and fterload by raising intrathoracic pressures. BiPAP further reduced work of breathing and more readily improves hypercarbia than CPAP alone. - if unable to tolerate bipap intubate Nitrates - start at initial dose of 5-10mic/min IV increasing in 5-10mic increments every 3-5 minutes as required and tolerated -- max 200mic/min - activate cGMP leading to vascular smooth muscle relaxation by sequestration of calcium into the SR - At lower doses are primarily venodilators and a venovaso dilators at high doses - This improves pump function while reducing o2 demand- added benifit of direct cononary artery dilation reducing risk of ischaemia - Tachyphylaxis occurs over hours to days - avoid in sidenafil Loop diuretics frusemide 40mg IV if naive if take regularly double maitenance dose - inhibit sodium resoprtion from renal filtrate resulting in significant increase in salt and water excretion. -in patient with volume overload actions lower plasma volume and pulmonary congestion. -diuretic affect begins within 10 minutes however symptom relief begins earlier as a result of drug induced neurohumoral changes acting as both vasodilaotr and promiting renal PG2e -patient without underlying chronic heart failure may have low plasma volumes and diuresiss in this group is unecessary and can lead to complications

Answer 4

Patient with ACPE and apparent systemic hypotension present a therapeutic dilemma . Coronary artery perfusion depend on the pressure gradient between the aorta and the LV in diastole. The combination of systemic hypotension and elevated left sided pressure dramatically decreases coronary artery perfusion. Vasopressor use may be required if this constellation truly exists however vasopressores can increase afterload, decrease CO and increased myocardial o2 demand, excerbate ischaemia and precipitate dysrhythmias. Judicious fluid bolus can be used initially 250 ml over 5-10 minutes if nil respiratory deterioration can be reported- fluid challenge alone will restore perfusing pressure in 50% of cases In those who have high filling pressure but low cardiac output vasopressors can be used -- can be counterproductive in those with acute MI and severe LV dysfunction as they increase mycocadial o2 demand - which may exacerbate ischaemia Choices incldue - dobutamine starting at 2.5mcg/kg/min increasing to 20mcg/kg/min as needed -Milronone (phosphodiesterase inhibitor, increase cardiac contractility and cause vaso,venodilation) - loading dose of 50mcg/kg then 0.375 -0.750 mcg/kg In hypotensive patients who are adequately volume repleted (true cardiogenic shock) and have appropriate vasopressor support norad is the pressor of choice It raises BP and coronary artery perfusion via alpha affects and has a modest inotrpy and the least overal increase in HR and contractility limiting o2 demand. EPI has strong beta and alpha activity and can increase myocardial o2 demand. Good at reversing stunned myocardium post surgery

Answer 5

Entra aortic balloon pump ECMO Extracorporeal ventricular assist device

Answer 6

- ACE inhibitors - Beta blockad (long term activation of the sympathetic nervous system, direct cardiotoxcitiy due to elevated NORAD, activation of the RAS and myocardial beta-adrenergic receptor downregulation are all associated with adverse effects) - Diuretics - Cardiac glycosides Other considerations - IACD - Antidysrhytmics - CA channel blocakde - Renal diaysis - CABG - Phosphodiesterase inhibtiors - Milrinone - statins

Answer 7

1) the balloon is timed to inflate and deflate in time with cardiac cycle 2) trigger options include - ECG (using R wave to identify onset of systole) if sinus rhythym - if paced then pacing spikes can be used - artieral waveform - an internal trigger mode is avialable for asytole arrested patients 3) During systole the balloon is deflated which creates suction reducing afterload that the LV needs to overcome to achieve SV 4) During diastole the balloon is inflated - this creates positive pressure within the aorta pushing blood toward the aorta - due to AV valve being closed blood is pushed into the ostium increasing coronary artery flow

Answer 8

Conduit from LV to aorta bypassing LV as pump