HEART FAILURE 2 Flashcards Preview

Term 5 - PathoPhysio > HEART FAILURE 2 > Flashcards

Flashcards in HEART FAILURE 2 Deck (23):

Cellular Changes:

  • Inefficient intracellular calcium handling
  • Adrenergic desensitization 
  • Myocyte hypertrophy 
  • Cell death (apoptosis) 
  • Myocardial fibrosis
  • The cellular changes in ventricular myocardium in heart failure is collectively known as ventricular remodeling


Basis for clinical presentations in patient with LVF

Shortness of breath (dyspnea) of different degree


3 ways Pulmonary congestion produces dyspnea

  1. Shortness of Breath (Dyspnea):
    • Elevated pulmonary capillary pressures due to an elevated left ventricular and atrial pressures
    • pulmonary venous congestion and pulmonary edema
    • Stimulation of juxtacapillary J receptors resulting in reflex shallow and rapid breathing.
    • Edema of the bronchial walls can lead to small airway obstruction and produce wheezing known as "cardiac asthma"
  2. Shortness of Breath (Dyspnea):
    • Replacement of air in the lungs by blood or interstitial fluid
    • Reduction of vital capacity, restrictive pulmonary changes and closure of the small airways
    • Increased “work of breathing” as the patient tries to distend stiff lungs
    • Respiratory muscle fatigue and dyspnea
  3. Shortness of Breath (Dyspnea):
    • Ventilation-perfusion mismatch
    • Widening of the alveolar-arterial O2 gradient, hypoxemia and increased dead space
    • Dyspnea


How does  Pulmonary congestion cause Orthopnea:

  1. Cause for Orthopnea:
    • From erect to recumbent position
    • Blood pooling in the pulmonary circulation coming from the extremities and abdomen
    • Marked elevation in LV pressure
    • Orthopnea
    • Patients usually learn to minimize orthopnea by sleeping with the upper body propped up by two or more pillows


How does Pulmonary congestion produces Paroxysmal Nocturnal Dyspnea:

  1. Cause for Paroxysmal Nocturnal Dyspnea:
    • Changes during sleep such as:
    • Reduced adrenergic support
    • Increased vagal activity
    • Normal nocturnal depression of resp center
    • Theses changes aggravate pulmonary pooling of blood causing sudden onset of severe respiratory distress at night called paroxysmal nocturnal dyspnea (PND)


Q image thumb


  • Physical examination findings in LVF & pathophysiological basis:
  • Pale, Cold, and Sweaty Skin:

  • Pale, Cold, and Sweaty Skin:
  • Pale & cold extremities is due to peripheral vasoconstriction to maintain blood flow to the vital organs
  • Sweating: Increased sweat gland activity as a part of thermoregulation when body heat cannot be dissipated through the constricted vascular bed of the skin


  • Physical examination findings in LVF & pathophysiological basis:
  • Bibasilar Rales, Pleural Effusion:

  • Bibasilar Rales, Pleural Effusion:
    • Increased fluid in the alveolar spaces can be heard as rales in bilateral lower lung fields.
    • Increased capillary pressures can also cause fluid accumulation in the pleural spaces


  • Physical examination findings in LVF & pathophysiological basis:
  • Sustained or Displaced Apical Impulse:

  • Sustained or Displaced Apical Impulse:
    • When the apical impulse is felt throughout the systole, it is sustained. Sustained impulse suggests an increase in left ventricular mass/thickness due to a high afterload (contraction against a high pressure/resistance).
    • When the left ventricular volume is increased (↑preload), the apical impulse is displaced downwards and laterally. Displaced impulse suggests volume-overload failures.


  • Physical examination findings in LVF & pathophysiological basis:
    • Third Heart Sound (S3):

  • Third Heart Sound (S3):
    • S3 is a low-pitched sound that is heard during rapid filling of the ventricle in early diastole.
    • Increased end-systolic volume and pressure characteristic of the failing LV, are responsible for the prominent S3
    • S3 is a consistent physical finding in CHF
    • Heard best at the apex (Mitral area)


  • Physical examination findings in LVF & pathophysiological basis:
  • Fourth Heart Sound (S4):

  • Fourth Heart Sound (S4):
    • It is a low-pitched sound at the end of diastole that corresponds to atrial contraction
    • S4 can be heard if the ventricles are stiff
    • Best heard laterally over the apex, particularly when the patient is partially rolled over onto the left side
    • S4 is commonly heard in any patient with heart failure resulting from diastolic dysfunction or Ischemic heart disease (IHD)


bat’s wing density

Chest X-ray characterized by bat’s wing density, cardiac enlargement in patient with pulmonary edema due to LVF

A image thumb

Cor pulmonale:

  • Condition characterized by enlargement of right ventricle with failure as a sequel of pulmonary disease
  • He has barrel-shaped chest, labored respiration, bilateral lower limb ankle edema, distended neck veins and hepatojugular reflux.


Right ventricular failure (RVF) - causes

  • Secondary to LVF because of an increased afterload placed on the right - most common 
  • Increased flow from a congenital shunt (ASD, VSD) with pulm hypertension and increased right ventricular afterload 
  • As a sequel of pulmonary diseases that cause either pathological changes in pulm vasculature or hypoxia-induced vasoconstriction 
  • Right ventricular ischemia or infarction.

A image thumb

How LVF possible in a patient with RVF:

A image thumb

Clinical Presentation of RVF:

  • Shortness of breath 
  • Pedal edema (pitting type) 
  • Abdominal pain


Basis for shortness of breath in RVF:

  1. LVF → pulmonary edema → dyspnea
  2. Existing pulmonary diseases such as pulmonary embolus, chronic obstructive pulmonary disease
  3. Congestion of the hepatic veins → ascites → restricted diaphragmatic movements → dyspnea
  4. Reduced right-sided cardiac output → reduced pulmonary circulation and left-sided output → Acidosis and hypoxia → air hunger (dyspnea)


Basis for Pedal Edema, Anasarca, Ascites in RVF:

  • Right ventricular failure
  • Elevated right-sided pressure
  • Accumulation of fluid in the systemic veins and venous congestion
  • Dependent edema (swelling of the feet and legs), Generalized edema (anasarca), Ascites (fluid in peritoneal cavity)


Basis for the Abdominal pain in RVF:

A image thumb

Physical examination findings in RVF:

  • Elevated jugular venous pressure & Hepatojugular reflux 
  • Sustained systolic heave of the sternum (due to right ventricular hypertrophy) 
  • Right-sided S3 heard best at the left sternal border
  • Additional signs of left ventricular failure such as bibasilar rales (if the primary cause is LVF)


Elevated Jugular Venous Pressure in RFV:

  • Elevated right atrial pressure indicates that the fluid is accumulating in the venous system due to a decreased right ventricular function
  • Other causes of elevated jugular pressures: -Pericardial tamponade -Constrictive pericarditis -Massive pulmonary embolism


Hepatojugular reflux in RFV:

  • Pressing on the liver for a short while (approximately 5 sec) leads to displacement of blood into the vena cava and an increase in jugular venous pressure
  • Sign of right ventricular failure


Q image thumb