Heart Failure (Exam IV) Flashcards
(102 cards)
1
Q
What ejection fraction would characterized HFrEF (heart failure with reduced ejection fraction) ?
A
≤ 40%
2
Q
HF may be caused by structural abnormalities of the _______, _______, _________, ________, or _______
A
pericardium, myocardium, endocardium, heart valves, or great vessels
3
Q
What ejection fraction would characterized HFpEF (heart failure with preserved ejection fraction) ?
A
≥ 50%
4
Q
What ejection fraction would characterized HFrEF (heart failure with reduced ejection fraction) ?
A
<40%
5
Q
Borderline HFpEF: Symptomatic HF w/ an EF btw ________%
A
40-49
6
Q
How many % of patients with HF have normal EF
A
50%
7
Q
- The proportion of pts with HFpEF is increasing d/t its relationship w/ conditions such as
A
HTN, DM, A-fib, obesity, metabolic syndrome, COPD, renal insufficiency, and anemia
8
Q
Pts with HFrEF are more likely to have________________ as well as a higher incidence of myocardial ischemia & infarction, previous coronary intervention, CABG, and PVD
A
modifiable risk factors (smoking, HLD)
9
Q
%s of HF Cases
A
- 52% HF cases are HFpEF
- 33% are HFrEF
- 16% are borderline HFpEF (EF 40-49%)
10
Q
- Women are more likely to be affected by _________
- Men more likely to be affected by __________
A
HFpEF
HFrEF
11
Q
- LV diastolic dysfunction is the primary determinant of ___________, whereas LV systolic dysfunction is the primary determinant for __________
A
HFpEF
HFrEF
12
Q
- The LV’s ability to fill is determined by:
A
Pulmonary venous blood flow
LA function
mitral valve dynamics
pericardial restraint
the elastic properties of the left ventricle
13
Q
In HFpEF, ________ LV filling pressures are required to achieve normal EDV
A
higher
14
Q
A steeper rise of the end-diastolic pressure-volume curve is indicative of ________ and ________
A
delayed LV relaxation and increased myocardial stiffness
15
Q
reduced LV compliance leads to ________, ________, ___________ and __________
A
LA hypertension, LA dysfunction, pulmonary venous congestion, and exercise intolerance
16
Q
Common Causes of LV Diastolic Dysfunction
A
17
Q
Delays in relaxation are c/b _________, which occurs due to inadequate perfusion or dysfunctional intracellular Ca++ homeostasis
A
failure of acTn-myosin disassociation
Tachycardia exacerbates this
18
Q
__________ occurs w/HFpEF despite having only a slightly depressed LV systolic funcTon
A
Exercise intolerance
19
Q
- Sx that are more common w/HFpEF:
A
paroxysmal nocturnal dyspnea,
pulmonary edema,
dependent edema
20
Q
- More common w/HFrEF:
A
S3 gallop
21
Q
WHich one is more difficult to diagnose: HFPEF or HFREF
A
In contrast to HFrEF, the initial diagnosis of HFpEF is more difficult, especially when the pt has little/no symptoms at rest
22
Q
Cardiac catheterization defines elevated LV systolic and diastolic stiffness using _________
A
pressure-volume analysis
23
Q
- Mean pulmonary capillary wedge pressure _________ at rest or _________ during exercise indicates HFpEF and is a predictor of mortality
A
> 15mmHg
25mmHg
24
Q
An early sign of LV failure & pulmonary venous HTN is:
A
distention of the pulmonary veins in the upper lung lobes
25
_________ appears as a hilar haze with ill-defined margins
* Perivascular edema
26
The ACC/AHA diagnostic criteria d/o 3 factors:
HF sx,
EF >50%,
and evidence of LVDD
27
EKG abnormalities are common in HF pts and are typically r/t underlying pathology s/a _____, ________, _________ and __________
LVH, previous MI, arrhythmias and conducTon abnormaliTes
* EKG alone has a low predictive value for HF dx or risk-prediction
28
What are the important biomarkers for HF?
Brain natriuretic peptide (BNP) & N-terminal pro-BNP
29
Natriuretic peptide concentrations are related to ______________, which is higher in HFrEF d/t LV dilation & eccentric remodeling
LV end-diastolic wall stress
30
In contrast, HFpEF is associated w/concentric hypertrophy, relatively normal LV chamber size, and lower LV end-diastolic wall stress, allowing for lower ____________
BNP or NT-proBNP levels
31
____________ and ___________ represent the inflammatory component of HF
C-reactive protein (CRP) and Growth differentiation factor-15 (GDF15)
32
The NYHA system focuses primarily on the ____________, whereas the ACC/AHA focus on the ______________
(* Pts are often classified using a combination of both scoring systems)
degree of physical limitation
presence & severity of HF
(these stages are progressive)
33
Treatments improves survival with _________, but not __________
HFrEF
HFpEF
* Medication treatments are ineffective for HFpEF
34
* HFpEF tx:
* HFrEF tx:
Mitigation of sx’s, treat associated conditions, exercise, weight loss
ΒB's and ACE-inhibitors
35
___________ are recommended to reduce LV filling pressures, decrease pulmonary venous congesTon, and improve HF sx
Loop diuretics
* Diuretics: 1st line tx for AHF
* If HoTN, pt may require hemodynamic support prior to diuretic therapy
* Furosemide, Bumetanide, and Torsemide, given as bolus or continuous infusions
36
___________ may be useful in poorly controlled HTN pts to prevent the HFpEF
* Thiazide diuretics
37
This class of drugs are Strongly recommended for HFrEF
But Benefit not clearly established for HFpEF
B-Blockers
38
___________ and _________ are the mainstay tx’s for HFrEF; however, no benefit in HFpEF unless used for managing HTN
ACE-inhibitors and ARBs
39
* Radiographic evidence of pulmonary edema may lag behind the clinical evidence by up to ______ hours
12
40
T/F: * Diastolic dysfunction is present in both HFrEF and HFpEF
T
41
* The goal of surgical treatment for chronic HF is to ___________ and ____________
prevent ventricular remodeling and preserve natural geometry of the heart
42
* Coronary revascularization via ______ or _______ can reverse LV dysfunction after MI
* Successful early revascularization may prevent permanent EF reductions
CABG or PCI
43
CRT stuff
* Cardiac resynchronization therapy (CRT): Aka “biventricular pacing,” is a tx for
HF w/a ventricular conduction delay (prolonged QRS)
* dual-chamber pacemaker stimulates heart to contract more synchronously
* CRT is recommended for pts w/EF < 35% and a QRS duration 120-150 ms
* CRT outcomes: better exercise tolerance, improved ventricular function, less hospitalizations, and decreased mortality
* Risks include: infection, misplacement, and device failure
44
______% of HF deaths are d/t sudden cardiac dysrhythmias
̴ 50%
45
Acute HF Tx is aimed at __________ and __________
decreasing volume & stabilizing hemodynamics
46
de novo acute heart failure meaning:
initial onset HF
47
* De novo AHF is characterized by : ________, _________ and _________
a sudden increase in filling pressures or acute myocardial dysfunction, leading to decreased perfusion and pulmonary edema
48
____________ is the leading cause of de novo HF; therefore, tx focuses on restoring cardiac perfusion, improving contracTlity, and stabilizing hemodynamics
* Cardiac ischemia
49
* Less common non-ischemic causes of de novo HF include ________, ________ and _____________
viral, drug-induced, and peripartum cardiomyopathy
50
__________ reduce filling pressures and afterload ; however, evidence is lacking on their efficacy in AHF
Vasodilators
* SNP is effective in rapidly decreasing afterload
* NTG is commonly used as an adjunct to diuretic therapy
* Overall, routine use of vasodilators is not shown to improve outcomes
51
______________________ are potential adjuncts, to reduce the arterial constriction, hyponatremia, and volume overload associated with AHF
* Vasopressin receptor antagonists
52
What are the mainstay for Pt's with acute reduced contractility or Cardiogenic shock
Positive Inotropes
Catecholamines (epinephrine, norepinephrine, dopamine, dobutamine) stimulate β-receptors on the myocardium to activate adenylyl cyclase to increase cAMP
PDE-inhibitors: inhibit cAMP degradation, cAMP increases intracellular
calcium and excitation-contraction coupling
53
Exogenous BNP such as ___________ inhibits the RAAS and promotes vasodilation, decreasing LVEDP and improving dyspnea
also does what?
Nesiritide,
* also induces diuresis & natriuresis and relaxes cardiac muscle
* However, Nesiritide has not shown advantage over traditional vasodilators such as NTG & SNP
54
Intra aortic ballon pump:
55
Impellaaaaaa
56
VADs
57
Pts on _______ likely have reduced lung perfusion as blood bypasses the lungs before returning to the aorta
Volatile anesthetics considerations:
Whats preferred?
ECMO
* INH anesthetics may be limited by functional shunting around the lungs
* TIVA preferred in pts on ECMO
58
Fentanyl considerations when pt is on ECMO?
ECMO membrane is lipophilic, causing many agents, including fentanyl, to become sequestered within the circuit
59
* Biventricular assist device (BiVAD)
* Once a pt on central ECMO is stabile, decoupling support of the ventricles with two circuits facilitates weaning of the left- or right-sided support
* Separate circuits can be achieved by percutaneous placement to support the right and left sides, separately
* Alternatively, the right and left sides can be centrally cannulated individually
60
* HF pts have an increased risk of developing ________, ________, ___________ and _________
renal failure, sepsis, pneumonia, and cardiac arrest
* require longer periods of mechanical ventilation; and have an increased 30-day mortality
61
* All pts with HF should have a ___________ to determine if they are compensated or require treatment
comprehensive preop exam
62
surgery should be postponed in pts experiencing decompensation, a recent change in clinical status, or in de novo acute heart failure
Yeah, taking them in for surgery ==> suicide mission
* Generally, diuretics be held on the day of surgery
63
__________ is indicated in pts w/worsening dyspnea
* A transthoracic echocardiogram (TTE)
64
* Conditions s/a HTN, DM, angina, afib, and renal failure, should be __________
optimized
65
* Cardiomyopathies are either confined to the heart or are part of systemic disorders
What are the 2 groups
Primary cardiomyopathies: are confined to the heart muscle
Secondary cardiomyopathies: pathologic cardiac involvement Assoc w/multiorgan
disorder
66
T/F Hypertrophic Cardiomyopathy is the most common genetic cardiovascular disease
T
67
* HCM usually presents w/ hypertrophy of the _________ and ________
Interventricular septum and the anterolateral free wall
68
HCM Pathophysiology is r/t:
myocardial hypertrophy,
LVOT obstruction,
mitral regurgitation,
diastolic dysfunction,
myocardial ischemia,
and dysrhythmias
69
in HCM: The hypertrophied myocardium has a prolonged _________ time and decreased _________
relaxation
compliance
70
____________ are the cause of sudden death in young adults with HCM
* Dysrhythmias
* Dysrhythmias are c/b disorganized cellular architecture, myocardial scarring, and an expanded interstitial matrix
71
* In asymptomatic pts, _______________may be the only sign of HCM
unexplained LVH
72
What EKG abnormalities are seen in HCM: and how many % have them?
75-90%
These include high QRS voltage,
ST-segment and T-wave alterations,
abnormal Q waves,
and left atrial enlargement
73
* Ejection fraction is usually >______%, reflecting the hypercontractility
80%
* In severe cases, the EF becomes depressed
74
Cardiac catheterization allows direct measurement of ___________
increased LVEDP
75
HCM tx:
Medical therapy
BBs and CCBs
76
HCM
Pts who develop HF despite BB & CCBs may show improvement with ______
diuretics
77
___________can be considered as add-on therapy
negative inotrope: improving LVOT obstruction and heart failure symptoms
* Disopyramide
78
________ often develops in HCM and is associated with increased risk of thromboembolism, heart failure, and sudden death
* A-fib
* Amiodarone is the most effective antidysrhythmic in these pts
* Long-term anticoagulation is indicated for recurrent or chronic AFib
79
* Surgery is reserved for pts w/ ______________ and ___________
large outflow tract gradients
severe sx
80
Surgical strategies:
Septal myomectomy
Cardiac cath w/injection to induce ischemia of the septal perforator arteries
Echocardiogram-guided percutaneous septal ablation
* Prosthetic mitral valve can also be inserted
* ICD placement is the primary tx for pts at risk of sudden cardiac death d/t dysrhythmias
81
echo in HCM shows myocardial thickness of:
>15mm
82
Dilated Cardiomyopathy
83
DCM:
* Echocardiogram typically reveals dilation of all 4 chambers, predominantly the ___, as well as ______________
LV
global hypokinesis
* Tx is similar to that of chronic HF
* anticoagulation is often initiated
84
DCM:
EKG often shows _________, __________,and ________
ST-segment and T-wave abnormalities and LBBB
85
DCM:
* common dysrhythmias include ________ and __________
PVC and Afib
86
DCM
_____________ placement decreases the risk of sudden death by 50%
* prophylactic ICD
87
* DCM is the principal indication for:
cardiac transplant
88
Stress Cardiomyopathy, AKA ____________
What is it?
Common sxs inclu
Apical ballooning syndrome
LV hypokinesis w/ischemic EKG changes, however the coronary arteries remain patent
* Temporary disruption of LV contractility, the rest of the heart has normal contractility
89
Common s/s of stress cardiomyopathy include:
Main causative factor:
CP and dyspnea
Stress (physical or emotional)
* Occurs in women than in men
90
When does peripartum cardiomyopathy rear its ugly head:
3rd trimester-5 months postpartum
91
peripartum cardiomyopathy dx is based on what 3 factors?
development of peripartum HF
absence of another explainable cause
LV systolic dysfunction with EF <45%
92
Secondary Cardiomyopathy are caused by:
diseases that lead to myocardial infiltration and diastolic dysfunction
93
Secondary Cardiomyopathy is most commonly caused by:
Other causes:
Amyloidosis
hemochromatosis, sarcoidosis, and carcinoid tumors
94
Secondary Cardiomyopathy sx:
* Sx: heart failure without cardiomegaly or systolic dysfunction
95
T/F: Secondary Cardiomyopathy Pts have low to normal BP and can develop orthostatic hypotension
T
96
____________is RV enlargement that may progress to right heart failure
* Cor pulmonale
97
Cor Pulmonale causes:
pulmonary hypertension,
heart disease,
significant respiratory,
connective tissue,
chronic thromboembolic disease
98
Cor Pulmonale most common cause:
COPD
99
Cor Pulmonale:
EKG may show signs of RA & RV hypertrophy
* RA hypertrophy is indicated by peaked P waves
* Right axis deviation and RBBB are also often seen
* Other diagnostic tests include: TEE, right heart cath, CXR
100
Key Points
101
Which type of heart failure is characterized by reduced compliance and restricted left ventricular filling?
LV Diastolic Failure
102
Which type of heart failure is characterized by reduced contractility, LV dilation, pulmonary congestion, and increased ESV and EDV volumes?
LV Systolic Failure
