Heart Failure - Exam V Flashcards
1
Q
Heart failure is an emerging worldwide ___?
A
epidemic
2
Q
How many people in the US will be treated for heart failure by 2030?
A
more than 8 million patients
3
Q
How is heart failure defined?
A
complex syndrome that results from any structural or functional impairment of ventricular filling or blood ejection.
4
Q
What does HF lead to?
A
Tissue-hypoperfusion, causing dyspnea, weakness, edema, and weight gain.
5
Q
What structural abnormalities are caused by HF?
A
abnormailites of the pericardium, myocardium, endocardium, heart valves, or great vessels.
6
Q
Define systolic HF?
A
HF with reduced EF (HFrEF, aka systolic HF) is classified as HF w/ EF ≤40%
7
Q
Define diastolic HF?
A
HF with preserved EF (HFpEF, aka diastolic HF): HF w/ EF≥50%
8
Q
What is a borderline HFpEF?
A
Symptomatic HF w/ an EF btw 40-49%
9
Q
Is dysfunction present in both HF with reduced & preserved EF?
A
Yes, in both HFrEF andHFpEF
10
Q
What are the distinguishing features btw HFrEF andHFpEF?
A
The LV dilation patterns, and remodeling, along with their different responses to medicaltreatment
11
Q
What is the main marker for determining HF risk factors, treatment, and outcomes?
A
Ejection fraction, measured on echocardiogram.
12
Q
~ 1/2 HF patients will have normal what?
A
Normal ejection (>50%)
13
Q
Patients with HFrEF are more likely to have what modifiable risk factors?
A
1.Smoking
2.hyperlipidemia
14
Q
Which Heart Failure patients have a higher incidence of myocardial ischemia and infarction, previous coronary intervention, CABG and PVD?
A
Patients with HFrEF
15
Q
What % HF cases are HFpEF
A
52%
16
Q
What % HF cases are HFrEF?
A
33%
17
Q
What % HF cases are borderline (EF 40-49%) ?
A
16%
18
Q
Women are more likely to be affected by what type of HF?
A
HFpEF
19
Q
Men are more likely to be affected by what type of HF?
A
HFrEF
20
Q
What type of LV dysfunction is the primary determinant of HFpEF?
Left ventricular dysfunction
A
LV diastolic dysfunction
21
Q
What type of LV dysfunction is the primary determinant of HFrEF?
Left ventricular dysfunction
A
LV systolic dysfunction
22
Q
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
23
Q
What is the majority of LVDD measurements?
(LVDD) = LV diastolic dysfunction
A
Depends on HR, loading conditions, contractility
24
Q
What is needed in HFpEF to achieve normal EDV?
A
higher LV filling pressures
25
What is a steeper rise of the end-diastolic pressure-volume is indicative of?
delayed LV relaxation and increased myocardial stiffness
26
What does a reduced LV compliance lead to?
LA HTN, LA dysfunction, pulmonary venous congestion, and exercise intolerance
27
Which proportion of HF patients is increasing due to its relationship w/ conditions such as hypertension, DM, A fib, obesity, metabolic syndrome, COPD, renal insufficiency, and anemia?
HFpEF
28
LV pressure-volume loops graph
| Slide 7
29
Common causes of LVDD?
| Left Vent. Diastolic Dysfunction
30
What causes a delay in relaxation?
| LV End-diastolic dysfunction
c/b failure of actin-myosin disassociation, which occurs due to inadequate perfusion or dysfunctional intracellular Ca++ homeostasis.
31
How does elevated afterload affect LV relaxation?
LV relaxation dependent on afterload, which is typically elevated in hypertensive pts
| High afterload(hypertension or aortic stenosis)can worsen LV relaxation
32
What is known to exacerbate diastolic dysfunction?
tachycardia
33
What occurs w/HFpEF despite having only a slightly depressed LV systolic function?
exercise intolerance
34
What contributes to subendocardial ischemica and further reduces exercise tolerance?
Prolonged coronary compression restricts diastolic blood flow.
35
Most common sx?
| Diagnosis of HF
* fatigue
* tachypnea
* dyspnea
* orthopnea
* S3 gallop
* JVD
* edema
* exercise intolerance
* reduced tissue perfusion
36
SX specific to HFpEF?
* paroxysmal nocturnal dyspnea
* pulmonary edema
* dependent edema
37
SX with HFrEF?
* S3 gallop
38
What is usually seen with the diagnosis of HFrEF?
reduced EF and presence of HF symptoms
| following standard guidelines
39
What procedure is used to identify elevated LV systolic and diastolic stiffness?
Cardiac cath (using pressure-volume analysis)
40
Measurement of RV filling provides what?
further information on the severity of HFpEF
41
mPAP seen at rest and during exercise is indicative of HFpEF? Can predict what else?
| Mean pulmonary capillary wedge
* mPAP **>15mmHg** at *rest *or **25mmHg** during *exercise* indicates ***HFpEF ***
* is a predictor of **mortality**
42
What can be detected from CXR?
* pulmonary dz
* cardiomegaly
* pulmonary venous congestion
* alveolar pulmonary edema
* interstitial pulmonary edema
43
What does distention of the pulmonary veins in the upper lung lobes on an CXR mean?
An early sign of LV failure & pulmonary venous HTN
44
A hilar haze with ill-defined margins on CXR mean?
Perivascular edema
45
What produces honeycomb pattern on CXR?
Kerley lines; which reflect interlobular edema.
46
How is alveolar edema seen on CXR?
Densities in the lung fields, typically in a butterfly pattern.
47
What is known to have have a lag behind clinical evidence by up to 12 hours?
Radiographic evidence of pulmonary edema.
48
Kerley lines in HF
49
Diagnosis of HFpEF
* Echocardiogram
50
ACC/AHA diagnostic criteria d/o 3 factors?
| Diagnosis of HFpEF
* HF sx
* EF >50%
* evidence of LVDD
## Footnote
This approach is useful for pts with clear sx, but may be too simplistic for subclinical HFpEF
51
The difference between the ACC/AHA and ESC criteria?
The ESC criteria is more specific and incorporates echocardiographic indexes and other measurements
52
EKG abnormalities in HF?
| Diagnosis of HF
EKG abnormalities are common in HF pts and are typically r/t underlying pathology s/a LVH, previous MI, arrhythmias and conduction abnormalities
53
Can you use EKG to diagnose HF?
NO, EKG alone has a low predictive value for HF dx or risk-prediction.
54
# LABs
Important biomakers?
| Diagnosis of HF
* brain natriuretic peptide (BNP)
* N-terminal pro-BNP
55
what disease has an elevated natriuretic peptide concentrations?
higher in HFrEF d/t LV dilation & eccentric remodeling (related to LV end-diastolic wall stress)
56
Lower BNP or NT-proBNP levels is seen in what type of HF?
HFpEF is assoicated w/concentric hypertrophy, relatively normal LV chamber size, and lower LV end-diastolic wall stress
57
How is troponin elevated?
d/t myocardial damage and serve as a measure of risk prediction.
58
C-reactive protein (CRP) and growth differentiation factor-15 (GDF15) represents what?
represents the inflammatory component of HF.
59
# Classification of HF
What does the New York Heart Association focus on?
on the degree of physical limitations.
60
# Classification of HF
What does ACC/AHA focus on?
Presence & severity of HF.
61
Why are HF stages considered progressive?
since progression of HF is linked to reduced-5 year survival.
62
NYHA & ACC/AHA classification table
| slide 17
63
# Chronic HF treatment
How is the survival rate of HFrEF & HFpEF?
Survival of pts w/HFrEF has improved with treatments, but survival with HFpEF remains unchanged.
64
What treatment is deemed as ineffective for HFpEF?
Medication treatments
65
TX of HFpEF?
Mitigation of sx’s, treat associated conditions, exercise, weight loss
66
What is the tx for HFrEF?
BB's and ACE-inhibitors
67
Why are loop diuretics recommoned for HF?
Loop diuretics are recommended to reduce LV filling pressures, decrease pulmonary venous congestion, and improve HF sx
68
What are thiazide diuretics used for?
Thiazide diuretics may be useful in poorly controlled HTN pts to prevent the HFpEF.
69
B-blockers are used to treat what type of HF?
* Strongly recommended for HFrEF
* Benefit not clearly established for HFpEF
70
When would you use ACEi or ARBs to treat HFpEF?
no benefit in HFpEF unless used for managing HTN
71
What is the mainstay treatment for HFrEF?
ACEi & ARBs
72
What are benefits of aerobic exercise?
reduces symptoms and increases quality of life.
73
What reduces major risk factors for HF, including HTN & DM?
Weight loss reduces major risk factors for HF, including HTN & DM.
74
What is the DASH diet and what does it improve?
* Salt-restricted dietary appraoches to stop HTN.
* Improves LV diastolic function, decreases arterial stiffness, and facilitates LV-arterial coupling in pts w/ HFpEF.
## Footnote
BP and blood glucose mgmt are also important.
75
What is the goal of surgical treatment for chronic HF?
Prevention of ventricular remodeling and preserve natural geometry of the heart.
76
How is coronary revascularization done?
via CABG or PCI can reverse LV dysfunction after MI
| Successfull early revascularization may prevent permanent EF reduction
77
What is biventricular pacing also known as?
cardiac resynchronization therapy (CRT)
78
What is CRT used to treat?
| cardiac resynchronization therapy
HF w/a ventricular conduction delay (prolonged QRS)
79
What are the risk included with biventricular pacing?
infection, misplacement, and device failure.
80
What patients are recommneded CRT as treatment?
Pts w/EF < 35% and a QRS duration 120-150 ms
81
What are the CRT outcomes?
* better exercise tolerance
* improved ventricular function
* less hospitalizations
* decreased mortality.
82
# Chronic HF - Surgical tx
What does implantable hemodynamic monitoring allow for?
remote observation of intracardiac pressure to guide tx.
83
What is CardioMEMS heart failure system used for?
| implantable hemodynamic monitoring
daily measurements of non-invasive PAP are obtained at home and uploaded to the physicians.
84
What are ICDs used for?
| implantable cardioverting-defibrillators
used for prevention of sudden death in pts with advanced heart failure.
| 50% HF deaths are d/t sudden cardiac dysrhythmias
85
# Chronic HF - surgical tx
LV assisted devices are used for what patients?
terminal stages of HF that may benefit form mechanical circulatory support (MCS) by a ventricular assist device (VAD)
86
What are LVAD used for?
* temporary ventricular assistance while heart is recovering its function
* Pts awaiting cardiac transplant
* Pts are on inotropes or balloon pump (IABP) with reversible medical conditions
* Pts with advanced HF who aren’t transplant candidates
87
How is chronic heart failure classified?
| what type of disease?
long-standing HF disease
88
What is acute heart failure?
rapid onset, often presenting w/ life-threatening conditions
89
What is the treatment for acute heart failure?
tx is aimed at decreasing volume & stabilizing hemodynamics
90
What is "de novo acute heart failure" ?
(initial onset HF)
* by a sudden increase in filling pressures or acute myocardial dysfunction, leading to **decreased perfusion and pulmonary edema**
| "De novo" = "from the beggining or new onset"
91
What is the leading cause of "de novo" HF?
Cardiac ischemia
92
What is the treatment goal of "de novo HF"?
* focuses on restoring cardiac perfusion
* improving contractility
* stabilizing hemodynamics
93
What are less common causes of "de novo" HF?
| Non-ischemic causes?
* Viral
* drug-induced
* peripartum cardiomyopathy
94
what is ADHF?
acute decompensated heart failure.
95
What are the sx for ADHF?
* fluid retention
* weight gain
* dyspnea
96
# Acute HF in Anesthesia
What is the expected hemodynamic profiles?
* Low CO
* high ventricular filling pressures
* HTN or hypotension
97
Where is the Central VAD/ ECMO cannula placed?
right atrium and aorta
98
What is the first line of treatment for acute heart failure?
Diuretics
99
What are some downsides to Central VAD/ ECMO?
it is Invasive
-it requires sternotomy or thoracotomy for placement
100
What do diuretics achieve in HF patients?
reduces intravacular volume: causing
* decreasing CVP
* decreasing PCWP
* reducing pulmonary congestion
101
What are some benefits to Central VAD/ ECMO?
- Complete ventricular decompression
- Avoidance of limb impairment
- Avoidance of superior vena cava syndrome
102
Do we give diuretics for hypotensive patients?
pt may require hemodynamic support prior to diuretics therapy.
103
What would be reduced in patients on ECMO as blood bypasses the lungs before returning to the aorta?
Reduced Lung Perfusion
104
What are some diuretics that we can give?
furosemide, bumetanide, and torsemide, given as bolus or continuous infusion
105
What role do vasodilators play in the treatment of acute heart failure?
Reduce filling pressures and afterload; evidence is lacking on the efficacy of AHF (not shown to improve outcomes)
106
What induction/maintenance agent may be limited by functional shunting around the lungs ?
Inhaled Anesthetics
107
108
Name two vasodilators mentioned in the lecture to help with the treatment of AHF:
1.Sodium Nitroprusside-rapidly decreases after load
2.Nitroglycerin-adjunct to diuretic therapy
109
What is preferred in patients with ECMO as far as induction?
TIVA
110
What role do vasopressin receptor antagonists play in the treatment of acute heart failure?
Potential adjuncts to reduce the arterial constriction, hyponatremia, and volume overload associated with AHF
111
What is the reason that, in ECMO, many agents (including fentanyl) that CRNAs use could become sequestered within the circuit?
The ECMO membrane is lipophillic
112
What role do positive inotropes play in the treatment of acute heart failure?
Mainstay tx for pts with acute reduced contractility, or cardiogenic shock
113
When would you see a biventricular assist device being used in AHF treatment?
Once a patient on central ECMO is stable, decoupling support of the ventricles with two circuits facilitates weaning of the left or right-sided support
114
name the catecholamines mentioned in the lecture that stimulate beta receptors on the myocardium to activate adenylyl cyclase to increase c AMP
epinephrine
norepinephrine
dopamine
dobutamine
115
What are two ways to wean left or right sided support with a BiVAD?
1. separate circuits can be achieved by percutaneous placement to support the right and left sides separately
2. alternatively, right and left sides can be centrally cannulated individually
116
What drugs that help treat AHF inhibit degradation of cAMP, which increases intracellular calcium and excitation-contraction coupling?
PDE- inhibitors (milrinone)
117
HF patients have an increased risk of developing what ?
renal failure, sepsis, pneumonia, and cardiac arrest
-these patients with require longer periods of mechanical vent; and have an increased 30 day mortality
118
What is the drug mentioned in lecture that is a commonly used inotropic agent for patients with AHF that works as a calcium sensitizer?
Levosimendan (increases HR and CO)
119
Why do all HF patients require a comprehensive preop exam?
To determine if they are compensated or require treatment
120
Name the Exogenous BNP drug that you can give for AHF that inhibits the RAAS and promotes vasodilation, decreasinf LVEDP and improving dyspnea:
Nesiritide
121
What conditions, when evaluating HF patients, should be optimized in preop?
HTN
DM
Angina
Afib
Renal Failure
122
What can Nesiritide also do?
it can induce diuresis and natriuresis and relax cardiac muscle. However, it has not shown advantage over traditional vasodilators such as NTG and SNP.
123
When should surgery be postponed in preop evaluation for HF patients?
-If they are experiencing decompensation
-A recent change in clinical status
-de novo acute heart failure
124
Name 5 Acute Heart Failure surgical treatments mentioned in lecture
Intra-aortic balloon pump
Impella
Peripheral VAD
Central VAD/ ECMO
Biventricular assist device (BiVAD)
125
What medications should be held or continued on day of surgery with HF patients?
diuretics held day of surgery
cont BB
hold ACE-i (pts may be at risk for intro Hypotension)
126
How does a Intra-aortic balloon pump work?
- Functions by balloon inflation after aortic valve closure, followed by deflation during systole
- It improves LV coronary perfusion by reducing LVEDP
127
What test is recommended in any patient with CV dz?
12-lead EKG
128
Degree of support on IABP depends on what?
set volume
size of the balloon
ratio of supported beats
129
When would a transthoracic echocardiogram (TTE) be indicated in preop management of HF?
In patients with worsening dyspnea
130
What is considered full support on a IABP?
1:1 (one inflation for every beat)
131
What labs do we check prior to surgery with HF patients?
CBC
electrolytes
liver function
coagulation studies
132
What is the preferred setting on the IABP in tachycardic patients?
1:2 (one inflation per every two heart beats)
133
Would we check a BNP in preop evaluation for HF patients?
No, BNP is not routinely recommended
134
Overall, how much improvement does IABP make for our acutely ill patients?
only modest improvements in COP (0.5-1L/min) and renders patients immobile, limiting its long-term use.
135
When should ICDs and pacemakers be interrogated?
They should be interrogated prior to surgery
136
What is an impella and how does it improve patients in AHF?
- it is a VAD, placed percutaneously to reduce LV strain and myocardial work
- It serves as a transition to recovery or a bridge to cardiac procedures (CABG, PCI, VAD, Transplant)
137
What is Cardiomyopathy?
It is a cardiac disease associated with mechanical or electrical dysfunction, often w/ ventricular hypertrophy or dilation
138
How long can an impella be utilized?
14 days
139
What are the 2 groups of cardiomyopathies we will see?
Primary cardiomyopathies
Secondary cardiomyopathies
140
Where does the Impella sit in the heart and how does it work mechanically?
-Sits in the Left Ventricle
-consists of a rotarty blood pump inserted through the femoral artery, advanced through the aortic valve and sits in the LV
-the pump draws blood continuously from the LV through the distal port and ejects it into the ascending aorta through its proximal port.
141
How do we distinguish primary cardiomyopathy from secondary cardiomyopathy?
Primary cardiomyopathy is confined to the HEART MUSCLE!!!
142
The impella ECP is designed for flows greater than what?
3.5 L/min
143
How is secondary cardiomyopathy different from primary?
It is PATHOLOGIC cardiac involvement associated with MULTIORGAN disorder.
144
What does a peripheral Ventricular assist device do to improve AHF?
It is a support device that can provide extracorporeal membrane oxygenation (ECMO)
145
What is Hypertrophic cardiomyopathy and is it primary or secondary?
- Characterized by left ventricular hypertrophy in the absence of other diseases capable of inducing ventricular hypertrophy
- HCM is a complex primary cardiomyopathy
146
What does a peripheral VAD consist of mechanically?
small pump and controller
147
What is the most common genetic CV disease?
Hypertrophic cardiomyopathy
148
What is a pro and con of the peripheral VAD?
the small pump and controller is helpful for transport, but it generates heat and causes more hemolysis and lower flows
149
What part of the heart is usually hypertrophied in hypertrophic cardiomyopathy?
- Interventricular septum
- Anterolateral free wall
150
When would you see a Central VAD/ ECMO in AHF treatment?
It may be necessary for cardiorespiratory support or an alternative to peripheral VAD
151
What is hypertrophic cardiomyopathy pathophysiology related to?
-myocardial hypertrophy
-Left ventricular outflow tract obstruction
-mitral regurgitation
-diatolic dysfunction
-myocardial ischemia
-dysrhythmias
152
What is the relaxation time and compliance like in hypertrophic cardiomyopathy?
prolonged relaxation
decreased compliance
153
What is the cause of sudden death in Young adults with HCM?
dysrhythmias
154
What are dysrhythmias caused by?
Disorganized cellular architecture, myocardial scarring, and expanded interstitial matrix
155
If you have an asymptomatic patient what may be the only sign that they have HCM?
Unexplained left ventricular hypertrophy
156
What percentage of patients show EKG abnormalities in HCM?
75-90%
157
What specific EKG abnormalities would we see in HCM patients?
High QRS voltage
ST-segment and T-wave alterations
Abnormal Q waves
Left atrial enlargement
158
In HCM what would the echo show in myocardial wall thickness?
>15mm
159
In HCM the EF is usually what?
>80%
reflecting the hypercontractility
160
In severe cases of HCM the Ejection fraction becomes what?
Depressed
161
What diagnostic procedure allows for direct measurement of increased LVEDP in HCM patients?
Cardiac catheterization
162
What is the medical therapy for HCM treatment?
BB and CCB
163
Patients with HCM who develop HF despite BB and CCB may show improvement with what drugs?
diuretics
164
What is a negative inotrope that improves LVOT obstruction and HF symptoms and can be considered as an add on therapy for HCM?
Disopyramide
165
What condition can develop in HCM and is associated w/ increased risk of thromboembolism, heart failure, and sudden death?
Atrial fibrillation
166
What is the most effective antidysrhythmic in HCM patients?
Amiodarone
167
What is indicated for HCM patients with recurrent or chronic Afib?
Long term anticoagulation
168
When you have a patient with HCM, surgery is only reserved for which patients?
- Patients with LARGE outflow tract gradients (LVOT)
- Patients with SEVERE symptoms
169
What are 3 surgical strategies listed in lecture that are for HCM?
1. Septal myomectomy
2. Cardiac cath with injection to induce ischemia of the septal perforator arteries
3. Echocardiogram-guided percutaneous septal ablation
170
What type of valve can be inserted for HCM surgical treatment?
Prosthetic mitral valve
171
What surgical treatment is the primary treatment for patients at risk of sudden cardiac death due to dysrhythmias?
ICD placement
172
What are the characteristics of dilated cardiomyopathy?
-Atrial and ventricular dilation
-Decreased ventricular wall thickness
-Systolic dysfunction
173
What is the initial symptom of dilated cardiomyopathy and what also could occur?
Heart failure is inital sx
CP may also occur
174
What could lead to mitral or tricuspid regurgitation?
Ventricular dilation
175
What are three BIG complications associated with dilated cardiomyopathy?
Dysrhythmias
Emboli
Sudden death
176
What does an echo reveal in dilated cardiomyopathy patients?
Dilation of all 4 chambers, predominantly the LV, as well as global hypokinesis
177
Treatments for dilated cardiomyopathy are similar to what other heart condition?
Chronic HF
178
With dilated cardiomyopathy what treatment is often initiated for these patients?
anticoagulation
179
What does the EKG reveal with Dilated cardiomyopathy?
ST segment and T wave abnormalities and LBBB
180
What are common dysrhythmias to look for with dilated cardiomyopathy?
PVC and Afib
181
What can physicians do prophylactically to decrease the risk of sudden death by 50% in dilated cardiomyopathy patients?
Place an ICD
182
What is the principal indication for cardiac transplant?
Dilated Cardiomyopathy
183
What is Apical ballooning syndrome?
Stress cardiomyopathy!!!
it is a LV hypokinesis with ischemic EKG changes, BUT the coronary arteries are PATENT!!!
184
In stress cardiomyopathy what contractility has a temporary disruption compared to the rest of the heart with normal contractility?
Left ventricular contractility has a temporary disruption
185
Chest pain and dyspnea are common symptoms associated with which cardiomyopathy?
Stress cardiomyopathy
186
What is the main causative factor of stress cardiomyopathy?
STRESS (physical or emotional)
187
Does stress cardiomyopathy occur more in men or women?
Women
188
When does peripartum cardiomyopathy arise? and is it dilated or hypertrophic cardiomyopathy?
-Arises during the peripartum period (3d trimester-5 months)
-It is a form of dilated cardiomyopathy
189
What 3 criteria is peripartum cardiomyopathy diagnosis based on?
1. development of peripartum HF
2. absence of another explainable cause
3. LV systolic dysfunction with EF < 45%
190
What is the most common cause of secondary cardiomyopathy?
Amyloidosis
191
What are other causes of secondary cardiomyopathy besides amyloidosis?
hemochromatosis, sarcoidosis, and carcinoid tumors
192
Heart failure without cardiomegaly or systolic dysfunction is significant for which type of cardiomyopathy?
Secondary Cardiomyopathy
193
What blood pressure changes would you see with secondary cardiomyopathy?
Low to normal BP and can develop orthostatic hypotension
194
What the heck is cor pulmonale?
Right ventricular enlargement that may progress to right heart failure
195
List the 4 causes of Cor Pulmonale that were mentioned in lecture:
1.Pulmonary hypertension
2. Heart disease
3. Significant respiratory connective tissue
4. Chronic thromboembolic disease
196
What is the specific most common cause of Cor Pulmonale?
CoPd - Cor Pulmonale
197
Right atrial and Right ventricular hypertrophy signs will show up on the EKG of which cardiac problem?
Cor Pulmonale
198
Right atrial hypertrophy is indicated by what on the EKG?
Peaked P waves
199
What other EKG changes could you see with Cor Pulmonale?
RBBB and Right axis deviation, remember this is right ventricular enlargement!!
200
What other diagnostic tests would you see with Cor Pulmonale?
TEE
R heart Cath
CXR
201
