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Cardiovascular II Final Exam > Heart Failure (Johnston) > Flashcards

Heart Failure (Johnston) Flashcards

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1
Q

Heart failure definition

A

-Inability of the heart to meet the metabolic demands of the body

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2
Q

Etiology of Heart failure

A
  • 60-75% is ischemic heart disease
  • 18% idiopathic, dilated cardiomyopathy
  • 12% valvular heart disease–has declined, except for calcific aortic stenosis
  • 10% Hypertensive heart disease; major factor in 75%: Congenital, viral myocarditis (Coxsackie or influenza A.B), toxins (alcohol, adriamycin, cocaine), endocrine–hypo/hyperthyroid, nutritional
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3
Q

Most common cause of LV systolic dysfunction is from

A

-ischemic heart disease

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4
Q

Basic causes of heart failure

A

-Restriction/Obstruction to Ventricular filling:
RV infarct
Constrictive pericarditis
Mitral stenosis
Atrial myxoma
Others: Thyrotoxicosis–AV fistula, beri beri

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5
Q

ACC/AHA Stage A Heart Failure

A
  • HF risk factors: hyperlipidemia, diabetic etc
  • No heart disease
  • No symptoms
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6
Q

ACC/AHA Stage B Heart Failure

A
  • Heart disease but no symptoms

- Asymptomatic LV dysfunction

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7
Q

ACC/AHA Stage C

A

-Prior or current HF symptoms

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8
Q

ACC/AHA Stage D

A
  • Refractory HF symptoms

- no drugs seem to work and need mechanical devices like pacemakers or heart transplant.

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9
Q

The goal of ACC/AHA stages is to identify patients at risk for developing HF. What are some of these risk factors associated with stage A?

A
  • CAD (ischemic, atherosclerotic)
  • HT
  • DM
  • obesity
  • Metabolic syndrome
  • Excess alcohol
  • Cardio/toxins or family history of cardiomyopathy
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10
Q

ACC/AHA stage B–patient symptoms

A
  • Asymptomatic
  • But has LVH and/or impaired LV function (low EF), previous MI, valvular disease
  • structural heart disease
  • hemodynamically stable
  • One year mortality is 15-30%
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11
Q

ACC/AHA Stage C classification and symptoms

A
  • Patient with current or past symptoms of HF with STRUCTURAL HEART DISEASE
  • SOB
  • Fatigue
  • Reduced exercise tolerance
  • one year mortality is 15-30%
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12
Q

ACC/AHA Stage D

A
  • Refractory HF
  • Eligible for specialized treatment (mechanical support, transplants)
  • One year mortality 50-60%
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13
Q

Patients at high risk for heart failure but without structural heart disease or symptoms of heart failure
-examples: hypertension, diabetes mellitus, obesity, CAD (post-MI or revascularization), peripheral vascular disease, CVA, family history, exposure to cardiac toxins

A

-Stage A

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14
Q
  • Patients with structural heart disease but without signs and symptoms of heart failure
  • Prior MI, LVH or reduced LVEF, asymptomatic valvular disease
A

-Stage B

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15
Q

Patients with structural heart disease with prior or current symptoms of heart failure
–known structural heart disease and dyspnea, fatigue, reduced exercise tolerance

A 
Stage C
NYHA class I-IV
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16
Q

Patients with refractory heart failure requiring specialized interventions

A 
-Marked symptoms at rest despite maximal medical therapy, with recurrent hospitalizations
NYHA class III-IV
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17
Q

NYHA functional classification clinical stages–classes focus on

A

-excercise capacity and symptomatic status of the disease (subjective)

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18
Q

NYHA Class I

A
  • No limitation of physical activity
  • No symptoms with ordinary exertion
  • One year mortality 5-10%
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19
Q

NYHA Class II

A
  • Slight limitation of physical activity
  • Ordinary activity causes symptoms
  • One year mortality 15-30%
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20
Q

NYHA Class III

A
  • Marked limitation of physical activity
  • Less than ordinary activity causes symptoms
  • Asymptomatic at rest
  • One year mortality 15-30%
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21
Q

NYHA Class IV

A
  • Inability to carry out physical activity without discomfort
  • Symptoms at rest
  • One year mortality 50-60%
  • symptoms include DYSPNEA, FATIGUE AND CHEST PAIN!!
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22
Q

Word associations: Class I=

A

-ASYMPTOMATIC

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23
Q

Word associations: Class II=

A
  • NO SYMPTOMS AT REST

- EXERTIONAL SYMPTOMS WITH ORDINARY ACTIVITY

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24
Q

Word associations: Class III=

A
  • NO SYMPTOMS AT REST

- SYMPTOMS WITH MINIMAL ACTIVITY (less than ordinary activity)

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25
Word associations: Class IV
SYMPTOMS AT REST!!
26
What test is essential in evaluation of HD/HF
- Echocardiogram!!! | - is non-invasive, bed-side mobile, no prep needed
27
Specific causes of heart failure
- Hypertensive heart disease: concentric hypertrophic - Ischemic heart disease: wall motion abnormality--doesnt move as it should - Hypertrophic heart disease--small ventricular cavity, big muscle, big cardiac silhouette - Infiltrative heart disease--amyloidosis, sarcoidosis, speckled pattern - Primary valvular heart disease
28
Its important to distinguish what in heart failure
-systolic heart failure from diastolic heart failure
29
Classification (Types) of heart failure
- Systolic/Diastolic - High/low - Acute/chronic - Right/Left - Forward/backward
30
Causes of ACUTE HF
- Acute MI - Ruptured papillary muscle - Mitral regurgitation - Aortic insufficiency - Toxins
31
Causes and symptoms of CHRONIC HF
- Multivalvular disease of dilated cardiomyopathy - Progresses slowly - Edema, weight gain
32
Systolic HF characteristics
- At least 50% of the cases - low SV - Increased ventricular filling pressure - EF is less than 40%, hypo perfusion with impaired ventricular emptying - Weak, fatigued, reduced exercise tolerance - Dyspnea on exertion, orthopnea, Paroxysmal nocturnal dyspnea
33
LVEF=
SV/EDV
34
Diastolic Heart Failure--Ejection fraction is
-NORMAL
35
Characteristics of Diastolic heart failure
- SOB - DOE - Pulmonary Edema - Inability of LV to relax/fill; increased resistance to ventricular filling; decreased compliance or increased stiffness - Decreased ventricular diastolic capacity - Impaired ventricular relaxation--acute ischemia, myocardial fibrosis, amyloidosis
36
Example of diseases associated with diastolic heart failure
- Restrictive/constrictive pericarditis | - Hypertensive/hypertrophic cardiomyopathy
37
High output HF seen in | High output but LOW ejection fraction
- Hyperthyroidism - Anemia - Pregnancy - AV fistula - beriberi - Pagets
38
Low output HF seen in
- Ischemic heart disease - Hypertension - Dilated cardiomyopathy - valvular and pericardial disease - MUCH MORE FREQUENT THAN HIGH OUTPUT FAILURE
39
Right sided HF
- Affects RV - Pulmonary HTN due to pulmonary embolus - Edema, hepatomegalia, venous distention
40
Left sided HF
- LV is overloaded - AS, MI - Dyspnea, orthopnea due to pulmonary congestion
41
Heart Failure syndrome--Compensatory
- Neurohormonal responses: - SNs - RAAS - Cytokine Activation - Altered renal physiology - LV remodeling
42
Mechanisms of Heart failure--RAAS
- Decreased renal perfusion - Increased renin, angiotensinogen, A1 - A1 is converted to A11 which increases BP by vasoconstriction which stimulates adrenal gland to release aldosterone - Leads to Na and water retention (increase preload, congestive symptoms and volume (expansion) - A11 is vasoconstrictor, increases PVR (increase after load)
43
Mechanisms of heart failure--Arginine vasopressin--AVP or ADH
- Stimulation of thirst leads to increase TBW and hyponatremia (dilutional) - Increases preload (salt and water retention)
44
Precipitating causes of heart failure
- Decompensation of the heart relates to underlying progression of heart disease - Non compliance with diet--25-50%--too much sodium, too many calories, too many stimulants (tea, coffee, colas) - Non compliance with meds--25-50%--too costly, SEs
45
Meds that worsen HF
- CCB - Beta blockers - NSAID - Antiarrhythmics
46
Conditions that can cause heart failure
- Infection--20%: fever, tachycardia, increased metabolic demands, hypoxia - Anemia: increased oxygen needs of tissues, increased cardiac output - Arrhythmias--20-30%: tachyarrhthmias--decrease diastolic filling time, leading to ischemia; bradycardia
47
Other causes of heart failure
- Physical over exertion - Fluid excess--transfusion/volume overload - Environmental--stress - Hypertension worsening - MI--ischemia/infarction - PE - Hypothyroid - Alcohol - Valvular heart disease worsening (MS, AS, MR, AI) - Pericardial disease
48
S3 gallop associated with
- Heart failure!! | - HF risk increases 10-11x with diagnosis of S3 gallop murmur!
49
Signs and Symptoms of Heart Failure
- Decreased arterial perfusion to organs and venous congestion (liver, lungs) leads to: Dyspnea--most common symptoms of HF - Excercise intolerance, orthopnea, PND, nocturnal angina--due to pulmonary congestion and increased LA pressure - PND increases the likelihood of heart failure 2 fold - Weakness, fatigue not specific for HF - Pulmonary edema--crackles in lungs--transudation of fluid from pulmonary capillaries into alveolar spaces and interstitium. May wheeze or cough (frothy--pink fluid); possible cyanotic and acidotic
50
More signs and symptoms of heart failure
- Hepatomegalia--passive congestion with increased LFTs, altered coagulation studies, ascites, increased abdominal girth, peripheral and sacral edema - JVD-CVP can be elevated in volume overload; prominent in cardiac tamponade and COPD (lung hyperinflation)
51
More signs and symptoms of heart failure
- S3, S4 - presence of S3 gallop increases likelihood of heart failure 11 fold - LV failure - Orthopnea, PND - Tachypnea, wheezing, crackles, decreased breath sounds - Dullness to percussion over pleural effusions
52
RV failure symptoms
- Peripheral/sacral edema - Hepatomegalia - Ascites - Increased JVD, HJR
53
Unilateral vs bilateral edema in heart failure
- Typically heart failure is associated with BILATERAL edema | - It is never unilateral! So if its unilateral, something else is causing it
54
Imaging/Lab used to diagnose HF
- There is NO single diagnostic test for HF | - It is largely a clinical diagnosis checked on a careful H&P
55
Chest X ray findings of HF
- Cardiomegalia - Pulmonary edema with central peripheral infiltrates - Increased size of vessels in upper portion of lungs - Pleural effusions
56
Transudates vs Exudate effusion
- Transudates associated with oncotic process including HF - Exudates are usually infective process or malignant process - SO HF is usually a transudate and is often blunting costophrenic angles
57
Echocardiogram characteristics and used to diagnose what kind of diseases
- Practical useful test - Mobile, bedside/ICU/ED - Chamber sizes, clots, tumors - Wall motion (ischemic), muscle thickness - Pericardial effisions - Valvular disease - Systolic/Diastolic heart failure--ejection fraction
58
ECG in heart failure
- may or may not be helpful - May have ischemia, infarction, hypertrophy - Rhythm disturbances (atrial, junctional, ventricular) - Tachycardia, bradycardia, Blocks
59
Lab--Cardiac enzymes--troponins T and I
- Troponins T and I--released from myocyte when damaged - Increase 2-12 hours from onset of chest pain - Peak 24-48 hours; return to baseline 5-14 days
60
Lab--Cardiac enzymes--Creatine kinase--CK (MB)
- Increase 3-12 hours from onset of chest pain - Peak 24 hours; baseline 1-3 days - Sensitivity
61
Other labs associated with HF
- CBC--Anemia secondary to chronic disease, anemia may aggravate HF - CMP--electrolyte imbalance--low Na, K - Pre-renal azotemia--high BUN to creatinine - UA--protein in urine - ABG-may have hypoxia, metabolic acidosis from lactic acidosis - Thyroid
62
If patient is in HF, greater than 65 years old with A. fib, must check what?!
THYROID!! | -Free T4, TSH
63
Lab--BNP in heart failure
- Brain natriuretic peptide - Neurohormone, made in ventricles - Sensitive to ventricle stretching and volume overload; preload/afterload are stimuli - Lower EF, higher BNP - If value is less than 100 pg/ml there is a 97% chance of no HF
64
-Increased BNP seen in what diseases?
in heart failure, AMI, PE, renal failure, old age
65
Hear failure most reliable signs
- S3 gallop! - hyponatremia and decrease in hemoglobin--both due to dilution due to fluid overload - Reduced ejection fraction
66
Differential Diagnosis of heart failure
- Pulmonary problems: PE, asthma, pneumonia - Cirrhosis: ascites, edema - Renal--edema - Venous insufficiency--edema

Cardiovascular II Final Exam (13 decks)

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