S9) Heart Failure Flashcards Preview

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Flashcards in S9) Heart Failure Deck (40):
1

What is heart failure?

Heart failure is a state in which the heart fails to maintain an adequate circulation for the needs of the body despite an adequate filling pressure

2

Outline the aetiology of heart failure

- Ischaemic Heart Disease

- Hypertension

- Dilated/hypertrophic Cardiomyopathy

- Valvular/Congenital Heart Disease

- Pericardial disease

- Arrhythmias

3

What are the clinical signs of chronic heart failure?

- Pulmonary congestion

- Venous congestion

- Dependent oedema

4

What are the symptoms of chronic heart disease?

- Dyspnoea

- Lethargy

- Orthopnoea

5

Describe the clinical features of Class I heart failure

No symptomatic limitation of physical activity

6

Describe the clinical features of Class II heart failure

- Slight limitation of physical activity

- Ordinary physical activity results in symptoms

- No symptoms at rest

7

Describe the clinical features of Class III heart failure

- Marked limitation of physical activity

- Less than ordinary physical activity results in symptoms

- No symptoms at rest

8

Describe the clinical features of Class IV heart failure

- Inability to carry out any physical activity without symptoms

- May have symptoms at rest

- Discomfort increases with any degree of physical activity

9

What are the factors affecting cardiac output?

- Heart rate

- Venous capacity (preload)

- Myocardial contractility

- Arterial and peripheral impedance (afterload)

10

What is Starling's Law of the Heart?

"The force developed in a muscle fibre depends on the degree to which the fibre is stretched."

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11

Describe the pathophysiology of Left Ventricular Systolic Dysfunction

- Increased LV capacity

- Reduced LV cardiac output

- Thinning of the myocardial wall

I.  Fibrosis and necrosis of myocardium

II.  Activity of matrix proteinases

12

What are the causes of Left Ventricular Systolic Dysfunction?

- Mitral valve incompetence

- Neuro-hormonal activation

- Cardiac Arrhythmias

13

Which structural heart changes occur after Left Ventricular Systolic Dysfunction?

- Loss of muscle

- Uncoordinated myocardial contraction

- Changes to the ECM (increase in collagen)

- Change of cellular structure and function (myocyte hypertrophy)

14

Describe ventricular remodeling after acute infarction 

 

 

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15

Describe ventricular remodeling in diastolic and systolic heart failure 

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16

Label the following images:

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17

Identify the 5 different pathways for neuro-hormonal activation

- Sympathetic Nervous System

- Renin-Angiotensin-Aldosterone System

- Natriuretic Hormones

- Anti-Diuretic Hormone

- Endothelin

18

Why is SNS stimulated in heart failure?

Early compensatory mechanism to improve cardiac output:

- Cardiac contractility

- Arterial and venous vasoconstriction

- Tachycardia

19

Outline the long-term deleterious effects of the SNS in heart failure

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20

When is RAAS commonly activated in heart failure?

- Reduced renal blood flow

- SNS induction of renin from macula densa

21

Outline the action of RAAS in heart failure

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22

In terms of the brain, blood vessels, heart and kidney, explain how Angiotensin II plays a key role in organ damage

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23

When are natriuretic peptides released in heart failure?

- Atrial distension

- Increased blood volume and pressure

24

Outline the action of natriuretic peptides in heart failure

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25

Outline the effect of ADH (vasopressin) in heart failure

ADH is increased in heart failure:

- Increased H2O retention

- Tachycardia and increased TPR → increased CO

26

Outline the action of endothelin in heart failure

- Endothelin is secreted by vascular endothelial cells resulting in renal vasoconstriction via autocrine activity 

- Activates RAAS (increased levels in some patients with heart failure)

27

Outline the effect of other chemicals in heart failure:

- Prostaglandin E2 and I2

- Nitric oxide

- Bradykinin

Prostaglandins: vasodilators stimulated by NA and RAAS to counter their effects

- Nitric oxide: potent vasodilator produced by endothelial cells via NO synthase (NO synthase may be blunted in HF)

- Bradykinin: promotes natriuresis, vasodilatation and stimulates production of PGs

28

What is oedema?

- Oedema is the excessive volume of fluid within the tissues (interstitial / intracellular) which can occur due to changes in capillary dynamics

- It is often seen in heart failure as there is increased capillary hydrostatic pressure 

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29

Vascular endothelium increases in peripheral arterial resistance. 
Why is this?

- SNS

- RAAS

- Reduced NO

- Increased endothelin 

30

Changes in vascular endothelium leads to skeletal muscle changes.

Identify some

- Reduced skeletal muscle blood flow

- Reduction in skeletal muscle mass (cachexia)

- Abnormalities of structure and function

31

Describe the renal effects associated with changes in the vascular endothelium

GFR is maintained in early HF by haemodynamic changes at the glomerulus – increased Na+ /H2O retention due to neurohormonal activation

- GFR falls in severe HF due to reduced renal blood flow leading to a subsequent rise in serum urea and creatinine

32

Describe the multi-factorial aetiology of anaemia associated with vascular endothelium changes

- Chronic inflammatory disease

- Expanded plasma volume

- Drug therapy (ACEi / Aspirin)

- Iron malabsorption

- Chronic renal failure

 

 

33

Heart Failure with Preserved Ejection Fraction (HFpEF) occurs in almost 50% of heart failure patients. 

Describe the clinical features of this condition

- Frequently elderly and female

- Often history of hypertension / diabetes / obesity

- Normal LV function with concentric remodelling

34

In four steps, describe the pathophysiology of HFpEF

⇒ Reduced LV compliance and impaired myocardial relaxation

Impaired diastolic LV filling (dependent on high LA pressure)

 RV dysfunction results from high LA and PA pressure

⇒ Triggers neuro-hormonal activation as per systolic heart failure

35

Identify the 5 clinical syndromes of heart failure

- Left Sided Heart Failure

- Right Sided Heart Failure

- Congestive cardiac failure

- LVSD (pump failure)

- HFpEF (failure of LV relaxation)

36

Identify the symptoms of Left Sided Heart Failure 

- Fatigue

- Exertional dyspnoea

- Orthopnoea

- Paroxysmal nocturnal dyspnoea (PND)

37

What are the clinical signs of Left Sided Heart Failure?

- Tachycardia

- Cardiomegaly (displaced apex beat)

- 3rd or 4th heart sound (‘Gallop rhythm’)

- Functional murmur of mitral regurgitation

- Basal pulmonary crackles (fluid in the lungs)

- Peripheral oedema

38

Describe the aetiology of Right Sided Heart Failure

- Chronic lung disease

- Pulmonary embolism / pulmonary hypertension

- Pulmonary/tricuspid valvular disease

- Left-to-right shunts (ASD/VSD)

- Secondary to left heart failure (most frequent)

39

What are the signs and symptoms of Right Heart Failure? 

- Fatigue

- ↑ JVP

- Pitting oedema

- Ascites

- Pleural effusion

- Dyspnoea

40

What is congestive (biventricular) heart failure?

Congestive heart failure is a chronic progressive condition in which the heart's function as a pump is inadequate to meet the body's needs

- Both the right and left sides of the heart fail to pump adequately, hence, the signs and symptoms of both right and left heart failure develop