Cardiovascular System and Heart Failure Quiz

Cardiovascular System

• The cardiovascular system comprises four chambers (two atria and two ventricles), separated by four valves.
• The right side valves are the tricuspid valve (between right atrium and right ventricle) and the pulmonary valve (between right ventricle and pulmonary artery).
• The left side valves are the mitral valve (between left atrium and left ventricle) and the aortic valve (between left ventricle and aorta).
• The left ventricle is thicker (10mm) than the right ventricle (3mm).
• Left ventricular pressure is four times greater than right ventricular pressure.
• Stroke volume (SV) is the amount of blood ejected by the ventricles in each heartbeat.
• Cardiac output (COP) is the amount of blood ejected per minute.
• Ejection fraction (EF) is the percentage of blood ejected by the ventricles, typically greater than 55%.

Heart Failure (HF)

• Heart failure is a clinical syndrome where the heart cannot maintain adequate cardiac output to meet the body's needs.
• It affects approximately 10% of people over 75.
• Venous return (preload) increases cardiac output, while arterial resistance (afterload) decreases cardiac output.
• Myocardial contractility increases cardiac output.
• Heart failure is often associated with neurohormonal activation.
• This activation can lead to deterioration of heart function.

Classification of Heart Failure

• Right-side heart failure
• Left-side heart failure
• Congestive heart failure
• High cardiac output heart failure
• Low cardiac output heart failure
• Systolic heart failure
• Diastolic heart failure

Classification of Heart Failure According to Onset of Clinical Pictures

• Acute heart failure
• Chronic heart failure
• Acute on top of chronic heart failure

New York Heart Association (NYHA) Classification of Heart Failure

• Class I: No limitation of physical activity
• Class II: Slight limitation of physical activity
• Class III: Marked limitation of physical activity
• Class IV: Symptoms occur even at rest; discomfort with any physical activity

Heart Failure Symptoms and Signs

• Right Side Heart Failure Symptoms: Hypochondrial pain, jaundice (cardiac cirrhosis), abdominal distension, dyspepsia, malabsorption, weight loss (cardiac cachexia), bilateral lower limb edema, generalized edema.
• Left Side Heart Failure Symptoms: Dyspnea, Orthopnea, paroxysmal nocturnal dyspnea (PND), cough & wheeze (cardiac asthma), dizziness, fatigue, weakness, chest pain, palpitation, syncope, cold periphery, oliguria, insomnia, headache, intermittent claudication.
• Right Side Heart Failure Signs: Raised jugular venous pressure (↑JVP), right hypochondrial tenderness with jaundice, ascites & hepatomegaly, bilateral lower limb edema / sacral edema, generalized edema.
• Left Side Heart Failure Signs: Gallop rhythm, bilateral basal crackles of lungs, pleural effusion, pallor, cold periphery, sweating, tachycardia, low blood pressure, oliguria, confusion, and memory impairment.

Heart Failure Risk Factors and Precipitating Factors

• Failure to take medications
• Hypertension
• Endocarditis
• Infections
• Drugs (verapamil, diltiazim, NSAIDS, steroids & IV fluid)
• Anemia
• Alcohol
• Endocrine problems (pheochromocytoma)

Acute Pulmonary Edema

• Pathophysiology: Sudden left ventricular failure leads to increased left ventricular pressure, which raises pressure in the left atrium and pulmonary capillaries causing pulmonary congestion, fluid movement to the alveoli and interstitium resulting in edema.
• Symptoms: Dyspnea, cough with frothy sputum, orthopnea, paroxysmal nocturnal dyspnea (PND), wheezing, hemoptysis.
• Signs: Agitation, pale periphery and central cyanosis, hypotension, bilateral basal crackles, raised jugular venous pressure (JVP).

Investigations for Acute Pulmonary Edema

• Chest X-ray
• Echocardiography
• Cardiac enzymes
• Arterial blood gas

Systemic Hypertension (HTN)

• It is a condition of chronically elevated blood pressure (≥139/89 mm Hg).
• Primary hypertension (essential HTN) accounts for 95% of cases and has unknown causes, potentially involving genetic factors and lifestyle issues.
• Secondary hypertension accounts for 5% of cases and results from identifiable underlying causes, such as renal artery stenosis and endocrine disorders.
• Target organs include blood vessels, heart, nervous system, kidneys, and retina.

Atherosclerosis

• It's an inflammatory disease of arterial walls characterized by lipid deposits (atheroma), potentially leading to partial or complete artery blockage.
• Risk factors include age, gender (males), smoking, diabetes mellitus, hypertension, elevated cholesterol, obesity, and a sedentary lifestyle.

Ischemic Heart Diseases (IHD)

• Stable angina (angina pectoris): chest pain caused by transient myocardial ischemia during exertion.
• Unstable angina: chest pain present at rest or with minimal exertion.
• Myocardial infarction (MI): irreversible myocardial damage due to prolonged ischemia.

Stable Angina (Angina Pectoris)

• Angina pectoris is chest pain due to transient myocardial ischemia, usually triggered by physical exertion or stress.
• It is often relieved by rest or nitroglycerin.
• Investigations involve stress ECG, CT coronary angiography, and possible echocardiography/myocardial perfusion scan.
• Treatment includes lifestyle modifications, nitrates, beta-blockers, and calcium channel blockers.

Unstable Angina and Non-ST Elevation Myocardial Infarction (NSTEMI)

• Unstable angina is chest pain due to transient myocardial ischemia that is often unpredictable and can occur at rest or with minimal exertion.
• If prolonged, myocardial damage occurs, resulting in NSTEMI.

Full Thickness Myocardial Infarction (STEMI)

• STEMI is characterized by prolonged ischemia and permanent damage to the myocardium, usually caused by a complete coronary artery blockage.
• Symptoms include persistent chest pain, shortness of breath, nausea, sweating, and possible shock.
• Investigations involve ECG with ST elevation, cardiac enzymes, and echocardiography.
• Treatment involves immediate reperfusion therapy (PCI or thrombolytic therapy) to restore blood flow to the affected area.

Acute Rheumatic Fever

• Acute rheumatic fever is an inflammatory disease that occurs after a streptococcal infection, typically pharyngitis or tonsillitis.
• Systemic manifestation includes polyarthritis, chorea, erythema marginatum, and subcutaneous nodules, predominantly in the young.
• It also affects the heart: pericarditis, myocarditis, endocarditis.
• Treatment involves antibiotics (penicillin) to eliminate any residual streptococcal infection and anti-inflammatory therapies like salicylates (aspirin).

Infective Endocarditis (IE)

• IE is an infection of the endocardium and/or heart valves, often due to bacterial or fungal colonization of damaged heart tissue, typically following a procedure creating a site for organism growth and potentially causing valve destruction or abscess formation.
• Causative organisms include streptococci and staphylococci (most common).
• Symptoms include fever, malaise, fatigue, and possible signs of systemic embolism (stroke, kidney damage).
• Diagnostics involve blood cultures, echocardiography and cardiac catheterization.
• Treatment involves long-term, high-dose antibiotic therapy, while surgery may be required.

Cardiomyopathies

• Includes hypertrophic, dilated, and restrictive cardiomyopathies, characterized by specific alterations in cardiac structure and function affecting stroke volume and output.

Acute Pericarditis

• Inflammation of the pericardium, often viral in origin, causing chest pain that worsens with deep breathing and lying down.

Pericardial Tamponade

• Accumulation of fluid within the pericardium under pressure, limiting cardiac filling.
• Symptoms include hypotension, distended jugular veins, and muffled heart sounds.
• Interventions involve pericardiocentesis (fluid aspiration).

Chronic Constrictive Pericarditis

• Progressive thickening and fibrosis of the pericardium limiting cardiac filling.
• Features include signs of right-sided heart failure, such as an enlarged liver, peripheral pitting edema, venous congestion and jugular venous distention (JVD).

Atrial Fibrillation (AF)

• AF is a rapid, irregular heartbeat originating in the atria, characterized by a lack of coordinated atrial contraction leading to inefficient blood flow.
• Associated with various underlying triggers, including hypertension, heart valve disease, and hyperthyroidism.
• Risk factors include older age, hypertension, coronary artery disease, and other heart conditions.

Supraventricular Tachycardia (SVT)

• SVT is a rapid heart rate originating above the ventricles, characterized by a narrow QRS complex on ECG.
• Common types include AV nodal reentrant tachycardia (AVNRT) and AV reentrant tachycardia (AVRT).
• Treatment involves slowing the heart rate with medication (e.g., adenosine) or interventions like cardioversion.

Ventricular Arrhythmias

• Ventricular ectopic beats are extra heartbeats that originate in the ventricles.
• Ventricular tachycardia (VT) is rapid and regular ventricular rhythm typically requiring intervention.
• Ventricular fibrillation (VF) is rapid and irregular ventricular rhythm, requiring immediate cardioversion.
• Causes include ischemia, heart failure, and cardiomyopathy.

Heart Block (HB)

• Conduction problems in the AV node or bundle branches.
• Includes first degree heart block, second degree heart block Mobitz type 1 and 2, and third degree heart block.