Heart Failure Overview Quiz
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Questions and Answers

What is the hallmark of heart failure?

  • High diastolic pressure
  • Normal ventricular pressure
  • Increased cardiac output
  • Low cardiac output (correct)

Which of the following reflects a common symptom of left heart failure?

  • Liver congestion
  • Orthopnea (correct)
  • Increased jugular venous pressure
  • Pitting edema

What causes increased pulmonary capillary pressure in left heart failure?

  • Decreased right ventricular pressure
  • Increased left ventricular end-diastolic pressure (LVEDP) (correct)
  • Increased systemic vascular resistance
  • Decreased left atrial pressure

Which condition is most commonly associated with right heart failure?

<p>Chronic obstructive pulmonary disease (COPD) (B)</p> Signup and view all the answers

What physiologic change occurs when a person with impaired ventricle lies flat?

<p>Increased venous return to the heart (C)</p> Signup and view all the answers

Which symptom is typically not associated with left heart failure?

<p>Lower extremity edema (D)</p> Signup and view all the answers

What does high pressure in the right atrium indicate?

<p>Elevated central venous pressure (C)</p> Signup and view all the answers

What physiological phenomenon leads to dyspnea in patients with left heart failure?

<p>Decreased left ventricular compliance (C)</p> Signup and view all the answers

What is a significant reason for the reduction in the use of digoxin for heart failure treatment?

<p>Digoxin was found to have no mortality benefit. (A)</p> Signup and view all the answers

What is the primary mechanism by which digoxin increases cardiac contractility?

<p>Inhibiting the Na-K-ATPase pump. (C)</p> Signup and view all the answers

Which patient population can benefit from the use of digoxin in heart failure treatment?

<p>Patients with persistent symptoms despite maximal therapy on other drugs. (C)</p> Signup and view all the answers

Which of the following statements about digoxin side effects is true?

<p>Digoxin can lead to significant side effects in some patients. (A)</p> Signup and view all the answers

What is the main treatment approach for chronic diastolic heart failure based on current guidelines?

<p>Management of comorbid conditions like hypertension and diabetes. (C)</p> Signup and view all the answers

What is a classic lung finding in heart failure?

<p>Rales (C)</p> Signup and view all the answers

Which hormone counteracts the effects of the renin-angiotensin-aldosterone system (RAAS)?

<p>Atrial natriuretic peptide (ANP) (B)</p> Signup and view all the answers

What indicates forward heart failure symptoms?

<p>Cool extremities and confusion (B)</p> Signup and view all the answers

What is a common diagnostic tool for assessing heart failure severity?

<p>Echocardiogram (A)</p> Signup and view all the answers

What does an increased left ventricular end-diastolic pressure (LVEDP) indicate?

<p>Left heart congestion/failure (C)</p> Signup and view all the answers

In systolic heart failure, what happens to stroke volume?

<p>Decreases due to decreased contractility (D)</p> Signup and view all the answers

What is a distinguishing factor of diastolic heart failure compared to systolic heart failure?

<p>Normal ejection fraction (A)</p> Signup and view all the answers

Which of the following is associated with lower extremity pitting edema in heart failure?

<p>Increased capillary hydrostatic pressure (C)</p> Signup and view all the answers

During hepatojugular reflux, what is a normal response of jugular venous pressure (JVP)?

<p>Sustained rise of over 3 cm with pressure (B)</p> Signup and view all the answers

What characterizes concentric hypertrophy seen in diastolic heart failure?

<p>Stiffened ventricle walls (B)</p> Signup and view all the answers

What typically indicates a failing right ventricle?

<p>Elevated jugular venous pressure (C)</p> Signup and view all the answers

What is a significant effect of the activation of the sympathetic nervous system in heart failure?

<p>Increased vascular resistance (B)</p> Signup and view all the answers

What is the main role of brain natriuretic peptide (BNP) in heart failure diagnosis?

<p>Indicates volume overload (A)</p> Signup and view all the answers

What change occurs in total peripheral resistance with decreasing cardiac output?

<p>Increases due to vasoconstriction (B)</p> Signup and view all the answers

What is the primary mechanism of action of ACE inhibitors in heart failure management?

<p>Block the conversion of AI to AII (A)</p> Signup and view all the answers

Which of the following drugs is known to have a side effect of dry cough?

<p>Captopril (B)</p> Signup and view all the answers

Which common side effect is associated with potassium-sparing diuretics?

<p>Hyperkalemia (D)</p> Signup and view all the answers

Which of the following beta blockers is beneficial in treating chronic systolic heart failure?

<p>Carvedilol (D)</p> Signup and view all the answers

What is the effect of neprilysin inhibitors like Sacubitril?

<p>Promote vasodilation and natriuresis (A)</p> Signup and view all the answers

Which class of medications directly block angiotensin II receptors?

<p>Angiotensin receptor blockers (ARBs) (A)</p> Signup and view all the answers

What is the main role of beta blockers in systolic heart failure treatment?

<p>Reduce mortality and hospitalizations (C)</p> Signup and view all the answers

Which side effect is specifically noted for spironolactone?

<p>Gynecomastia (C)</p> Signup and view all the answers

What is a key effect of using an implantable cardiac defibrillator (ICD)?

<p>Reduce the risk of sudden cardiac death (B)</p> Signup and view all the answers

Which medication should not be given together with ACE inhibitors due to the risk of angioedema?

<p>Neprilysin inhibitors (C)</p> Signup and view all the answers

What effect does ivabradine have on heart rate?

<p>Decreases heart rate without affecting contractility (B)</p> Signup and view all the answers

What condition is NOT typically treated with specific drug therapy as per heart failure guidelines?

<p>Diastolic heart failure (A)</p> Signup and view all the answers

Which drug class is associated with the reduction of renal failure in chronic heart failure treatment?

<p>ACE inhibitors (D)</p> Signup and view all the answers

What is the defining characteristic of high output heart failure?

<p>High cardiac output (D)</p> Signup and view all the answers

Which condition is commonly associated with diastolic heart failure?

<p>Age (C)</p> Signup and view all the answers

What is a primary cause of systolic heart failure?

<p>Myocardial infarction (C)</p> Signup and view all the answers

What is the classic sign of restrictive heart disease?

<p>Increased jugular venous pressure (B)</p> Signup and view all the answers

What process initiates tachycardia-mediated cardiomyopathy?

<p>Prolonged rapid heart rate (A)</p> Signup and view all the answers

Which of the following statement is true regarding Fabry disease?

<p>It is caused by a deficiency of α-galactosidase A (D)</p> Signup and view all the answers

What is a major cause of restrictive cardiomyopathy linked to granulomas?

<p>Sarcoidosis (D)</p> Signup and view all the answers

What type of heart failure is categorized by heart failure with preserved ejection fraction?

<p>Diastolic heart failure (B)</p> Signup and view all the answers

Which symptom is most commonly associated with restrictive heart disease?

<p>Significant dyspnea (D)</p> Signup and view all the answers

What is the primary consequence of chronic alcohol consumption on the heart?

<p>Cardiomyopathy (C)</p> Signup and view all the answers

Which of the following is a potential consequence of tachycardia-mediated cardiomyopathy?

<p>Reversible heart function improvement (A)</p> Signup and view all the answers

Which heart failure type shows symptoms despite normal left ventricular function?

<p>Diastolic heart failure (D)</p> Signup and view all the answers

Which viral infection commonly leads to myocarditis?

<p>Coxsackie virus (D)</p> Signup and view all the answers

What hallmark of restrictive cardiomyopathy is indicated by Kussmaul's sign?

<p>Elevated JVP during inspiration (C)</p> Signup and view all the answers

What is the primary function of loop diuretics in treating acute heart failure?

<p>Inhibit Na-K-Cl pump for salt-water excretion (C)</p> Signup and view all the answers

Which of the following is a common cause of acute exacerbations of heart failure?

<p>Dietary indiscretion (A)</p> Signup and view all the answers

What is the main mechanism of action for nitrates in heart failure therapy?

<p>Venous dilation to reduce preload (D)</p> Signup and view all the answers

What notable side effect is associated with the use of furosemide?

<p>Hypokalemia (D)</p> Signup and view all the answers

Which inotropic agent is primarily a beta-1 agonist known for increasing heart rate and contractility?

<p>Dobutamine (C)</p> Signup and view all the answers

What is a significant risk associated with the routine use of inotropes in heart failure patients?

<p>Increased mortality (D)</p> Signup and view all the answers

What should post-discharge follow-up focus on to prevent readmission in heart failure patients?

<p>Medication adherence (D)</p> Signup and view all the answers

What is an important effect of metolazone when used in conjunction with loop diuretics?

<p>Provides a diuretic boost (A)</p> Signup and view all the answers

What distinguishes acute heart failure therapy from chronic heart failure therapy?

<p>Focus on symptom relief versus reduction in mortality (A)</p> Signup and view all the answers

Which class of drugs is primarily used for 'afterload reduction' in heart failure management?

<p>Vasodilators (B)</p> Signup and view all the answers

Which of the following best describes the effect of NSAIDs on heart failure?

<p>Increased salt and water retention (B)</p> Signup and view all the answers

What common symptom would likely lead to an ER presentation for a patient with acute heart failure?

<p>Dyspnea (B)</p> Signup and view all the answers

Which of the following agents is primarily a vasodilator that requires careful monitoring due to its potential for hypotension?

<p>Nitrates (C)</p> Signup and view all the answers

In a case of systolic heart failure, what is the expected outcome of using an inotrope?

<p>Increased heart rate and contractility (C)</p> Signup and view all the answers

Flashcards

What is heart failure?

A weakened heart muscle cannot pump blood effectively, leading to fluid buildup in the lungs and body. This typically results in shortness of breath, fatigue, and swelling.

What is diastolic heart failure?

Diastolic heart failure occurs when the heart is unable to relax and fill properly between heartbeats. This leads to inadequate blood flow to the body.

What is systolic heart failure?

Systolic heart failure occurs when the heart is unable to contract forcefully enough to pump blood effectively to the body. This can lead to fluid backup and various symptoms.

How does digoxin affect heart rate?

Digoxin can be used to slow heart rate in patients with rapid atrial fibrillation. It achieves this by suppressing the conduction of electrical signals through the atrioventricular (AV) node.

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What are the benefits of digoxin in heart failure?

Digoxin improves symptoms and quality of life in patients with systolic heart failure experiencing symptoms despite maximal doses of other medications.

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What is cardiac output?

A vital sign that directly reflects the heart's pumping efficiency. A low value indicates that the heart is not pumping enough blood.

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What is the main consequence of a failing heart chamber?

In heart failure, pressure within the heart chambers increases due to the struggling heart's inability to efficiently move blood.

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What is the hallmark of left heart failure?

A high pressure within the left ventricle (LV) is a strong indicator of left heart failure. It signifies that the LV is not effectively emptying, causing a buildup of pressure.

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How does left ventricular pressure impact the lungs?

Increased pressure within the left ventricle (LV) leads to increased pressure in the left atrium (LA), ultimately affecting the lungs.

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What's the consequence of increased pulmonary capillary pressure?

Elevated pulmonary capillary pressure causes fluid to leak into the lungs, leading to shortness of breath. This is a common symptom of heart failure.

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What is the common cause of right heart failure?

Right heart failure is often a consequence of left heart failure. The backflow from the left side of the heart puts extra strain on the right side, leading to increased pressures in the right heart chambers.

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What are the symptoms of right heart failure?

Right heart failure is characterized by increased pressure in the venous system. This leads to symptoms such as swollen ankles and neck veins.

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Diastolic Heart Failure

A type of heart failure characterized by the heart's inability to relax and fill properly, leading to decreased filling and reduced cardiac output.

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Ejection Fraction (EF)

The percentage of blood ejected from the left ventricle with each heartbeat. It is a measure of the heart's pumping efficiency.

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End Systolic Volume (ESV)

The amount of blood remaining in the left ventricle after each contraction.

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End Diastolic Volume (EDV)

The amount of blood in the left ventricle at the end of diastole (relaxation) before contraction.

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Stroke Volume (SV)

The amount of blood pumped out of the left ventricle with each heartbeat.

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Hypertrophic Cardiomyopathy

A type of cardiomyopathy characterized by thickening of the heart muscle, making it difficult for the heart to relax and fill properly.

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Myocarditis

A type of cardiomyopathy characterized by inflammation of the heart muscle, often caused by viral infections.

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Systolic Heart Failure

A type of heart failure characterized by the heart's inability to pump blood effectively, leading to reduced cardiac output.

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High Output Heart Failure

A condition where the heart pumps excessively, often due to underlying conditions like severe anemia or thyroid disease.

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Restrictive Cardiomyopathy

A rare type of cardiomyopathy characterized by stiffening of the heart muscle, making it difficult for the heart to fill with blood.

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Heart Failure with Preserved Ejection Fraction (HFpEF)

Refers to heart failure with a preserved ejection fraction, indicating that the heart's pumping function is normal, but its ability to relax and fill is impaired.

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Endocardial Fibroelastosis

A condition characterized by thickening of the endocardium, the inner lining of the heart, which can lead to restrictive cardiomyopathy.

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Hemochromatosis

A rare condition characterized by the accumulation of iron in the heart, potentially leading to restrictive cardiomyopathy.

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Amyloidosis

A type of cardiomyopathy caused by the accumulation of amyloid protein in the heart, which can cause restrictive cardiomyopathy.

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Sarcoidosis

A condition characterized by the formation of granulomas, small inflammatory nodules, in various organs, including the heart, which can lead to restrictive cardiomyopathy.

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Cor Pulmonale

A condition where the heart's right ventricle is weakened, leading to congestion in the body, often due to lung disease.

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Chronic

Characterized by symptoms that are present over a long period of time, typically three months or more.

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Forward Heart Failure

Reduced blood flow from the heart, leading to symptoms like fatigue, weight loss, and cool extremities.

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Acute

Characterized by symptoms that develop suddenly and are usually intense, often lasting less than three months.

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Acute Exacerbation

A sudden worsening of symptoms in a chronic condition, such as heart failure.

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Euvolemic

A state of balanced fluid volume in the body, where there is neither excess nor deficit.

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Rales

Fluid-filled alveoli (air sacs) in the lungs, often heard as crackling sounds when listening with a stethoscope.

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Dietary Indiscretion

The most common cause of acute exacerbations of heart failure, involving increased sodium intake.

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Edema

A condition where excess fluid builds up in the tissues, causing swelling.

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Heart Failure Cells

Iron-laden macrophages found in the lungs, indicating chronic heart failure.

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Pitting Edema

Edema that leaves a pit when pressed, indicating fluid retention.

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Elevated Jugular Venous Pressure (JVP)

The pressure in the jugular vein, normally 6-8 cmH2O, is elevated in heart failure, indicating congestion.

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Hepatojugular Reflux

An increase in JVP when pressure is applied to the abdomen, indicating a weakened right ventricle.

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ADH (Antidiuretic Hormone)

A hormone that helps to regulate fluid balance by controlling water reabsorption in the kidneys.

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Pitting Edema

Fluid accumulation in the lower legs due to increased capillary pressure, a common symptom of heart failure.

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RAAS (Renin-Angiotensin-Aldosterone System)

A group of hormones that regulate blood pressure and fluid balance, including renin, angiotensin, and aldosterone.

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Loop Diuretics

A class of drugs that block the reabsorption of sodium, chloride, and potassium in the kidneys, leading to increased urine output.

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S3 Heart Sound

A heart sound heard during early diastole, indicating high pressure in the left atrium.

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Nitrates

A medication that dilates blood vessels, reducing the workload on the heart.

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S4 Heart Sound

A heart sound heard during late diastole, indicating a stiff left ventricle.

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Vasodilators

A class of drugs that dilate blood vessels, reducing the resistance that the heart has to pump against.

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Contractility

The heart's ability to contract and pump blood effectively during systole.

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Lusitropy

The heart's ability to relax and fill with blood during diastole.

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Inotropes

Medications that increase the force of the heart's contractions, making it pump more efficiently.

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Beta-1 agonists

A class of drugs that increase the heart rate and contractility, which are often used to treat heart failure.

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Ventricular Compliance

The ability of the ventricle to stretch and fill with blood.

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Heart Failure Readmission

A common complication of heart failure that can occur after discharge from the hospital.

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What are the two major physiological systems that are chronically overactive in systolic heart failure? What are the benefits of blocking these systems?

The renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system are chronically overactive in systolic heart failure. Blocking these systems leads to improved survival and reduced disease progression.

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How do ACE inhibitors and ARBs differ in their mechanism of action?

ACE inhibitors block the conversion of angiotensin I to angiotensin II, while ARBs directly block angiotensin II receptors.

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What is the clinical benefit of using ACE inhibitors and ARBs in systolic heart failure?

Both ACE inhibitors and ARBs reduce mortality and hospitalizations in systolic heart failure.

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How do ACE inhibitors lead to a dry cough and angioedema?

Bradykinin is a vasodilator that is normally broken down by ACE. ACE inhibitors prevent this breakdown, leading to increased bradykinin levels.

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How have the roles of beta blockers changed in the management of systolic heart failure?

Beta blockers were once contraindicated in systolic heart failure due to their negative inotropic effects. However, three agents (metoprolol, carvedilol, and bisoprolol) have been shown to improve survival and reduce hospitalization rates.

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How do aldosterone antagonists work and what is a common side effect?

Aldosterone antagonists, such as spironolactone and eplerenone, block the effects of aldosterone, leading to increased sodium and water excretion and potassium sparing. They can cause hyperkalemia.

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What are the potential side effects of spironolactone and eplerenone related to their structure?

Spironolactone and eplerenone are similar in structure to testosterone and progesterone. This can lead to gynecomastia in men and amenorrhea in women with spironolactone.

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How do neprilysin inhibitors work and what are their effects on the RAAS system?

Neprilysin inhibitors, such as sacubitril, block the breakdown of ANP and BNP. This leads to vasodilation, natriuresis, diuresis, and reduced sympathetic tone, counteracting the effects of RAAS.

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What is Entresto and how does it benefit patients with systolic heart failure?

Entresto is a combination of sacubitril and valsartan, which blocks the angiotensin II receptor. This therapy has been shown to improve survival and reduce hospitalizations.

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What is ivabradine and what is its role in the treatment of systolic heart failure?

Ivabradine selectively inhibits the sinus node, slowing heart rate without affecting contractility. It is used in patients with elevated heart rate despite maximal beta blocker therapy.

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What are the main drug classes used in the treatment of chronic systolic heart failure?

The mainstay of treatment for chronic systolic heart failure involves medications like ACE inhibitors/ARBs, beta blockers, aldosterone antagonists, neprilysin inhibitors, and ivabradine.

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What is the role of an ICD in the management of systolic heart failure?

An implantable cardiac defibrillator (ICD) is a device that delivers electrical shocks to terminate life-threatening ventricular arrhythmias.

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What are the risks and benefits of ICD implantation?

The implantation of an ICD carries risks such as bleeding, infection, and inappropriate shocks. Nevertheless, ICDs can improve mortality in appropriate patients.

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What is biventricular pacing and how does it work?

Biventricular pacing, or cardiac resynchronization therapy (CRT), involves pacing both ventricles to improve cardiac function and reduce symptoms.

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How does the treatment pathway for heart failure differ based on its nature?

The treatment pathway for heart failure depends on whether it is acute or chronic, and whether it is diastolic or systolic.

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Study Notes

Heart Failure Basics

  • Heart failure is an impaired ability of the heart to pump blood effectively, resulting in low cardiac output (CO).
  • A visual analogy depicts the heart as a pump, and the body's circulation as the flow of water from a tank.
  • Left ventricular failure leads to increased left ventricular pressure (LV pressure).
  • LVEDP (left ventricular end-diastolic pressure) is always high in left heart failure.
  • A hallmark of left heart failure is less blood pumped out, with more blood left behind in the heart.
  • A stiff ventricle (diastolic HF) leads to high pressure.
  • Increased LVEDP leads to increased left atrial pressure and increased pulmonary capillary pressure.
  • Increased pulmonary capillary pressure leads to dyspnea and pulmonary edema.
  • Increased right heart pressures lead to high pressure in the venous system.
  • High jugular venous pressure (neck veins) is a sign.
  • Capillary leakage leads to pitting edema.

Heart Failure Pathophysiology

  • Failing chambers lead to increased pressures in the cardiac chambers.
  • Left ventricular failure leads to increased LV pressure.
  • LV systolic pressure depends on contractility (can be low).
  • LVEDP is always high in left heart failure.
  • Less blood pumped out, more left behind.
  • Stiff ventricle (diastolic HF)→high pressure.

Heart Failure Pathophysiology: Pulmonary Systems

  • Increased LVEDP → increased LA pressure.
  • Increased LA pressure → increased pulmonary capillary pressure.
  • Increased pulmonary capillary pressure leads to dyspnea and pulmonary edema.
  • Increased pressure in the pulmonary artery (PA) leads to increased right ventricular (RV) pressure.
  • Increased RV pressure → increased right atrial (RA) pressure.
  • Right atrial pressure is equal to central venous pressure.

Heart Failure Signs/Symptoms

  • Physiological effects of lying flat (supine): Increased venous return, redistribution of blood volume from extremities and splanchnic beds to the lungs, and worsened pulmonary congestion and breathing.
  • Left heart failure: Dyspnea especially on exertion. Paroxysmal nocturnal dyspnea (wake up SOB), Orthopnea (can't breathe lying flat).
  • Right heart failure: Increased jugular venous pressure. Lower extremity edema, Liver congestion (rarely can cause cirrhosis), "Backward failure"

Heart Failure Right Heart Failure

  • The most common cause of right-heart failure is left heart failure.
  • Right heart failure can occasionally occur in isolation (not related to left heart failure).
  • High pressure in the pulmonary artery, right ventricle, and right atrium usually occur secondary to a lung process.
  • Pulmonary hypertension and COPD often lead to this type of failure.

Heart Failure Signs/Symptoms: Low Flow

  • Low flow signs/symptoms ("forward failure"): Loss of appetite, weight loss (cachexia), confusion (mental status changes), cool extremities, and narrow pulse pressure.
  • Narrow pulse pressure is only seen in systolic heart failure

Heart Failure Lung Findings

  • Classic finding in heart failure is rales (crackles).
  • Fluid-filled alveoli "pop" open with inspiration.
  • Chest X-ray shows congestion, although this may not be apparent in chronic heart failure.

Heart Failure Lung Findings (Cellular Level)

  • Heart failure cells, hemosiderin (iron) laden macrophages, and brown pigment are found in macrophages (specialized immune cells).

Heart Failure Signs/Symptoms (Jugular Venous Pressure)

  • Elevated jugular venous pressure (normal 6-8 cm H2O) is a key symptom.
  • Look for height of double bounce (caused by a and v waves).

Heart Failure Hepatojugular Reflux

  • Pressure on the abdomen raises JVP 1-3 cm normally.
  • The increase is greater in people with failing right ventricle(RV).

Heart Failure Signs/Symptoms (Edema)

  • Lower extremity pitting edema.
  • Increased capillary hydrostatic pressure.
  • Fluid leak from capillaries to tissues

Heart Failure Abnormal Heart Sounds

  • S3 (associated with high left atrial pressure).
  • S4 (associated with stiff left ventricle).
  • Displaced apical impulse indicates an enlarged heart.

Heart Failure Pathophysiology (Systemic Response)

-All forms of heart failure cause a decrease in cardiac output.

  • Activation of the sympathetic nervous system results.
  • Activation of the renin-angiotensin-aldosterone system occurs.
  • Both systems work together to lead to increased peripheral vascular resistance and sodium and water retention.

Heart Failure Total Peripheral Resistance

  • Cardiac output decreases, leading to vasoconstriction.
  • Angiotensin II and the sympathetic nervous system cause this to happen, leading to a higher total peripheral resistance (TPR).
  • . Blood pressure is often high but can be low.

Heart Failure Sodium/Water Retention

  • Decreased cardiac output → decreased effective circulating blood volume.
  • This stimulates the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS), triggering anti-diuretic hormone (ADH) release to increase sodium/water retention.

Heart Failure Other Hormones (ANP)

  • Atrial natriuretic peptide (ANP) is released in response to atrial stretch.
  • ANP is a vasodilator and promotes increased diuresis, which counteracts the effects of the RAAS system.

Heart Failure Other Hormones (BNP)

  • Brain natriuretic peptide (BNP) is released by ventricles from volume and pressure overload.
  • BNP helps to counteract RAAS and provide a diagnosis for heart failure. High levels suggest heart failure, while low levels suggest something else.

Nesiritide

  • Recombinant BNP.
  • Causes vasodilation.
  • Lowers afterload and increases CO.
  • Failed to improve efficacy in clinical trials

Heart Failure Diagnosis

  • Most commonly, diagnosis is based on typical signs, symptoms and elevated BNP level.
  • Heart catheterization is used for specific diagnostic measurement.
  • Increased LVEDP suggests left heart congestion/failure.
  • Increased RA/RVEDP suggest right heart congestion/failure

Systolic and Diastolic Heart Failure

  • Ejection fraction is reduced (systolic).
  • Ejection fraction is normal (55-65%) (diastolic).

Systolic vs. Diastolic Heart Failure (Signs and Symptoms)

  • Both have similar congestive signs and symptoms (dyspnea, orthopnea, paroxysmal nocturnal dyspnea, rales, ↑ JVP, pitting edema)
  • The exception is systolic heart failure exhibits low flow symptoms, including cool extremities, cachexia and confusion.

Dilated Cardiomyopathy

  • Systolic heart failure with LV cavity dilation.
  • Volume overload (chronic retention of fluid in cavity)
  • Increased myocyte size and sarcomere lengths in series.
  • Normal wall thickness.

Concentric Hypertrophy

  • Pressure overload in the ventricle.
  • Chronic hypertension, or aortic stenosis
  • Causes a decrease in compliance (stiff ventricle).
  • Increased myocyte size and sarcomere increase in parallel resulting in thickness of walls

Systolic Heart Failure (Problem/Mechanism)

  • Problem is in systole (contraction) - The heart cannot effectively pump blood out.
  • Ejection fraction is low
  • Stroke volume is decreased.
  • Increased end-systolic volume.
  • End-diastolic volume is increased.
  • Left ventricular end-diastolic pressure (LVEDP) is increased.

Diastolic Heart Failure (Problem/Mechanism)

  • Problem is in diastole (filling).
  • The heart cannot effectively fill with blood
  • EDV is decreased.
  • LVEDP is elevated (due to ventricular stiffness).

Systolic vs. Diastolic Heart Failure (Values)

  • The table shows normal, systolic/dilated, and diastolic values for EDV, ESV, SV/CO, and EF%.

Systolic Heart Failure (Causes)

  • Myocardial infarction (MI) is the most common cause.
  • Ischemic cardiomyopathy and many non-ischemic cardiomyopathies are also causes.

Diastolic Heart Failure (Causes)

  • The exact cause is unknown, however, concentric hypertrophy, age, diabetes & hypertension are common associated conditions.

Nonischemic Cardiomyopathy (Viral)

  • May follow an upper respiratory infection, and often associated with viruses (including Coxsackie).
  • Virus enters myocytes and causes myocarditis that can progress to cardiomyopathy.
  • Myocarditis phase is often missed/undiagnosed.

Nonischemic Cardiomyopathy (Peri-partum)

  • Late in pregnancy and early post-pregnancy.
  • Exact cause is unknown, but likely multifactorial.

Nonischemic Cardiomyopathy (Chemotherapy)

  • Usually comes from anthracycline chemotherapy.
  • Antitumor antibiotics Doxorubicin and Daunorubicin can cause it.

Nonischemic Cardiomyopathy (Familial)

  • Mutations in sarcomere proteins (including Beta and Alpha myosin heavy chain, and Troponin)
  • Many are autosomal dominant, some are x-linked or autosomal recessive.

Nonischemic Cardiomyopathy (Tachycardia-mediated)

  • Constant, rapid heart rate for weeks or months.
  • Causes a decrease in LV systolic function.
  • Usually reversible with slowing the heart rate

Nonischemic Cardiomyopathy (Takotsubo/Apical Ballooning)

  • Stress-induced cardiomyopathy occurs after sever emotional distress.
  • Leads to a markedly reduced left ventricular ejection fraction (LVEF).
  • It presents as increased CK, MB, Troponin, and EKG changes.
  • Looks like anterior myocardial infarction (MI), but no coronary disease.

Nonischemic Cardiomyopathy (Alcohol)

  • Chronic alcohol consumption can cause cardiomyopathy.
  • It's thought to be due to toxic metabolites.
  • It can sometimes reverse with cessation.

High Output Heart Failure

  • Heart is in overdrive.
  • Causes include severe anemia, thyroid disease, thiamine deficiency (beriberi), and arteriovenous (AV) Fistulas.
  • Exact mechanism is unclear.
  • Defining characteristic is a high cardiac output.
  • It can present as high JVP, and pulmonary edema.

Restrictive Cardiomyopathy

  • Something infiltrates the myocardium.
  • Granulomas (sarcoid) and amyloid protein (amyloidosis) are infiltrators.
  • Heart cannot relax and fill effectively.
  • Severe diastolic dysfunction, with LVEF being normal.

Restrictive Heart Disease (Clinical Features)

  • Dyspnea (shortness of breath).
  • Prominent right heart failure signs (elevated jugular venous pressure (JVP), lower extremity edema, liver congestion; possibly leading to cirrhosis).

Restrictive Heart Disease (Classic Signs)

  • Kussmaul's sign: Inspiration causes a rise in jugular venous pressure (JVP).

Restrictive Heart Disease (Rhythm Disturbances)

  • Myocardial infiltration can disrupt electrical activity.
  • Arrhythmias (including sudden death risk).
  • Atrioventricular (AV) block.

Restrictive Heart Disease (Major Causes: Amyloidosis)

  • Amyloid protein deposits in the heart.
  • Various forms of amyloidosis include primary, and secondary.

Restrictive Heart Disease (Classic Signs: EKG)

  • Thickened myocardium can be visualized.
  • Low-voltage on EKG may appear in cases of amyloidosis and Fabry's disease.

Restrictive Heart Disease (Major Causes: Sarcoidosis)

  • Granuloma formation often observed in the lungs, but can affect other extra-pulmonary organs, including the heart.

Restrictive Heart Disease (Major Causes: Fabry Disease)

  • Lysosomal storage disease with deficiency of alpha-galatosidase A leads to ceramide trihexoside accumulation.

Restrictive Heart Disease (Major Causes: Hemochromatosis)

  • Iron excess commonly causing dilated cardiomyopathy.
  • Can rarely lead to restrictive cardiomyopathy.

Restrictive Heart Disease (Major Causes: Post-Radiation)

  • Acute inflammation/Fibroblast recruitment may occur from radiation.
  • Accumulation of collagen and fibronectin may occur.

Restrictive Heart Disease (Major Causes: Other Causes)

  • Pericarditis, pericardial disease, coronary artery disease, valvular disease, conduction abnormalities, or restrictive cardiomyopathy can all cause long-term effects.

Restrictive Heart Disease (Major Causes: Eosinophilic Infiltrations)

  • Eosinophils may infiltrate myocardium, often with acute episodes/myocarditis (often asymptomatic.)
  • Chronic phase often consists of endomyocardial fibrosis and myocyte death.
  • Thrombus formation is common (embolic stroke risk).

Restrictive Heart Disease (Major Causes: Endocardial Fibroelastosis)

  • Endocardial thickening (innermost myocardium) is seen in infants during their first year.
  • Proliferation of fibrous (collagen) and elastic fibers.

Acute Heart Failure

  • Congestion / Swollen
  • Pulmonary Edema
  • Pitting Edema
  • Increased Jugular Vein Pressure (JVP)

Acute Heart Failure (Causes of Exacerbation)

  • Dietary indiscretion and high salt intake.
  • Poor medication compliance.
  • Infection, trauma or surgery.

Acute Heart Failure Treatment

  • Primarily focus on symptom relief in hospitalized setting.
  • Contrast with chronic treatment focus on lowering mortality/hospitalizations and preventing further progression.
  • Treat with same type of therapies whether diastolic or systolic based HF.

Loop Diuretics

  • Inhibit Na-K-Cl pump in the ascending loop of Henle.
  • Increase salt and water excretion, which eases congestion.
  • IV form is better in cases of GI distress.
  • Common side effects include hypokalemia and volume depletion.

Thiazide-like Diuretic (Metolazone)

  • Thiazide-like diuretic.
  • Inhibits Na/Cl reabsorption in the distal tubule.
  • A "kick" for loop diuretics to increase diuresis.
  • Other side effects include additional fluid and K+ loss.

Nitrates

  • Predominant mechanism is venous dilation.
  • Expanding veins hold more blood in a way that shifts blood away from the left ventricle.
  • Leads to lower LVEDV (preload) and LA pressure.
  • Reduces pulmonary edema and improves dyspnea (difficulty breathing).

Nitrates (Side Effects)

  • Side effects include headache (from increased blood vessel dilation), flushing, and hypotension.

Vasodilators

  • Generally aim to reduce afterload and improve cardiac output.
  • ACE inhibitors and hydralazine classically used.

Nitrates plus Hydralazine

  • Combination therapy used in acute and chronic HF.
  • The combination therapy reduces preload (nitrates) and afterload (hydralazine).
  • Improves symptoms in acute cases and improves mortality in others.

Inotropes

  • Increase contractility, but only used in systolic heart failure.
  • Inotropes will NOT work for diastolic HF when contractility is normal.
  • Inotropes work by activating beta-1 pathways.
  • Some increase heart rate and contractility in smooth muscle.
  • May cause vasodilation leading to hypotension

Inotropes (Milrinone)

  • Phosphodiesterase 3 inhibitor.
  • Breaks down cAMP.
  • Inhibits PD3, which increases cAMP, and contributes to increased inotropy and vasodilation.
  • Side effect: hypotension.

Inotropes (Dobutamine)

  • Mostly beta-1 agonist.
  • Increases heart rate and contractility.
  • Weak beta-2 agonist means vasodilation.
  • Side effect: hypotension.

Inotropes (Dopamine)

  • Does not cross the blood-brain barrier, so few CNS side effects.
  • Low dose is a dopamine agonist, leading to some vasodilation in kidneys.
  • Medium dose is a beta-1 agonist, increasing heart rate and contractility.
  • High dose is an alpha agonist causing vasoconstriction.

Inotropes (Epinephrine)

  • Also dose-dependent effects.
  • Low dose is both beta-1 and beta-2 agonist, increasing heart rate, contractility and vasodilation.
  • High dose is an alpha agonist, increasing vasoconstriction.

Inotrope Risks

  • Inotrope use may increase mortality.
  • Inotropes are used in very sick patients and closely monitored.

Typical Acute Heart Failure Course

  • ER presentation (initiation of heart failure symptoms).
  • Hospitalized with symptom management (including symptom relief with Lasix, nitroglycerine, and/or inotropes
  • Symptoms improving → transition to oral medication

More Complex Acute Heart Failure Course

  • ER presentation (with known LVEF and other presenting complications).
  • Hospitalization, symptom management and improving symptoms.

Heart Failure Readmission

  • Recurrence is common following discharge from medical care due to heart failure.
  • Post-discharge follow-up is important and critical.

Chronic Heart Failure

  • Most patients need chronic therapy with diuretics (such as oral furosemide).
  • Some need long acting nitrates, in addition to the diuretics.
  • The choice of therapies depends on whether it is systolic or diastolic dysfunction.

Chronic Systolic Heart Failure Therapies

  • ACE inhibitors or ARBs, beta-blockers, aldosterone antagonists, neprilysin inhibitors, and ivabradine are effective therapies.

Implantable Cardioverter-Defibrillator (ICD)

  • Used to reduce annual SCD Risk, often due to ventricular tachycardia.

Biventricular Pacemakers

  • Cardiac Resynchronization Therapy (CRT) is used to improve heart function and coordination, often with better response/results after CRT

Chronic Heart Failure Treatment Pathway

  • Acute heart failure receives RX for symptom management.
  • For chronic heart failure, appropriate treatment pathways for diastolic and systolic failure exist.

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Test your knowledge on heart failure with this comprehensive quiz. Explore topics such as symptoms, treatments, and physiological changes associated with left and right heart failure. Perfect for medical students and healthcare professionals alike.

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