Heart Failure Notes PDF

NOTES NOTES HEART FAILURE GENERALLY, WHAT IS IT? ▪ Normal preload, ↓ contractility (inotropy; PATHOLOGY & CAUSES...

NOTES NOTES HEART FAILURE GENERALLY, WHAT IS IT? ▪ Normal preload, ↓ contractility (inotropy; PATHOLOGY & CAUSES force of contraction) → inadequate emptying of ventricles during systole → ▪ A complex clinical syndrome characterized ↓ EF ≤ 40 (HFrEF); often also have some by the heart’s inability to effectively fill and/ degree of diastolic dysfunction or eject (pump) blood ▪ Stroke volume (SV): volume (mL) of blood HF with preserved ejection fraction pumped by heart per contraction (HFpEF) ▪ Cardiac output (CO): volume of blood ▪ Diastolic HF; “filling dysfunction” pumped by heart per minute (L/min) ▪ Causes: restrictive cardiomyopathy (e.g. ▫ CO = SV X heart rate amyloidosis, sarcoidosis), valve disease, hypertension ▪ Preload: amount of blood in left ventricle before contraction ▪ Ventricles noncompliant and unable to fill during diastole → ↑ filling pressures ↓ ▪ Afterload: stress on the ventricular wall preload, normal contractility → ↓ SV → during systole preserved EF ≥ 50 (HFpEF) ▫ ↑ systemic resistance, ↑ blood viscosity, aortic valve stenosis, ventricular dilation → ↑ afterload TYPES ▪ Inotropy: cardiac contractility ▪ Biventricular heart failure ▪ Ejection fraction (EF): % of blood leaving ▫ Left, right failure; systolic/diastolic heart during each contraction ▪ Cor pulmonale ▫ Heart failure secondary to any cause of ▫E= ( stroke volume end diastolic volume ) x100 pulmonary arterial hypertension ▪ Left-sided heart failure ▫ Impaired ability of the left ventricle ▪ Frank–Starling mechanism: loading to maintain adequate cardiac output ventricle with blood during diastole, without an increase in left-sided filling stretching out cardiac muscles → more pressures forceful contraction; ↑ SV during systole ▪ Right-sided heart failure Heart failure (HF) with reduced ejection ▫ Impaired ability of the right ventricle to fraction (HFrEF) deliver of blood flow to the pulmonary ▪ Systolic HF; “pump dysfunction” circulation and ↑ right atrial pressure ▪ Causes: ↓ contractility/force of contraction ▪ Classification based on structure and (e.g. myocardial infarction, myocarditis), symptoms ↓ blood supply to the heart (e.g. ▫ ACC/AHA HF Stages, NYHA Classes coronary artery disease), ↑ afterload (see table) (e.g. hypertension), impaired mechanical function (e.g. valve disease) OSMOSIS.ORG 55  RISK FACTORS ▪ Arrhythmias ▪ Cardiac disorders: ischemic heart disease, ▪ End organ damage: due to lack of perfusion valvular heart disease, hypertension, LV ▪ Liver damage (congestive hepatopathy) hypertrophy, peripartum cardiomyopathy, ▪ Exacerbation myocarditis, congenital heart disease, ▫ See mnemonic chronic tachyarrhythmias ▫ Certain drugs may exacerbate HF; ▪ Other chronic diseases: hypertension, e.g. NSAIDs, excessive doses of beta diabetes, obesity, chronic lung disease, blockers, calcium channel blockers, infiltrative diseases (e.g. amyloidosis) cyclophosphamide ▪ Toxins: cigarette smoking, ethanol, cardiotoxic medications (e.g. doxorubicin, amphotericin B); illicit drugs (e.g. MNEMONIC: FAILURE amphetamines, cocaine) Exacerbation of Heart failure ▪ High-output states: thyrotoxicosis, anemia Forgot medication ▪ ↑ age Arrhythmia/Anemia Ischemia/Infarction/Infection COMPLICATIONS Lifestyle (e.g. too much salt) ▪ Cardiogenic shock Upregulation of CO (e.g. ▪ Biventricular heart failure pregnancy, hyperthyroidism) ▫ Left/right-sided HF precursor/ Renal failure complication of each other Embolism (e.g. pulmonary) 56 OSMOSIS.ORG  Chapter 9 Heart Failure OTHER DIAGNOSTICS SIGNS & SYMPTOMS ▪ History and physical examination identifying characteristic symptoms, ▪ High filling pressures: pulmonary edema, evidence of fluid retention and/or dyspnea, orthopnea, exercise intolerance, hypoperfusion and functional impairment paroxysmal nocturnal dyspnea (PND), due to cardiac dysfunction basilar crackles, tachypnea, jugular venous distention (JVD), hypoxemia, fatigue, ECG peripheral edema, hepatomegaly, S3 ▪ Identifies contributing rhythm disturbances ▪ Low cardiac output: tachycardia, hypotension, cool extremities, ↓ pulse pressure, ↓ urine output, ↓ appetite DIAGNOSIS DIAGNOSTIC IMAGING Chest X-ray ▪ Detects cardiomegaly, chamber and vessel enlargement, pulmonary congestion, presence of pericardial and pleural effusions Doppler echocardiography ▪ Evaluates hemodynamics related to in valvular and biventricular function Right heart (pulmonary artery) catheter- ization TREATMENT ▪ Measures CO (cardiac index), filling pressures, pulmonary capillary wedge MEDICATIONS pressure (PCWP) ▪ Individualized in accordance with New MRI York Heart Association (NYHA) class, EF, comorbidities ▪ Visualizes ventricular volumes, mass, presence of myocardial remodeling ▪ Angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blockers (ARB) LAB RESULTS ▪ Beta-blocker (carvedilol, bisoprolol, ▪ ↑ B-type natriuretic peptide (BNP) and/or metoprolol ER) N-terminal pro-BNP ▪ Aldosterone agonist ▪ ↑ serum creatinine and blood urea nitrogen ▪ Mineralocorticoid receptor antagonist (BUN) indicates glomerular filtration rate ↓ (HFpEF) GFR due to hypoperfusion ▪ Acute decompensation ▪ ↑ serum total bilirubin and aminotransferase ▫ See mnemonic indicates congestive hepatopathy from right-sided HF ▪ ↑ serum lactate if cardiogenic shock ▪ Exercise testing: six-minute walk test and/or a cardiopulmonary exercise test measuring oxygen uptake (Vo2) evaluates exercise capacity OSMOSIS.ORG 57  MNEMONIC: POND OTHER INTERVENTIONS Acute decompensation ▪ Lifestyle modifications Position (upright) +/- positive ▫ Low dietary salt, exercise as tolerated, pressure ventilation (e.g. smoking cessation, minimize alcohol BiPAP) intake Oxygen ▪ Ventricular assist device (VAD) Nitrates ▪ Implanted defibrillator Diuretics ▪ Biventricular pacemaker for resynchronization SURGERY ▪ Heart transplant ▫ Considered in NYHA class of III or IV despite maximized medical and resynchronization therapy COR PULMONALE osms.it/cor_pulmonale ▪ Recent surgery, hypercoagulable states (↑ PATHOLOGY & CAUSES risk of pulmonary embolism) ▪ Right ventricular hypertrophy, dilation, and/or dysfunction due to pulmonary COMPLICATIONS hypertension secondary to pulmonary ▪ RV failure disease (e.g. chronic obstructive pulmonary ▪ Liver dysfunction disease (COPD), pulmonary fibrosis), upper airway obstruction (e.g. obstructive sleep apnea, obesity-hypoventilation SIGNS & SYMPTOMS syndrome), or chest wall irregularities (e.g. kyphoscoliosis) ▪ Dyspnea, chest pain, peripheral edema, ▪ Acute cor pulmonale develops in the jugular venous distension, hepatomegaly setting of a sudden volume and/or pressure overload in the right side of the heart; e.g. massive pulmonary embolism DIAGNOSIS ▪ ↑ pulmonary vascular resistance → ↑ pulmonary circuit afterload → ↑ right DIAGNOSTIC IMAGING ventricular workload → right ventricular hypertrophy or dilatation → impaired right Chest X-ray ventricular function and failure → ↑ right ▪ Visualizes right ventricular hypertrophy, atrial pressure → fluid back-up into venous distended pulmonary vasculature, circulation → peripheral edema pulmonary edema Echocardiography RISK FACTORS ▪ Detects structural and functional changes ▪ Presence of parenchymal or vascular lung of right ventricle; estimates right ventricular disease, chronic airway obstruction systolic pressures ▪ Smoking 58 OSMOSIS.ORG  Chapter 9 Heart Failure MRI SURGERY ▪ Visualizes right ventricular hypertrophy, ▪ Heart-lung transplant for resistant cor right atrial enlargement, tricuspid valve pulmonale dysfunction regurgitation, retrograde flow Cardiac catheterization OTHER INTERVENTIONS ▪ ↑ elevated central venous pressure, ↑ ▪ Treat underlying disease process right ventricular, end-diastolic pressure, ▪ Lifestyle evidence of underlying pulmonary disease ▫ Low dietary salt, exercise as tolerated, smoking cessation TREATMENT MEDICATIONS ▪ Supplemental oxygen ▪ Loop diuretic DIASTOLIC HEART FAILURE osms.it/diastolic-heart-failure PATHOLOGY & CAUSES SIGNS & SYMPTOMS ▪ A clinical syndrome characterized by failure ▪ Fatigue, dyspnea, orthopnea, exercise of the heart to pump sufficient blood to intolerance, pulmonary rales, JVD meet the metabolic needs of the body due to ↓ ventricular filling ▪ HF with preserved ejection fraction DIAGNOSIS (HFpEF) ▪ Filling dysfunction DIAGNOSTIC IMAGING ▫ Stiff, non-compliant ventricle → ↓ Chest X-ray ventricular relaxation → ↑ end diastolic ▪ Cardiomegaly; pulmonary vascular pressure → ↑ resistance to filling → congestion; enlargement of right atrium, ↓ preload → EF ≥ 50, ↓ SV, ↓ CO → ventricle, and pulmonary arteries pulmonary congestion Doppler echocardiography RISK FACTORS ▪ Altered mitral flow velocity, ↑ LVEDP, LV ▪ ↑ age, restrictive cardiomyopathy (e.g. hypertrophy with concentric remodeling, amyloidosis, sarcoidosis); hypertrophic LA enlargement, ↑ pulmonary artery cardiomyopathy, long-standing systolic pressure (PASP) hypertension, valve disease (especially aortic stenosis), CAD, diabetes, obesity LAB RESULTS ▪ ↑ BNP/NT-proBNP COMPLICATIONS ▪ Arrhythmias, pulmonary embolism, pulmonary hypertension, right ventricular failure OSMOSIS.ORG 59  OTHER INTERVENTIONS TREATMENT ▪ Manage contributing factors and associated conditions MEDICATIONS ▪ Lifestyle modifications Alleviation of symptoms ▫ Smoking cessation, ↓ sodium intake, ▪ Diuretics; antihypertensives weight management, ↓ alcohol intake ▫ Beta blockers, ACE inhibitors, ARBs, aldosterone antagonists LEFT HEART FAILURE osms.it/left-heart-failure RISK FACTORS PATHOLOGY & CAUSES ▪ Coronary artery disease, infiltrative disease (e.g. amyloidosis, hemochromatosis) → ▪ A clinical syndrome due to an alteration cardiomyopathy of structure and/or function of the left ▪ Hypertension, aortic stenosis → ↑ afterload ventricle (LV) resulting in ↓ cardiac output, pulmonary congestion, and ↓ peripheral ▪ Mitral or aortic regurgitation → ↑ preload perfusion ▪ Exposure to toxins → myocardial damage ▪ Categorized according to left ventricular ▪ Arrhythmias → ↓ filling, ↓ ineffective ejection fraction (LVEF) contractions ▫ Systolic HF: ↓ LVEF ≤40 percent (HFrEF) ▪ age > 60 ▫ Diastolic HF: preserved LVEF (HFpEF) ▪ Obesity ▪ ↓ cardiac output → backup of blood into ▪ Diabetes mellitus/metabolic syndrome left atrium → pulmonary circulation → ↑ pressure in pulmonary capillaries → COMPLICATIONS pulmonary edema → ↓ gas exchange, ▪ Pulmonary edema, pulmonary hemorrhage dyspnea (congested capillaries burst), pleural ▪ Neurohormonal compensatory mechanisms effusion, renal insufficiency ▫ RAAS and adrenergic activation → renal salt and water retention + vasoconstriction → ↑ contractility, ↑ SIGNS & SYMPTOMS circulating volume → ↑ CO, ↑ organ perfusion ▪ Exertional dyspnea, orthopnea; (PND), ▫ Adverse effects of compensation: ↑ pulmonary edema (frothy, pink-tinged afterload, ↑ LV workload, LV remodeling sputum), bibasilar rales, cough, nocturia, ▫ Natriuretic peptide secretion occurs in restlessness, confusion. S3/S4 response to compensatory mechanisms and atrial stretch → diuresis, natriuresis, partial RAAS inhibition 60 OSMOSIS.ORG  Chapter 9 Heart Failure Echocardiography ▪ LV hypertrophy with eccentric remodeling, ↑ LVEDP, LA enlargement, ↑ PASP OTHER DIAGNOSTICS ▪ ECG ▫ Identifies contributing rhythm disturbances TREATMENT Figure 9.1 The gross pathological appearance MEDICATIONS of pulmonary edema. Exerting pressure on ▪ Diuretics, beta blockers, ACE inhibitors, the lung parenchyma causes frothy white ARBs, ARNI, hydralazine/nitrate fluid to exude from it. combination, aldosterone antagonists ▪ Acute decompensation ▫ See mnemonic DIAGNOSIS LAB RESULTS MNEMONIC: POND ▪ ↑ BNP/NT-proBNP Acute decompensation Position (upright) +/- positive pressure ventilation (e.g. DIAGNOSTIC IMAGING BiPAP) Chest X-ray Oxygen ▪ Cardiomegaly, pulmonary vascular Nitrates congestion, enlargement of right atrium, Diuretics ventricle, and pulmonary arteries MEDICATIONS ▪ Diuretics, beta blockers, ACE inhibitors, ARBs, ARNI, hydralazine/nitrate combination, aldosterone antagonists ▪ Acute decompensation ▫ See mnemonic SURGERY ▪ Heart transplant OTHER INTERVENTIONS ▪ Manage contributing factors and associated conditions ▪ Lifestyle modifications: smoking cessation, ↓ sodium intake, weight management, ↓ Figure 9.2 A plain chest X-ray image alcohol intake demonstrating pulmonary edema. The ▪ Cardiac rehabilitation vessels at the hila are prominent and there ▪ Implantable cardioverter-defibrillator (ICD) are numerous Kerley B lines. ▪ Ventricular assist device OSMOSIS.ORG 61  Figure 9.3 The histological appearance of pulmonary edema. There is flocculent fluid within the alveolar spaces. Figure 9.4 Pitting edema in an individual with left-sided heart failure. RIGHT HEART FAILURE osms.it/right-heart-failure COMPLICATIONS PATHOLOGY & CAUSES ▪ Eventual failure of left side of heart ▪ Tricuspid regurgitation ▪ A clinical syndrome due to an alteration of structure and/or function of the right ▪ Congestive hepatopathy ventricle (RV) leading to suboptimal ▪ Cardiac cachexia delivery of blood flow to the pulmonary ▫ Nausea, vomiting, anorexia, and diffuse circulation and/or elevated venous abdominal pain due to abdominal pressures venous congestion → weight loss ▪ ↑ venous pressure → systolic volume overload ▪ ↑ RV workload (most often due to SIGNS & SYMPTOMS pulmonary congestion secondary to LV failure) → RV hypertrophy → ↓ pumping ▪ JVD, hepatojugular reflux, fatigue (related ability to poor gas exchange), exercise intolerance, peripheral edema, hepatosplenomegaly, ascites, S3/S4 CAUSES ▪ Left-sided heart failure, associated pulmonary edema (most common cause), DIAGNOSIS right ventricular infarction, bacterial endocarditis, pulmonic valve stenosis, DIAGNOSTIC IMAGING cardiomyopathy Chest X-ray ▪ Cardiomegaly, pulmonary vascular congestion; enlargement of right atrium, ventricle, pulmonary arteries 62 OSMOSIS.ORG  Chapter 9 Heart Failure Echocardiography ▪ Evaluates RV size and function; detects hemodynamic alterations MRI ▪ Myocardial tissue, ventricular volume, muscle damage Right heart catheterization ▪ ↑ pressure in heart chambers and lungs LAB RESULTS ▪ ↑ BNP/NT-proBNP ▪ ↑ serum total bilirubin and aminotransferase indicates congestive hepatopathy OTHER DIAGNOSTICS Figure 9.5 A distended external jugular vein ▪ Clinical presentation: right heart (EJV) in an individual with right heart failure. dysfunction, rule out left heart dysfunction ECG ▪ Identifies contributing rhythm disturbances TREATMENT MEDICATIONS ▪ Loop diuretics ▫ Fluid management ▪ Vasopressors ▫ Circulatory support OTHER INTERVENTIONS ▪ Treat underlying condition MNEMONIC: LMNOP Treatment for Right heart failure Lasix Morphine Nitrites Oxygen VassoPressors OSMOSIS.ORG 63