Dentistry Degree Unit III Lesson 17 PDF

Dentistry Degree 17 UNIT III: HEART FAILURE © Copyright Universidad Europea. Todos los derechos reservados Prof. Antonio Pellín Carcelén Internal use...

Dentistry Degree 17 UNIT III: HEART FAILURE © Copyright Universidad Europea. Todos los derechos reservados Prof. Antonio Pellín Carcelén Internal use Dra. Isabel Andújar Pérez  Unit III PHYSIOPATHOLOGY AND SEMIOLOGY OF THE CARDIOVASCULAR SYSTEM INDEX ▪ LESSON 12: Introduction to the Pathology of the Circulatory System. ▪ LESSON 13: Atherosclerosis. ▪ LESSON 14: Ischemic Heart Disease. ▪ LESSON 15: Arterial Hypertension. ▪ LESSON 16: Valvular Diseases. ▪ LESSON 17: Heart Failure. ▪ LESSON 18: Rhythm Disorders. Normal ECG. Main Arrhythmias. ▪ LESSON 19: Vascular Pathology of Lower Limbs. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  Unit III. Lesson 17 INDEX 1. Circulatory Insufficiency. 2. Heart Failure. 3. Decompensated Heart Failure. 4. Shock. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 1. CIRCULATORY INSUFFICIENCY. 1.1. General concepts. Inability of the circulatory system to provide the tissues with the amount of blood they need in each moment. Consequences: ✓ Decrease in tissue oxygenation. ✓ Decrease in the contribution of substrates necessary for metabolism. ✓ Defect in the removal of residual products. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 1. CIRCULATORY INSUFFICIENCY. 1.2. Classification. Heart failure Global CIRCULATORY INSUFFICIENCY Shock Organ specific Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.1. Concept. Heart failure is a complex syndrome that combines: INABILITY OF THE HEART TO PUMP ENOUGH BLOOD ACCORDING TO THE METABOLIC NEEDS OF THE TISSUES. NEUROHUMORAL COMPENSATORY REACTION. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.2. Classification. Systolic dysfunction Low-output HF (Lo-HF) (failure of the pump) Diastolic dysfunction Heart failure Excessive decrease of systemic High-output HF vascular resistance Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.3. Mechanisms and causes. → Low-output HF due to systolic dysfunction: ✓ Arrhythmias ✓ Myocardial injury o ischemia o myocarditis o toxic or metabolic myocardiopathies ✓ Mechanical ventricular overload o Pressure overload: HBP or valve stenosis o Volume overload: valvular insufficiency or anomalous communication Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.3. Mechanisms and causes. → Low-output HF due to diastolic dysfunction: ✓ Arrhythmias. ✓ Atrio-ventricular flow obstruction: valve stenosis. ✓ Less distensibility of the ventricles during diastole: o pericardial effusion o ischemia o hypertrophy Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.3. Mechanisms and causes. → High-output HF: ✓ Anemia ✓ Beriberi ✓ Hyperthyroidism ✓ Paget´s disease Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.4. Compensatory mechanisms. When heart failure starts, the body develops compensatory mechanisms to increase cardiac output. ✓ Therefore, HF can be: o compensated (correct function of compensation mechanisms). o decompensated or congestive (failure of compensation mechanisms). Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.4. Compensatory mechanisms. ✓ There are two types of compensatory mechanisms: o Systemic neuro-endocrine response. o Ventricular remodeling. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.4. Compensatory mechanisms. → Systemic neuro-endocrine response and effects: Effects Sympathetic system activation Catecholamines release Preload increase R-A-A system activation Increased stroke volume Increased ADH secretion Increased heart rate Increased contractility Vasoconstriction (increased resistance) Redistribution of blood flow Response Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.4. Compensatory mechanisms. → Ventricular remodeling: It develops in response to pressure or volume overload: PRESSURE OVERLOAD CONCENTRIC MYOCARDIAL HYPERTROPHY VOLUME OVERLOAD ECCENTRIC MYOCARDIAL HYPERTROPHY Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.4. Compensatory mechanisms. → Ventricular remodeling: PRESSURE OVERLOAD: VOLUME OVERLOAD: Concentric myocardial hypertrophy Eccentric myocardial hypertrophy Afterload increase. Passive dilation with increased preload. Increased oxygen consumption. Increased oxygen consumption. Decreased contractility. Decreased contractility. Sarcomeres replication in parallel. Sarcomeres replication in series. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.4. Compensatory mechanisms. → Ventricular remodeling: Pressure overload Volume overload Increased systolic wall Increased diastolic wall stress stress (afterload) (preload) Ventricular remodeling Sarcomeres in parallel Sarcomeres in series Concentric hypertrophy Normal Eccentric hypertrophy Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 2. HEART FAILURE. 2.5. Pathogeny. ✓ Increased oxygen consumption by the myocardium. ✓ Decrease in contractility (more intense in eccentric hypertrophy). ✓ Decrease in distensibility (more intense in concentric hypertrophy). ✓ Emergence of fetal isoforms of sarcomeres (less efficient). ✓ Reduction of contractile myocardial mass: cytotoxicity of catecholamines increased apoptosis necrosis © Copyright Universidad Europea. Todos los derechos reservados increase in fibrous tissue Prof. Antonio Pellín Carcelén  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.1. Concept. ✓ Acute decompensated heart failure can be defined as the sudden or gradual onset of the signs or symptoms of heart failure requiring unplanned office visits, emergency room visits, or hospitalization. ✓ When compensation mechanisms become ineffective and adverse effects predominate, decompensated heart failure appears. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.2. Clinical manifestations. ✓ Regardless of the underlying precipitant of the exacerbation, pulmonary and systemic congestion due to increased left- and right-heart filling pressures is a nearly universal finding in ADHF (acute decompensated heart failure). ✓ Clinical manifestations: o Tissue hypoperfusion or ischemia o Lung congestion o Systemic venous congestion Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. ✓ Left-sided heart failure ✓ Right-sided heart failure ✓ High-output heart failure Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.1. Left-sided heart failure. → Anamnesis: ✓ Dyspnea ✓ Orthopnea ✓ Paroxysmal nocturnal dyspnea ✓ Generalized muscular weakness ✓ Decrease intellectual performance ✓ Oliguria ✓ Nicturia (LeMone, Enfermería médicoquirúrgica, Pearson) Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.1. Left-sided heart failure. → Physical exploration: Inspection Palpation Auscultation Pale and cold skin. The apex beat is displaced to Third and/or fourth heart Peripheral cyanosis. the left and down. sounds (gallop rhythm) Mitral insufficiency functional murmur Bibasilar crackles and/or wheezes (rhonchi) in the middle fields Pleural effusion. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.1. Left-sided heart failure. → Complementary exploration: ECG X-Rays Echocardiogram Left ventricular hypertrophy. Left ventricular growth. Measurement of the degree Signs of passive pulmonary of hypertrophy, dilation and congestion. cardiac contraction. Calculation of ejection fraction. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.2. Right-sided heart failure. Right-sided heart failure appears due to causes that affect only the RV, such as pulmonary hypertension due to lung disease. → Anamnesis: ✓ Signs similar to those of the left-sided HF but of less intensity and without pulmonary venous congestion. (LeMone, Enfermería médicoquirúrgica, Pearson) Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.2. Right-sided heart failure. → Physical exploration: Inspection Palpation Auscultation Pale and cold skin. The apex beat of the right Third and/or fourth heart Jugular vein distension. ventricle. sounds (gallop rhythm) Edemas in in the legs, ankles, Hepatomegaly. Tricuspid insufficiency GI tract and liver. functional murmur. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.2. Right-sided heart failure. → Physical exploration: Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.2. Right-sided heart failure. → Physical exploration: Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.2. Right-sided heart failure. → Complementary exploration: ECG X-Rays Echocardiogram Right ventricular hypertrophy Cardiomegaly (at the expense Measurement of the degree (not always). of the right chambers of the of hypertrophy, dilation and heart). cardiac contraction. Measurement of the pressure in the pulmonary artery. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. → In summary: LEFT HEART FAILURE RIGHT HEART FAILURE Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. 3.3.3. High-output heart failure. It occurs when the normally functioning heart cannot keep up with an unusually high demand for blood to one or more organs in the body. Prior to ventricular failure, the patient shows: ✓ Hyperdynamic state to raise cardiac output ✓ Hot skin, tachycardia and possible functional murmurs. When the heart fails, the symptoms of decompensated HF appear with normal but insufficient output. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 3. DECOMPENSATED HEART FAILURE. 3.3. Classification. Classification according to the New York Heart Association: Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. Heart failure Global CIRCULATORY INSUFFICIENCY Shock Organ specific Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.1. Concept. Global circulatory failure that always occurs abruptly and determines generalized ischemia (due to inadequate perfusion to the tissues). Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization. This most commonly occurs when there is circulatory failure. Shock is initially reversible, but must be recognized and treated immediately to prevent progression to irreversible organ dysfunction. (LeMone, Enfermería méd icoquirúrgica, Pearson) Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.2. Classification. ✓ Cardiogenic shock ✓ Hypovolemic shock ✓ Distributive shock ✓ Obstructive shock ✓ Multifactorial, a combination of more than one form of shock Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.2. Classification. → Cardiogenic shock: Decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. ✓ AMI ✓ Myocardiopathies ✓ Valvulopathies Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.2. Classification. → Hypovolemic shock: Emergency situation in which severe blood or fluid loss makes the heart unable to pump enough blood to the body. ✓ Severe hemorrhages ✓ Severe burns ✓ Gastrointestinal fluid loss ✓ Sequestration of fluid in extensive inflammatory foci Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.2. Classification. → Distributive or vasodilatory shock: Distributive shock (or vasodilatory shock), leads to decreased blood flow to the brain, heart, and kidneys causing damage to vital organs. It also leads to leakage of fluid from capillaries into the surrounding tissues, further complicating the clinical picture. ✓ sepsis ✓ anaphylaxis ✓ neurogenic shock (in some cases of trauma) Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.2. Classification. → Obstructive shock: Caused by physical obstruction of circulation either into or out of the heart. The mechanisms that lead to obstructive shock are: ✓ either prevent blood from entering the right heart during diastole such as a tension pneumothorax or pericardial tamponade, ✓ or prevent the heart from ejecting the blood due to a physical obstruction, as in the case of pulmonary embolism or left ventricular outflow obstruction. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.3. Compensatory mechanisms. → Systemic neuro-endocrine response and effects: Effects Sympathetic system activation Catecholamines release Increased sodium and water R-A-A system activation reabsorption (kidney) Increased ADH secretion Increased heart rate Increased contractility Vasoconstriction (increased resistance) Redistribution of blood flow Response (Given the speed of the shock, these mechanisms are less intense). Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.4. Manifestations and consequences. → Anamnesis: ✓ Confusion state, progressive clouding and coma. ✓ Oliguria. ✓ Dyspnea. Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados  UNIT III. LESSON 17. HEART FAILURE. 4. SHOCK. 4.4. Manifestations and consequences. → Physical exploration: Inspection Palpation Laboratory Pale and cold skin. Tachycardia. Metabolic acidosis. Peripheral cyanosis. Hypotension. Sweating. Weak pulse (thread-like Hyperventilation. pulse) Prof. Antonio Pellín Carcelén © Copyright Universidad Europea. Todos los derechos reservados © Copyright Universidad Europea. Todos los derechos reservados Internal use Dra. Isabel Andújar Pérez