Heart failure Notes

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Osmosis High-Yield Notes

This Osmosis High-Yield Note provides an overview of Heart failure essentials. All Osmosis Notes are clearly laid-out and contain striking images, tables, and diagrams to help visual learners understand complex topics quickly and efficiently. Find more information about Heart failure:

Heart failure

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

Osmosis High-Yield Notes

This Osmosis High-Yield Note provides an overview of Heart failure essentials. All Osmosis Notes are clearly laid-out and contain striking images, tables, and diagrams to help visual learners understand complex topics quickly and efficiently. Find more information about Heart failure by visiting the associated Learn Page.