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WVCCardiac 2011 2

the cardiac study guide for lecture 2 at WVC year 1

Heart Failure Failure of the heart to pump blood through the body Sometimes called pump failure Causes insufficient perfusion of body tissues and organs 75% caused by hypertension Healthcare costs $24.3 billion dollars
Left Heart Failure Most hf starts as left hf Also called left-sided heart ventricular failure or chf May be acute or chronic May be due to sys or dia failure Associated with decreased CO and elevated pulmonary venous pressure Cardiac muscle hypertrophy (LVH)
Left-sided Systolic Failure Heart unable to contract forcefully in systole to eject adequate blood for circu. Preload ↑ with ↓ contract; afterload ↑with ↑ peripheral resistance (hypertension) The eject frac ↓, tissue perfusion is ↓Blood accumulates in pulm. vess. CO is impaired
Left-sided Diastolic Heart Failure Stiffening or hypertrophy of the left ventricle Less compliance, unable to fill adequately Cardiac output is decreased but ejection fraction may be near normal
Symptoms of Left Heart Failure Decreased Cardiac Output Fatigue, weakness Oliguria during day Confused, restless Dizziness Tachycardia Weak peripheral pulses Pallor Cool extremities Angina
other Symptoms of Left Heart Failure Pulmonary Congestion Hacking cough, worse at night Dyspnea Crackles, wheezes Frothy, pink-tinged sputum Tachypnea S3, S4 summation gallop
Right Heart Failure Can be caused by left heart failure, right ventricular MI or pulmonary hypertension (cor pulmonale) Right heart is unable to empty adequately Increased volume and pressure develop systemically Systemic venous congestion with peripheral edema
Symptoms of Right Heart Failure Jvd Enlarged liver & spleen Anorexia, nausea Dep. edema Edema starts lower & moves ↑ Dist abdomen Polyuria at night Weight gain ↑ bp from ex volume OR ↓ bp from hf
more facts on Right Heart Failure Systemic congestion Retention of fluid Neck vein distention Increased abdominal girth Edema is an unreliable sign of heart failure Weight is the best indicator
Compensatory Mechanisms All the compensatory mechanisms increase myocardial oxygen consumption The body compensates for heart failure by: Tachycardia: to increase output Enlarging: to pump more blood Developing more muscle mass (hypertrophy): to pump more strongly
Compensatory Mechanisms II Sympathetic nervous system- ↑hr vasoconstriction Renin-angiotensin system- ↓blood flow to the kidneys activates the RAS. ↑preload & afterload
more Compensatory Mechanisms II Neurohumoral responses- immune inflammatory response, BNP, ADH & endothelin Myocardial hypertrophy- thickening of the walls of the heart to provide more muscle mass. The final compensatory mechanism
Right side heart failure Diagnostics Chest x-ray Electrolytes, CBC, UA, ABG, BNP Echocardiogram Thalium or T-phos scans MUGA - gives ejection fraction Pulmonary Wedge Pressure
CHF Meds and interventions ACE-Inhibitors Diuretics Nitrates Cardiac Glycosides Beta Blockers Low sodium diet Fluid restriction
Staging of Heart Failure Stage A: at high risk but no structural changes or symptoms Stage B: structural changes but no symptoms Stage C: structural changes and current or history of heart failure Stage D: end stage disease, ongoing chronic support & treatment
Valvular Heart Disease Heart valves do not fully open or close Usually valves of the left heart Tricuspid valve damage usually following endocarditis Rarely pulmonic valve Mitral (Bicuspid) - Stenosis, Regurgitation, Prolapse Aortic - Stenosis, Regurgitation
Mitral Stenosis Rheumatic fever most common cause Valves thicken, become fibrotic, calcified Pulmonary congestion and right heart failure
Symptoms of Mitral Stenosis Fatigue Dyspnea on exertion Paroxysmal nocturnal dyspnea Hemoptysis Hepatomegaly Jvd Pitting edema A fib Rumbling, apical diastolic murmur
Mitral Regurgitation Changes in the leaflets cause incomplete closure of the valve. Backflow from the left ventricle Symptoms begin when left ventricle fails
Symptoms of Mitral Insufficiency Fatigue Dyspnea on exertion Orthopnea Palpitations A fib JVD Pitting edema High-pitched holosystolic murmur
Mitral Prolapse The leaflets enlarge and prolapse into the left atrium during systole May be asymptomatic May progress to mitral regurgitation
Symptoms of Mitral Valve Prolapse Atypical chest pain Dizziness, syncope Palpitations Atrial tachycardia Ventricular tachycardia Systolic click
Aortic Stenosis Valve orifice narrows Obstructs left ventricular outflow during systole Increased resistance or afterload Hypertrophy of left ventricle
Symptoms of Aortic Stenosis Dyspnea on exertion Angina Syncope on exertion Fatigue Orthopnea Paroxysmal nocturnal dyspnea Harsh, systolic crescendo-decrescendo murmur
Aortic Regurgitation Leaflets do not close properly during diastole The valve ring may be dilated Left ventricular failure
Symptoms of Aortic Insufficiency Palpitations Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Fatigue Angina Sinus tachycardia Blowing decrescendo diastolic murmur
Medications and Interventions for Aortic Insufficiency Reduce preload or afterload with medications Coumadin for atrial fibrillation Rest, energy conservation Surgical replacement or dilation Education for medications, disease process, energy conservation, prophylactic antibiotics
Pericarditis Inflammation of the pericardium Acute pericarditis may be fibrous, serous, hemorrhagic, purulent or neoplastic Postpericardiotomy syndrome
Symptoms of Pericarditis Substernal, precordial pain radiating to the left neck, shoulder or back Pericardial friction rub Elevated WBCs Fever Changes in T wave Atrial fibrillation
Interventions for Pericarditis Non-steroidal anti-inflammatory drugs Corticosteroids Acute pericarditis may need hospitalization Bacterial pericarditis will need antibiotics and pericardial drainage Complications include atrial fibrillation, cardiac tamponade, heart failure
Pericardial Tamponade Complication of pericarditis Pericardial space fills with fluid and restricts diastolic ventricular filling Pericardiocentesis
Symptoms of Tamponade Jugular vein distention Pulsus paradoxus – systolic BP> 10 mm Hg points higher on expiration than inspiration Signs of decreased cardiac output Muffled heart sounds Circulatory collapse
Infective Endocarditis Bacterial infection of the endocardium Hx of IV drug abuse, valve replacement or cardiac defects Endocardium is eroded and bacteria forms a vegetative lesion Endocardium and valve are destroyed Mortality rate 12% to 15% with treatment
Symptoms of Infective Endocarditis Fever with chills, night sweats, malaise and fatigue New cardiac murmur Heart failure Evidence of systemic embolization Petechiae Positive blood cultures
Treatment for Infective Endocarditis Rest, activity followed by rest Antibiotics IV for 6 weeks May need surgical removal of infected valve and replacement
Rheumatic Endocarditis Occurs after Rheumatic fever, upper respiratory infection with Group A beta-hemolytic streptococcus Inflammation of all layers of the heart
Rheumatic Endocarditis cont. Forms small nodules on the myocardium that turn to scar tissue Hemorrhagic and fibrous lesions form on the leaflets of the valves, primarily the mitral & aortic
Symptoms of Rheumatic Endocarditis Tachycardia Cardiomegaly New heart murmur or change in existing murmur Pericardial friction rub EKG changes Heart failure Evidence of existing streptococcal infection
Cardiomyopathy Subacute or chronic enlargement of the heart muscle Dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy. Treatment is usually palliative, death within 5 years
Dilated Cardiomyopathy Most common type (87%) Damage to muscle fibers Normal ventricle thickness but dilation of atria and ventricles Impaired systolic function
Hypertrophic Cardiomyopathy Asymmetrical ventricular hypertrophy of the left ventricle Obstruction of the left ventricular outflow Diastolic filling abnormalities Congenital or hereditary genetic trait
Medications for Hypertrophic Cardiomyopathy Diuretics Vasodilators Cardiac glycosides Beta adrenergic blockers Calcium antagonists (Diltiazem)
Diagnostics and Interventions for Hypertrophic Cardiomyopathy Echocardiogram Radionuclide imaging (thalium scan) Cardiac catheterization Medications ICD (Implanted Cardiac Defibrillator) Surgical: Excision of hypertrophied septum, cardiomyoplasty, heart transplant
Heart Transplant Criteria: Life expectancy less than 1 year Under 65 years of age Normal or slightly increased pulmonary vascular resistance Absence of active infection Stable psychosocial status No evidence of drug or alcohol abuse
Coronary Artery Disease Narrowing or occlusion of the vessels feeding the heart muscle Ischemia occurs when insufficient o2 is available, symptom angina Infarction occurs when heart muscle begins to die from anoxia, sometimes first symptom is lethal arrhythmia
Leading cause of death on the USA Coronary Artery Disease
Risk Factors for Development of CAD Age Heredity Gender Smoking Obesity Sedentary Stress Dietary habits Diabetes Hypertension Hyperlipidemia
Hypertension BP: force of blood exerted against vascular system walls Sys BP amount of pressure exerted by the left ventricle during contraction (systole) Dia BP: amount of pressure sustained in the arteries during the relaxation phase of the heart (diastole)
BP Regulation Baroreceptors – carotid sinus, aorta and left ventricle Chemoreceptors – sensitive to rise in CO2 during hypoxia
BP regulation cont. ANS- balance of parasympathetic & sympathetic in response to changes Renal System- retention or excretion of water & sodium, renin-angiotensin system
BP Regulation 1 Autonomic nervous system Arterial Baroreceptors Body Fluid Volume Renin-Angiotensin-Aldosterone Vascular Autoregulation
The Silent Killer May be few symptoms Comes on gradually Damages vessels in heart, brain, kidneys and peripheral vasculature
Hypertension levels Blood pressure of >140 systolic and >90 diastolic Three Stages: Stage I - BP 140/90 to 159/99 Stage II - BP 160/100 to 179/109 Stage III - BP > 180/110
Types of Hypertension Essential Hypertension Secondary Hypertension Malignant Hypertension
Essential Hypertension Primary type Accounts for 85% to 90% of all hypertension Risk factors: Similar to risk factors for coronary artery disease. Many risk factors can be controlled with lifestyle changes
Secondary Hypertension Caused by other disease processes or medications Most commonly associated with renal disease Can also be a problem with endocrine function, brain tumors or encephalitis
Malignant Hypertension Severe hypertension: Systolic >200, Diastolic >150 Progresses rapidly Symptoms of blurred vision, headache, dyspnea, uremia Unless interventions are begun quickly, patient may have CVA, heart failure or renal failure This is a medical emergency
Hypertension Intervention Decrease risk factors: diet, exercise Low sodium diet Medications Diuretics Vasodilators Calcium Channel Blockers ACE-Inhibitors Beta Blockers Angiotensin II Receptor Blockers (ARB)
Diuretics Loop diuretics- furosemide (lasix) Thiazides- HCTZ (Diuril, Hydrodiuril) Potassium sparing- Spironolactone (aldactone), Triamterone (dyrenium)
Vasodilators Relax vascular smooth muscle and reduce total peripheral resistance Minoxidil, Doxazosin, Terazosin, Nitroglycerin, Nitroprusside
Calcium Channel Blockers Interfere with the movement of calcium ions Results in reduced vasoconstriction Nifedipine, Verapamil, Diltiazem
ACE- Inhibitors Inhibits the action of the angiotensin-converting enzyme ACE is a strong vasoconstrictor Postural hypotension is common Captopril, Enalapril and Lisinopril
Beta-Blockers Block adrenergic impulses in the heart and peripheral vessels Lower heart rate and contractility Propranolol, Atenolol, Nadolol & Metoprolol
Angiotension II Receptor Blockers Inhibit vasoconstriction by stopin binding of Angiotensin II to receptor sites but not inhibiting ACE Protect against renal failure in patients with DM II and don’t cause cough Example: losartan (Cozaar), olmesartan (Benicar) and candesartan (Atacand)
Assessment of Hypertensive Crisis Symptoms of severe headache, extremely high BP, dizziness, blurred vision, disoriented Intervention: Place in semi-fowler position, oxygen, IV nitroprusside or other antihypertensive, monitor BP q5-10 min Monitor for CVA, seizures, dysrhyth. or angina
Created by: jsilvestri9720