CVS- CHF pathophy& treat
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| Difference in terms heart failure, heart attack, and sudden cardiac death(SCD) and Shock | 1.HF[de^CO(tx ionotropes)& fluid overload/ high PCWP(tx diuretic]2. MI. 3. Arrhythmia 4.cardiogenic/distributive/septic/hypovolemic shock(tx vasoconstrictors to in^ BP in spepsis),de^/in^ CO,CI, lo BP & MAP,lack of perfusion.BP=CO x tpr
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| Define heart failure | Inability of heart to meet the metabolic demand of body. Due to contraction / filling problem. Result in de^ CO & CI (organ perfusion) with or w. out volume overload or preload (in^ wt 3-5lb/wk,congestion PDWP>18)
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| Continuation of definition of HF | Final pathway of many cardiac disorder.May result in activation of compensatory mechanism.it further progress the HF. Can be prevented and controlled but not cured.if not tx,lead to cardiogenic shock (no perfusion to organ). death is due to SCD.
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| 1.Types of HF? 2.define diastolic HF? how is it different from systolic HF in diagnosis and treatment? | 1.Systolic and diastolic HF.2.Due to ventricles filling problem. Inadequate filling due to thick wall. EF is normal(60%) or >50%. Seen in elderly. Main reason is HTN. treatment is to de^ HR give more time to fill.
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| Why do we need to differentiate systolic and diastolic HF | Pathophysiology And haemodynamicly same but causes & treatment differ.
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| Define Systolic HF.Causes of systolic HF | Due to inadequate ventricular contraction. EF is decreased < 40%. more prevalent.1.Due to de^ muscle mass (IHD,MI). 2. Ventricular hypertrophy- pressure (BP) or volume(valve regurgitation) overload. 3.dilated cardiomyopathy (genetic)4. thyroid disease(hi
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| Causes of diastolic HF | 1.Ventricular stiffness ( MI,LVH,cardiomyopathy,infiltrated myocardial disease)2.pericardial desese 3. Mitral or tricuspid stenosis.
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| Rx that can ppt HF? remember CO= HR x SV | 1. Neg. ionotrops-BB, non DHP CCB, antiarrhythmic, antifungal. 2. Cardiotoxic rx-doxorubicin,cyclophosphamide, ethanol, amphetamine 3. Rx causing Na, water retention –Steroid, NSAID,actose
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| Define compensated HF/ stable HF | In this state rx keep patient symptom free ( no symptom of volume overload/ decreased perfusion). Decreased CO is compensated with rx.
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| Define acute decompensated or exacerbation of HF | Acute worsening of symptom of decreased CO, which leads to hypoperfusion ( may lead to shock or end organ failure ie, MAP)and volume overload. need fluid restriction(<2L fluid,<2gm of Na) and diuretics
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| Define End stage or refractory or advanced HF | Patient has persistent symptoms of hypoperfusion or fluid overload despite optimal treatment.
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| Define Cardiogenic shock? What is septic shock? | shock(low SBP <90, MAP <65 and impaired organ perfusion) due to pumping issue of heart. sign&symp. of HF + sympt. of shock.low CO in both.( BP= CO x TPR). also high preload ( fluid), afterload in cardiogenic shock. tx inotropes. septic due to infection.
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| What are compensatory mechanism from the decreased CO and its adv & disadv. | 1.In^ sympath. to in^ CO. but In^ HR &O2 demand,Heart work harder2. Activation of RAAS to in^ co by kidney. But volume overload 3.Vasoconstiction to stunt blood away from nonessential organ but in^ SVR 4.ventri. remodeling to de^myocardial stress, fibrosi
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| Define CO what is normal value? What are the determinant of CO. how do u measure hemodynamics. how do treat low CO? | Volume of blood ejected/ min. 4-6L/min. HR x SV.(Blood volume in body is 5L). swan-ganz catheter or pulmonary artery catheter.if low organ perfusion or MAP <65, pressor agent/squeezers or dopamine, if SBP<90/symptoms of hypoperfusion ie low CO,ionotro,bp
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| Define cardiac index CI and normal values? what does that mean if you have low CI? what are the sign and symptoms of low CI? | 1.CO per m2 ( body size)2. Nor.range of 2.8-4.2 L/min/M2. target/goal in shock is >2.2. 3. low value shows impaired hypoperfusion of organs.4.UOP(kindey), mental status change/poor thinking(brain), cold clammy skin/periphery(vasoconstriction to compensate
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| Define stroke volume SV? What are determinants of SV? what is normal SVR value ? | 1.Volume ejected/ beat. 2.Preload ( frank starling mechanism. PCWP/pulmonary capillary wedge pressure, measure LV preload, CVP/central venous pressure, measure Rigt Ventri. preload), afterload( measured by SVR/systemic vascular)contractility.3.SVR nor 900
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| Define Mean arterial pressue MAP? what's the normal value? ref sign and symptoms of low organ perfusion in CI definition card. | CO x SVR or after load. or 1/3(SBP)+2/3(DBP).it show organ perfusion.average pressure throughout the cardiac cycle of contraction. During cardiac cycle 2/3 of the time is spent in diastole and 1/3 in systole. N-90-110. target MAP>65 or SBP <90 if MAP valu
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| Define pulse pressure | difference between SBP and DBP. indicator of arterial wall tension/ arterial “stiffness” (arteriosclerosis and/or atherosclerosis). can predict cardiovascular risk (isolated systolic hypertension).
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| How do you measure preload. whats normal. what do you mean by high or low preload and how do you treat those? | Measured hemodynamically by PAOP/pulmonary artery occlusive pressure, PCWP/pulmonary capillary wedge pressure. it measure left ventricular preload.optimal <12 mmg/hg(15-18).CVP measure R. ventricular preload / R. ventricular filling pressure. normal<5.dir
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| Phathophysiology | MI or HTN lead to de^ CO, which leads to activation of neurohormaone Angio 2, aldosterone(fluid overload/preload), Nor epi ( in^ afterload), endothelin 1, natriuretic peptide, Arginine Vasopressin(AVP), proinflamatory cytokines. These neurohormones activ
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| What happens in left and right sided HF. | Left HF-Blood not effectively pumped from the left ventricle to the peripheral circulation. cause pul. edema if not treated end up in R. side HF.
Right-Blood not effectively pumped from the right ventricle into the lungs.leads to peripheral symptoms.
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| General Signs and Symptoms of CHF: | Fatigue due to de^ CO. dyspnea due to fluid retention,.tachycardia (compensation),cardiomegaly, nocturea(body compensate for the lack of perfusion at night, poor thinking(lack of brain perfusion).
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| symptoms of left side HF |
DOE,
PND,
Pulmonary edema,
Orthopnea,
Tachypnea,
Cough,
Bibasilar rales,
S3 Gallop rhythm,
Pleural effusions.
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| symptoms of right side HF | N & V, anorexia
Abdominal distention,
JVD,
Spleenomegaly,
Hepatomegaly,
HJR,
Peripheral edema (“tightness”),
Ascites.
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| Diagnosis | Signs and symp.
Labs- B type natriuretic peptide increased in fluid overload/peload. s.creatin in^ in hypoperfusion to kidney
Echocardiography <40% (normal 60%)
Alternatives: cardiac catheterization to measure hemodynamics like co, CI, preload,afterloa
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| Classifying and Categorizing the HF Patient | 1.Functional Classification by NYHA,
2. Hemodynamic Subset - used for treating decompensated HF and cardiogenic shock,
3.HF staging by ACC/AHA -used for treating stable HF
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| New York Heart Association Functional Classification based on severity of symptom | Class I No limitation of physical activity,
Class II Slight limitation of physical activity,
Class III Marked limitation of physical activity,
Class IV Unable to carry on any physical activity w/o discomfort.
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| What are ACC/AHA Stages of Heart Failure. ADV of staging system- cannot push back from stage C to B. it recognizes evolution and progression of the disorder AND risk factor modification and preventive treatment strategies (stable HF) | Stage A
High risk; no structural abnormalities. normal EF.
Stage B-
Structural abnormalities; no symptoms. normal EF.
Stage C-
Structural abnormalities; current or previous symptoms.
Stage D-
End stage symptoms refractory to treatment.
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| what are Hemodynamic Subsets of HF?( use a pulmonary artery catheter or swan -ganz catheter to measure CO, R, L intra cardiac pressure ) used to tx decompensated HF and to evaluate rx is working | Subset I Normal -warm ,dry (CI > 2.2,PCWP < 18).
Sub. II Pulmonary Congestion/high preload.warm,wet(CI > 2.2,PCWP > 18).
Sub.III Hypoperfusion.cold,dry(CI < 2.2, PCWP < 18)
Sub. IV Pulmonary Congestion & Hypoperfusion.cold, wet(CI < 2.2,PCWP>18
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| goals of therapy and what is the cause of death | 1.Remove or mitigate the underlying cause.2. Relieve symptoms and improve quality of life.3.Prevent occurrence or development / progression. dx is prevented/ controlled but not cured.death of HF is due to arrhythmia-use (ICD) better than rx in systolic HF
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| nonpharmacologic measures of treatment? How do you determine fluid overload? how do u treat it/ | 1.Physical activity in stable HF.limit in fluid overload 2.Restriction of Na,water intake in fluid overload.< 2gm of Na, <2L/day of fluid. Wt gain >1Lb/day X several consecutive days or >3-5lb/ week show fluid overlaod.also dyspnea,orthopnea,pul.edema.tx
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| 5 Drug therapy for routine use of stable HF- systolic dysfunction | ACEI, ARB , beta blocker ,Diuretics , aldosterone antagonists, digoxin
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| Drug therapy for decompensated HF- systolic dysfunction. What are vasoactive agents? when do u use vasoconstrictors. | loop diuretics de^ preload, fluid overload/high PCWP.may add vasodilators to de^preload.CI is low with low MAP give pressoer agent dopamine.low CI with symptomatic low SBP <90/ worsening of RF, inotropes, if no symptom/>90 SBP,IV vasodilator. vasoactive-i
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| Drug therapy for diastolic dysfunction |
Beta blockers and non DHP to decrease HR and give more time to fill heart.
Diuretic for fluid overload.
Amodarone if AF.
Treat HTN
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| Treatment of stage A and goals | Pts with no symptoms only risk factors. Goals: control HTN, lipid disorders, metabolic syndrome, smoking cessation, Discourage alcohol, Encourage regular exercise. Therapy:ACEI or ARB in patients for vascular disease or diabetes
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| Treatment of stage B and goals | Pts with no symptoms but have str. Disease. Goals:All measures under Stage A. Therapy:ACEI or ARB + Beta-blockers. only monotherapy accepted
is ACEI in HF.
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| Treatment of stage C and goals | Pts,symptom of fluid/congestion &decrease EF <40%. Goals, All Stage A ,B. Na restriction. Therapy, ACEI + beta blockers + digoxin .add diuretics if fluid overload. if no relief, aldosterone antagonists, ARBs, hydralazine/nitrates. Devices-ICD/CRD
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| Treatment of stage D and goals | symptomatic at rest despite maximal medical therapy. Goals-All measures under A, B and C (as appropriate). Treat each subset like decompensated HF/ cardiogenic shock with ionotropic/ vasodilators. device or surgery- ICD/CRD for arrhythmia, Heart transplan
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| Clinical pearls- ACE/ ARB in HF | ACEI or ARB esp in patients for vascular disease or diabetes. reduce further injury and prevent remodeling and EF(antagonize compensatory mechanism).
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| Clinical pearls -ACEI in HF, place in therapy and benefit in HF | The only RX for monotherapy in stable HF. attenuating the deleterious effects of neurohormones, prevent remodeling and EF. de^ progression of HF. improve symptoms. de^ mortality . de^ preload and afterload.symptomatic improvement in weeks. Strat low go s
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| Clinical pearls- ARB In HF, agents and place in therapy | losartan , candensarten, valsartan FDA approved for HF. May be used if intolerant to ACEI, but not a monotherapy. May be added to ACE in stage 3 or 4 HF if BP is not controlled with other RX. decrease preload and afterload.
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| Clinical pearls- Beta blocker/BB in stable HF only | only 3 in bb aproved in HF -bisoprolol, Toprol XL, coreg.Bisoprolol eliminated kidney.Not a monotherapy. use in HF due to its effect to antagonize catecholamine compensatory mechanism. it has a negative ionotropic effect. so D/c in decompensation.but neve
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| Clinical pearls of rx in HF- BB | De^ sympathetic compensatory mechanism. de^myocardial O2 demand. De^ progression of disease in HF.less mortality.neg. iono & chronotropic.hold when unstable stage or volume overload.Symptom worsen in the beginging of treatment then get better
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| Clinical pearls- Diuretic in HF | Diureticsfor symptomatic treatment of fluid overload(loop is most efficient) if wt increased 3-5/b per week.Work same day. Don’t decrease moratlity.decrease preload and fluid overlaod/PCWP.Still monotherapy not accepted stable HF.end pt of Tx-decrease wt
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| Clinical pearls- aldosterone antagonist in HF | It decrease the neurohomone release in HF, It de^ progression of disease in HF. de^ afterload/SVR. If pt has still high BP after other treatment
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| Other rx for stable HF | • Hydralazine/ Nitrates, if bp is not controled
• DHP CCB esp amlodipine, felodipine in systolic HF since less negative ionotripic effect.
• Non DHP CCB good to decrease HR in diastolic HF
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| Clinical pearls of treating sudden cardiac death/SCD in HF | SCD is the a common cause of death in HF. Usually VF /VT. Antiarrhythmic rx not useful in systolic HF. Use ICD or CRT in functional calss 3 or 4 of HF. ICD for primary and secondary prevention to improve survival in HF. for diastolic HF,use amiodarone
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| Clinical pearls of rx in HF- digoxin | Is positive ionotriopic agent, which increase myocaridal ca and thus cardiac output.neg.chronotrop.Digoxin- TDM 0.5-1 ng/ml . >2 toxicity
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