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on 23-Apr-2016 (Sat)

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Flashcard 1335194684684

Tags
#dennett #philosophy
Question
You can’t do much carpentry with your bare hands and [...] —BO DAHLBOM
Answer
You can’t do much carpentry with your bare hands and you can’t do much thinking with your bare brain. —BO DAHLBOM


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pdf

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Flashcard 1335197830412

Tags
#cardiology
Question
What is a diastolic heart failure?
Answer
Heart failure with preserved ejection fraction, usually with a restrictive pattern where it can't relax properly


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Flashcard 1335199665420

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#cardiology
Question
What are features of diastolic heart failure?
Answer
  • Impaired relaxation – energy dependant
  • Increased LV stiffness (not always hypertrophied)
  • Atrial dysfunction (esp. if they are dilated)
  • F>M (unclear why – yet systolic dysfunction M>F)


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Flashcard 1335201500428

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#cardiology
Question
[...] may decompensate clinically and develop dilated chamber – all roads lead to a “Dilated” cardiomyopathy.
Also may experience sudden and unexpected death through an arrhythmic mechanism.
Answer
Diastolic heart failure


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Flashcard 1335203597580

Tags
#cardiology
Question
Diastolic heart failure may [...] clinically and develop dilated chamber – all roads lead to a “Dilated” cardiomyopathy.
Also may experience sudden and unexpected death through an arrhythmic mechanism.
Answer
decompensate


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Flashcard 1335205432588

Tags
#cardiology
Question
Diastolic heart failure may decompensate clinically and develop [...] – all roads lead to a “Dilated” cardiomyopathy.
Also may experience sudden and unexpected death through an arrhythmic mechanism.
Answer
dilated chamber


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Flashcard 1335207267596

Tags
#cardiology
Question
Diastolic heart failure may decompensate clinically and develop dilated chamber – all roads lead to a “ [...] ” cardiomyopathy.
Also may experience sudden and unexpected death through an arrhythmic mechanism.
Answer
Dilated


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Flashcard 1335209102604

Tags
#cardiology
Question
Diastolic heart failure may decompensate clinically and develop dilated chamber – all roads lead to a “Dilated” cardiomyopathy.
Also may experience [...] through an arrhythmic mechanism.
Answer
sudden and unexpected death


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Flashcard 1335210937612

Tags
#cardiology
Question
Diastolic heart failure may decompensate clinically and develop dilated chamber – all roads lead to a “Dilated” cardiomyopathy.
Also may experience sudden and unexpected death through an [...] mechanism.
Answer
arrhythmic


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Flashcard 1335212772620

Tags
#cardiology
Question
What is another type of cardiomyopathy?
Answer
Arrhythmogenic right ventricular cardiomyopathy (ARVC)


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Flashcard 1335214607628

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#cardiology
Question
In Arrhythmogenic right ventricular cardiomyopathy (ARVC):

There is increased [...] tissue infiltration into the right and left [...]
Answer
fibrofatty
ventricles


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Flashcard 1335216442636

Tags
#cardiology
Question
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is most associated with [...] mutations
Answer
desmosomal protein


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Flashcard 1335218277644

Tags
#cardiology
Question
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is potentially [...]
Answer
heritable


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Flashcard 1335220112652

Tags
#cardiology
Question
Arrhythmogenic right ventricular cardiomyopathy (ARVC) can cause [...]
Answer
sudden death –arrhythmia


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Flashcard 1335222471948

Tags
#cardiology
Question
What is the triangle of dysplasia in Arrhythmogenic right ventricular cardiomyopathy (ARVC)?
Answer
location where one typically finds increased fibrofatty tissue replacement in wall of right ventricle


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Flashcard 1335224306956

Tags
#cardiology
Question
What are other types of heart muscle disease that can cause heart failure
Answer
  • Endocardial fibroelastosis
  • Thyrotoxicosis DCM
  • Ventricular septal defect
  • Giant cell Myocarditis


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Flashcard 1335226141964

Tags
#cardiology
Question
What is Cor Pulmonale?
Answer
Right heart failure


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Flashcard 1335227976972

Tags
#cardiology
Question
Cor pulmonale is right heart failure associated with [...]
Answer
pulm HTN


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Flashcard 1335229811980

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#cardiology
Question
Cor pulmonale is typically secondary to [what 2 diseases] with left to right shunts
Answer
pulmonary disease or congenital heart disease


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Flashcard 1335231646988

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#cardiology
Question
Cor pulmonale is typically secondary to pulmonary disease or congenital heart disease with [...]
Answer
left to right shunts


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Flashcard 1335233481996

Tags
#cardiology
Question
Stroke volume is a function of [3 things]
Answer
preload, afterload, and contractility


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Flashcard 1335235317004

Tags
#cardiology
Question
preload is
Answer
the amount of blood in the ventricle at the end of diastole


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Flashcard 1335237152012

Tags
#cardiology
Question
afterload is
Answer
the load the ventricles must overcome before blood can
be ejected


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Flashcard 1335238987020

Tags
#cardiology
Question
contractility is
Answer
the amount of force ventricles can generate


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Flashcard 1335240822028

Tags
#cardiology
Question
What are the hemodynamic alterations in Heart Failure?
Answer
-increased afterload
-decreased contractility

-which causes decreased stroke volume

-and the preload will increase to try and maintain cardiac output (but not perfect) - end diastolic pressure will also increase


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Flashcard 1335242657036

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#cardiology
Question
What is acute decompensated heart failure?
Answer
-the pt is in unstable balance with chronic LV dysfn (on the tipping point)
-Adverse further changes in hemodynamics can
result in “decompensation” - tipping pt over to heart failure


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Flashcard 1335244492044

Tags
#cardiology
Question
normal ejection fraction is [...]
Answer
60%


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Flashcard 1335246327052

Tags
#cardiology
Question
Acute decompensation is
Answer
rapid onset of signs and
symptoms of heart failure


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Flashcard 1335248162060

Tags
#cardiology
Question
Acute decompensation can be the [...] or an acute
worsening of chronic heart failure
Answer
first presentation


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Flashcard 1335249997068

Tags
#cardiology
Question
Acute decompensation can be the first presentation or an [...] of chronic heart failure
Answer
acute worsening


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Flashcard 1335251832076

Tags
#cardiology
Question
With LV failure, there is increased [...] -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure
Answer
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure


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Flashcard 1335253667084

Tags
#cardiology
Question
With LV failure, there is increased LV filling pressures -> [...] -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure
Answer
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure


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Flashcard 1335255502092

Tags
#cardiology
Question
With LV failure, there is increased LV filling pressures -> increased LA pressure -> [...] -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure
Answer
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure


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Flashcard 1335257337100

Tags
#cardiology
Question
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> [...] -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure
Answer
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure


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Flashcard 1335259172108

Tags
#cardiology
Question
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> [...] -> increased RA pressure -> increased systemic pressure
Answer
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure


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Flashcard 1335261269260

Tags
#cardiology
Question
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> [...] -> increased systemic pressure
Answer
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure


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Flashcard 1335263104268

Tags
#cardiology
Question
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> [...]
Answer
With LV failure, there is increased LV filling pressures -> increased LA pressure -> transmission of back-pressure -> pulm edema (d/t HTN) -> obligatory rise in driving pressure of RV to compensate (increased RV pressure) -> increased RA pressure -> increased systemic pressure


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Flashcard 1335264939276

Tags
#cardiology
Question
Symptoms of Acute Decompensated
Heart Failure
Answer
Low Forward Output
‐ Fatigue (no longer same CO)
‐ Weakness and muscle atrophy (muscles can't use O2 same way anymore either)
‐ Exercise intolerance (degree directly related to prognosis)
‐ Lightheadedness
‐ Syncope

Congestion
– Shortness of breath
– Orthopnea
– PND
– Peripheral edema
– Abdominal pain, bloating


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Flashcard 1335266774284

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#cardiology
Question
Potential physical exam findings
in HF patients
Answer
• Vital signs: tachycardia, hyper or hypo‐tension,
diminished pulse amplitude
• JVP elevated, + hepatojugular reflux
• Peripheral edema, ascites, pulsatile liver
• Crackles over lung fields
• Soft S1, +S3, murmur (usually mitral regurgitation)


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Flashcard 1335268609292

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#cardiology
Question
Patient Profiles of Acute Decompensated Heart Failure
-what would you do for them?
Answer
-Dry & Warm + wet & warm -> consider vasodilators (to unload the heart)
-dry & cold + wet & cold -> consider inotropes (to warm them up)

-low perfusion = cold
-high congestion = wet (dry out these pt's)


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Flashcard 1335270706444

Tags
#cardiology
Question
Some helpful tests in acute decompensated
heart failure
Answer
ECG
– MI, ischemic changes, arrhythmia conduction
abnormality
Labwork
– Renal function, electrolytes, troponin, CBC
– Brain natriuretic peptide (BNP) +/‐


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Flashcard 1335272541452

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#cardiology
Question
BNP is released when [...]
Answer
the ventricles are stretched


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Flashcard 1335274376460

Tags
#cardiology
Question
BNP measurement helps as an adjunctive test in HF when [...]
Answer
uncertain dx


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Flashcard 1335276211468

Tags
#cardiology
Question
Some helpful tests in acute decompensated
heart failure ‐ Imaging
Answer
• CXR – high yield - check for pulm edema
• Echocardiogram – LV/RV function, valves, pericardium;
should be done if no recent assessment
• Heart catheterization as indicated - measure pressure inside heart
– Active ischemia, need for accurate hemodynamic information


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Flashcard 1335278046476

Tags
#cardiology
Question
Acute decompensated heart failure is a
[...]
Answer
medical emergency


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Flashcard 1335279881484

Tags
#cardiology
Question
What are the general principles of therapy for acute decompensated heart failure?
Answer
• Stabilize, monitor frequently for improvement
• Identify precipitating cause(s)
• Initiate drugs to improve symptoms
• Initiate drugs to impact long‐term survival
• Ensure appropriate follow‐up plan


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Flashcard 1335281716492

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#cardiology
Question
How do you ensure pt stability in acute decompensated heart failure?
Answer
• Elevate head of bed
• Frequent vital signs, telemetry if unstable
• Oxygen to keep O2 sats > 92%
• Establish IV access
– Start diuretic and/or vasodilator (lowers hydrostatic pressure in pulm vessels to get fluid out of pulm interstitium) therapy as
appropriate
• Non invasive positive pressure ventilation might
be needed (only for pts with pulm edema)


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Flashcard 1335283813644

Tags
#cardiology
Question
How does positive pressure ventilation help in heart failure?
Answer
The positive airway pressure splints the airways open, driving transudated fluid out of the alveoli
-this decreases preload to LV, reducing the work of breathing

-decreases LV preload by minimizing venous return to the LA & LV
-may increase afterload of RV


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Flashcard 1335285648652

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#cardiology
Question
What are Drugs that improve hemodynamics and make people
feel better
Answer
• Diuretics
• Morphine
• Digoxin
• Vasodilators
• Inotropes


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Flashcard 1335287483660

Tags
#cardiology
Question
What is a loop diuretic used for in heart failure?
Answer
a tool to manage fluid
overload/congestion
-commonly used b/c potent
-Symptom control for short or long-term use

• IV diuretics (furosemide) more effective
– Gut edema might limit oral absorption
– Causes pulmonary venodilation ~5‐10mins
– Diuretic effect ~15‐20 mins (very immediate effect)
• High doses can worsen renal function (b/c low ECF volume)
• Diuretic resistance can occur (will need higher and higher doses)
• Ototoxicity at very high doses

-brings down LV end diastolic pressure/volume


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Flashcard 1335289318668

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#cardiology
Question
How does morphine help in heart failure?
Answer
• Can be given in a monitored and supervised
setting
• Pulmonary veno‐dilator, reduces preload
• Reduces sympathetic activation
• Reduces the sensation of being dyspneic
• Monitor for hypotension, respiratory
depression


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Flashcard 1335292202252

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#cardiology
Question
digoxin & cardiac glycosides [do what]
Answer
increase contractility

-via accumulation of Ca within the myocyte


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Flashcard 1335294037260

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#cardiology
Question
What role does digoxin play in heart failure
Answer
Digoxin ‐ Pearls
• Very weak effect on myocardial contractility
• Increases vagal tone to slow heart rate
– Most useful in patients with atrial fibrillation
• Improves symptoms long‐term
• Caution: narrow therapeutic index
– Toxicity is life‐threatening


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Flashcard 1335297182988

Tags
#cardiology
Question
What do vasodilators do in acute heart failure?
Answer
definition: Vaso-active agent that decreases mean arterial pressure or increases venous capacitance

-decreases afterload & preload (unloads the heart to increase stroke volume)
-don't use if hypotensive
-e.g. nitroglycerin, nitroprusside, hydralazine

Nitrates best for short term use
- can cause significant drop in BP
- tachyphylaxis common
- cyanide toxicity with nitroprusside


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Flashcard 1335297707276

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#cardiology
Question
What do inotropes do in heart failure?
Answer
definition: Agent that increases myocardial contractility; may also have vasoactive actions

-may increase/decrease afterload & preload (another slide said decreases afterload & preload)
-e.g. dobutamine (beta agonists), milrinone (phosphodiesterase inhibs), dopamine, norepi/epi

NOT routinely used (can hasten death)
– For patients with very low cardiac output or
cardiogenic shock only
– Can cause tachycardia, arrhythmia, hypotension


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Flashcard 1335300853004

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#cardiology
Question
How to optimize medical therapy in acute heart failure
Answer
• Attempt to initiate and optimize ACE inhibitor (increases survival) and beta blocker
for LV systolic dysfunction when patients is stable
• Blood pressure, renal function, electrolytes should be monitored
when titrating ACEi
– ~30% rise in creatinine may be expected with ACEi
• Start beta blocker only when patient is stable and compensated
– Negative inotrope effects in short‐term
– Avoid abrupt withdrawl


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Flashcard 1335302688012

Tags
#cardiology
Question
A few medications to avoid in acute
decompensated heart failure
Answer
• Calcium channel blockers
– Negative inotrope effects
• Routine administration of anti‐arrhythmic drugs
• Non‐steroidal anti‐inflammatory agents
– Promote hypertension, Na retention


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Flashcard 1335304523020

Tags
#cardiology
Question
How can you prevent further hospitalization in acute heart failure?
Answer
• Don’t forget the other stuff
– Limit Na intake
– Limit fluid intake <1.5 L/day
– Exercise prescription and cardiac rehabilitation
– Early and regular follow‐up for medication titration
• Difficult to manage patients should be referred to
a multi‐disciplinary disease management clinic


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Flashcard 1335306358028

Tags
#cardiology
Question
Causes of heart failure:
Underlying structural heart diseases
Answer
A useful approach is to classify causes anatomically:
Coronary arteries MI, chronic ischemic heart disease
Myocardium Cardiomyopathies, with or without identifiable known cause
Endocardium Valvular disease (stenosis/regurgitation)
Pericardium Constrictive pericarditis
Systemic diseases Anemia, nutritional, metabolic


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Flashcard 1335308193036

Tags
#cardiology
Question
What is the spectrum of heart failure?
Answer
Stage A - at risk of developing stage B
High risk (longstanding HTN, DM, smoking, etc), no symptoms
Stage B - e.g. post-MI; not HF, but vulnerable
Structural disease
No symptoms
Stage C - acute (PE) or chr
Symptomatic
Stage D - palliative care, devices, transplant
Refractory symptoms
Very advanced HF


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Flashcard 1335310028044

Tags
#cardiology
Question
What neurohumoral activation happens when the heart begins to fail?
Answer
when CO & systemic BP decreases

1) sympa is first activated (NE/E)
2) over days-weeks, RAAS is activated
3) last stage is non-osmotic release of vasopressin (seen in sickest pt's, measured by low serum Na)

-all 3 lead to augmented HR, contractility vasoconstriction, decreased renal excretion of Na/H2O -> restoration of circulating volume/preload & CO (initially adaptive)


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Flashcard 1335312125196

Tags
#cardiology #exam
Question
What are the concepts under remodelling? What is the underlying mechanism?
Answer
Anatomic changes in the ventricle that are
initially adaptive to hemodynamic stress
following myocardial injury
• Altered geometry and cell biology of the
myocardium later becomes maladaptive as it
is mechanically disadvantageous
Neurohumoral activation is the key underlying
mechanism


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Flashcard 1335313960204

Tags
#cardiology
Question
For a given ejection fraction,
stroke volume is greater with [...] hypertrophy
Answer
eccentric

-b/c starting with larger load


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Flashcard 1335315795212

Tags
#cardiology
Question
LV hypertrophy (concentric hypertrophy) is seen with [...]
Answer
increased pressure load/wall tension

-thickened wall helps to reduce wall tension


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Flashcard 1335318154508

Tags
#cardiology
Question
[...] is a central
mechanism of progressive HF
Answer
Neurohumoral activation
-myocardial insult -> LV dysfn -> neurohumoral activation -> progressive LV remodelling (cycles back to LV dysfn)


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Flashcard 1335320251660

Tags
#cardiology
Question
[...] is a principal target for medical therapy in decompensated heart failure
Answer
Neurohumoral activation


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Flashcard 1335322086668

Tags
#cardiology #exam
Question
What's observed with diastolic HF?
Answer
-impaired filling (stiff)
-HF with preserved ejection fraction (systolic fn)
-normal LV size
-concentric hypertrophy
-increased wall thickness
-diastolic pressure has to increase to maintain same preload

-may coexist with systolic HF


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Flashcard 1335323921676

Tags
#cardiology #exam
Question
what's observed with systolic HF?
Answer
-impaired contraction
-low LV ejection fraction
-LV dilatation
-eccentric hypertrophy (to augment stroke volume)
-normal wall thickness

-may coexist with diastolic HF


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Flashcard 1335328378124

Tags
#cardiology
Question
non-pharm therapies for chr HF
Answer
• Restrict Na intake <2g / day
• Limit fluid intake < 1.5 L / day
• Monitor weight daily
• Appropriate exercise


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Flashcard 1335330999564

Tags
#cardiology
Question
drugs that can make ppl feel better in chr HF
Answer
• Diuretics
• Digoxin
• Inotropes


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Flashcard 1335332834572

Tags
#cardiology
Question
drugs that improve survival in chr HF
Answer
• ACE inhibitors / Angiotensin II Receptor Blockers (ARBs)
• Combination Angiotensin Receptor Blockers and Neprilysin Inhibitors (ARNIs)
• Beta Blockers
• Aldosterone antagonists

-these drugs act on the neurohumoral activation to prevent progressive remodelling


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Flashcard 1335334669580

Tags
#cardiology
Question
What should we know about the use of beta blockers in chr HF?
Answer
• Decrease rates of sudden cardiac death (less ischemia, less abn heart rhythm)
• Decrease LV remodelling
• Improve BP in long-term
• Decrease mitral valve regurgitation
• Caveat:
– Negative inotropic effect can paradoxically
worsen HF in decompensated patients (so only start in well compensated pts who can tolerate)


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Flashcard 1335336504588

Tags
#cardiology
Question
aldoesterone receptor antagonists increase the risk of [...]
Answer
hyperkalemia
-does improve survival in HF pts (mild form of diuretic)


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Flashcard 1335338339596

Tags
#cardiology #exam
Question
What are the starting treatments for pts with chr HF?
Answer
• All patients with left ventricular systolic
dysfunction (ejection fraction < 40%) should be on an ACE inhibitor and beta blocker
• Patients with symptomatic heart failure
and very low ejection fraction should be on
an aldosterone blocker (higher stage)


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Flashcard 1335340174604

Tags
#cardiology
Question
What can we do for pts with more advanced HF?
Answer
shocking - implantable cardioverter defib
pacing - cardiac resynchronization (pacing both ventricles)
pumping - longterm ventricular assist device


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