on 23-Apr-2016 (Sat)

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#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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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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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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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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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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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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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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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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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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Question

What is another type of cardiomyopathy?

Answer

Arrhythmogenic right ventricular cardiomyopathy (ARVC)

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Question

In Arrhythmogenic right ventricular cardiomyopathy (ARVC):

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

Answer

fibrofatty
ventricles

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Question

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is most associated with [...] mutations

Answer

desmosomal protein

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Question

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is potentially [...]

Answer

heritable

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Question

Arrhythmogenic right ventricular cardiomyopathy (ARVC) can cause [...]

Answer

sudden death –arrhythmia

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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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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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Question

What is Cor Pulmonale?

Answer

Right heart failure

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Question

Cor pulmonale is right heart failure associated with [...]

Answer

pulm HTN

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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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Question

Cor pulmonale is typically secondary to pulmonary disease or congenital heart disease with [...]

Answer

left to right shunts

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Question

Stroke volume is a function of [3 things]

Answer

preload, afterload, and contractility

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Question

preload is

Answer

the amount of blood in the ventricle at the end of diastole

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Question

afterload is

Answer

the load the ventricles must overcome before blood can
be ejected

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Question

contractility is

Answer

the amount of force ventricles can generate

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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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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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Question

normal ejection fraction is [...]

Answer

60%

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Question

Acute decompensation is

Answer

rapid onset of signs and
symptoms of heart failure

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Question

Acute decompensation can be the [...] or an acute
worsening of chronic heart failure

Answer

first presentation

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Question

Acute decompensation can be the first presentation or an [...] of chronic heart failure

Answer

acute worsening

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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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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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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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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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#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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#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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#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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#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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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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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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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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Question

BNP is released when [...]

Answer

the ventricles are stretched

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Question

BNP measurement helps as an adjunctive test in HF when [...]

Answer

uncertain dx

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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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Question

Acute decompensated heart failure is a
[...]

Answer

medical emergency

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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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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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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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Question

What are Drugs that improve hemodynamics and make people
feel better

Answer

• Diuretics
• Morphine
• Digoxin
• Vasodilators
• Inotropes

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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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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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Question

digoxin & cardiac glycosides [do what]

Answer

increase contractility

-via accumulation of Ca within the myocyte

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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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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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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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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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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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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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#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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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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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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#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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Question

For a given ejection fraction,
stroke volume is greater with [...] hypertrophy

Answer

eccentric

-b/c starting with larger load

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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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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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Question

[...] is a principal target for medical therapy in decompensated heart failure

Answer

Neurohumoral activation

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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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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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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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Question

drugs that can make ppl feel better in chr HF

Answer

• Diuretics
• Digoxin
• Inotropes

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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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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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Question

aldoesterone receptor antagonists increase the risk of [...]

Answer

hyperkalemia
-does improve survival in HF pts (mild form of diuretic)

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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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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