Heart Failure Part 1

Front 1

What is a simplified definition of heart failure (think Nichols) and explain the pathway.

Back 1

Heart failure = pump failure --> inadequate perfusion --> not enough blood where it needs to be--> inadequately pumped blood backs up (not enough where it needs to be/too much where it is not needed)

Front 2

What are the symptoms of heart failure?

Back 2

Symptoms associated with inadequate perfusion or those associated with blood backup under pressure with fluid transudation

Increased pulmonary venous pressure

Front 3

What does increased pulmonary venous pressure cause even before transudation of fluid into the lungs?

Back 3

Dyspnea

Front 4

What cause central venous pressure to increase and what causes it to decrease?

Back 4

Increase = volume overload
Decrease = volume depletion

Front 5

True or false. There is a wide range of normal volumes and pressures.

Back 5

True

Front 6

What is the normal range of central venous pressure?
Thus, what is the average of normal central venous pressure (CVP)?

Back 6

2-8 mm Hg
6 mm Hg

Front 7

How do you determine CVP?

Back 7

Physical examination
Tip of central venous catheter in superior vena cava

Front 8

A CHF patient has a CVP of 5. How do you determine if this was an increase or a decrease from normal?

Back 8

Given bolus of fluid, if number goes up and stays up, volume depletion is not the problem. If number goes up then drops again, patient may have heart failure and volume depletion.

Front 9

What could volume depletion be due to?

Back 9

Intestinal hemorrhage due to ischemia due to heart failure.

Also painless spontaneous retroperitoneal hemorrhage from anticoagulation.

Front 10

What are the equations relating stroke volume and end volumes?

Back 10

SV = LVEDV-LVESV
LVESV = LVEDV-SV

Front 11

What is the normal value range for LVEDP?

Back 11

4mm Hg --> 12 mm Hg
Use 10 mm Hg as average or "normal"

Front 12

What are the normal LVEDV ranges?

Back 12

65 ml --> 240 mL
Use 120 mL as normal (we use 150 mL in calculations)

Front 13

What is the normal stroke volume range?

Back 13

55 mL --> 100 mL

Use 70 mL for normal (but we use 100 mL in teaching calculations)

Front 14

What are the normal EF ranges?

Back 14

50% --> 75%
60% is an average of normal, but use 67% (2/3) for teaching.

Front 15

What are normal LVESV ranges?

Back 15

15 mL --> 145 mL
Use 50 mL as normal LVESV

Front 16

What would be the change in these components from a normal heart to a failing heart (increase or decrease)

LVEDP
LVEDV
SV
EF
LVESV

Back 16

LVEDP = increase
LVEDV = increase
SV = decrease
EF = decrease
LVESV = increase

Think of a DILATED CM in heart failure.

Front 17

What is the initial symptom of heart failure? When is it observed?

Back 17

Dyspnea
With exertion

Front 18

True or false.
Most heat failure patients only exhibit failure on one side?

Back 18

False!
Most have both left and right heart failure

Front 19

What is the threshold for heart failure when patients begin to exhibit symptoms (think stroke volume)?

Back 19

25% reduction in forward stroke volume

Front 20

What does sever acute uncompensated aortic regurgitation require?

Back 20

Emergency surgery!

Front 21

True or false. Mitral valve regurgitation can either be a cause of heart failure or an effect of it.

Back 21

True

Front 22

What type of murmur does mitral regurgitation cause?
What type of murmur does mitral stenosis cause?

Back 22

Systolic murmur (ventricular pumping)
Diastole

Front 23

Aortic regurgitation causes a murmur during what?
When does aortic stenosis cause a murmur?

Back 23

Diastole
Systole

Front 24

What are four symptoms of left heart failure?

Back 24

1. Dyspnea on exertion --> dyspnea at rest
2. Orthopnea (shortness of breath when lying flat)
3. PND (paroxysmal nocturnal dyspnea)
4. Fatigue

*JUST THINK TIRED AND CAN'T BREATHE!

Front 25

What are two symptoms of right heart failure?

Back 25

1. Edema of feet, ankles, legs
2. Abdominal distention

Front 26

What are signs of left heart failure? (4)

Back 26

1. Bibasilar pulmonary crackles
2. Tachycardia
3. S3
4. Pedal, ankle, or leg edema (by different mechanism than right sided)

Front 27

What are the signs of right heart failure?

Back 27

1. Pedal, ankle, or leg edema
2. Jugular venous distention
3. Hepatomegaly
4. Ascites (fluid accumulation in abdominal cavity)

*JUST THINK EVERYTHING BELOW THE HEART GETS FULL OF WATER (the backed up pressure)

Front 28

What is the pathophysiologic mechanism of edema?
LEFT SIDED HEART FAILURE

Back 28

Draw this out!

Front 29

Left heart failure causes pulmonary edema by causing a buildup of ___________ in the _________, _________, __________ and eventually the __________.

Back 29

Pressure
Left ventricle --> left atrium --> pulmonary veins --> pulmonary capillaries

Front 30

At what pulmonary capillary pressure does fluid start to transudate out of them into the interstitium causing interstitial pulmonary edema?

Back 30

20 mm Hg (about double that of normal)

Front 31

At what pulmonary capillary pressure does fluid start to transudate out into the alveoli causing alveolar pulmonary edema?
What is this associated with?
What can also cause alveolar edema?

Back 31

25 mm Hg
Wet moist crackles
Acute lung injury

Front 32

What two things can cause acute pulmonary injury? How can you ell them apart?

Back 32

Septic shock = normal pulmonary capillary pressure
Hemorrhagic shock = low pulmonary capillary pressure

Front 33

How do you measure pulmonary capillary pressure?
What is this technique called?

Back 33

Pass a catheter with pressure monitor through SVC, right atrium, right ventricle, and pulmonary artery until it is wedged into the smallest artery it will fit into --> inflate balloon and measure pressure

Swan-Ganz catheterization

Front 34

What is the pulmonary capillary wedge pressure approximately the same as?

What else can t measure?

Back 34

Left atrial pressure and left ventricular end diastolic pressure

Mixed venous O2 sat and cardiac output

Front 35

Most common signs and symptoms of heart failure?

Back 35

Appreciate the order.

Front 36

Label each.

Back 36

Top = systolic heart failure
Middle = normal
Bottom = diastolic heart failure

Front 37

What is associated with systolic heart failure?

Back 37

Many elderly patients develop heart failure with dyspnea, orthopnea, PND and bibasilar pulmonary crackles, but HAVE A NORMAL OR NEAR NORMAL EJECTION FRACTION!
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Front 38

What is associated with normal heart failure?

Back 38

Long-standing hypertension, often with obesity, and concentric left ventricular hypertrophy.
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Front 39

What is associated with diastolic heart failure?
Another name?

Back 39

Noncompliant stiff left ventricles with impaired diastolic function and filling
Heart failure with preserved ejection fraction.

Front 40

Why do heart failure patients have tachycardia?

Back 40

1. SNS
2. E and NE from adrenal

Front 41

Why do HF patients have elevated B-type natriuretic peptide? What does it do?

Back 41

Vasodilation
Increased urinary sodium excretion

Front 42

True or false.

B-type natriuretic peptide (BNP) is counterregulatory.

Back 42

TRUE!

Front 43

If the patient died and came to autopsy, his heart would likely have this gross pathology. Can you describe and diagnose it?
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Back 43

erwerw

Front 44

The condition shown in the previous image can be complicated by the condition shown here; what is it?

Risk of what further complication?

Back 44

Mural thrombus formation
Embolization

Front 45

What is this?
Why did it form?
Will it embolize? Why or why not?

Back 45

Mural thrombus
Myocardial infarction (compare upper and lower wall)
Not likely because it is organizing

Front 46

She has this condition; can you describe and diagnose it?

Back 46

The mitral valve is severely thickened and fibrotic, with shortened and fused chordae tendineae, and the left atrium is severely dilated.

Rheumatic mitral stenosis!

Front 47

What is this?

Back 47

Cardiac apex = best place to hear mitral valve murmurs

Front 48

Do most patients with cor pulmonale have heart failure?
Why do many more patients with right heart failure?

Back 48

No, they are compensated
Because of left heart failure, NOT cor pulmonale

Only a small group of patients with right heart failure due to cor pulmonale

Front 49

ksdjlfksd

Back 49

Atherosclerosis

Front 50

An 80-year-old white male has a history of smoking, hypertension, obesity, diabetes and dyslipidemia.
He presents with increasing dyspnea on exertion, paroxysmal nocturnal dyspnea and 2-pillow orthopnea.
Diagnosis?

Back 50

Heart failure

Front 51

An 80-year-old white male has a history of smoking, hypertension, obesity, diabetes and dyslipidemia. He presents with increasing dyspnea on exertion, paroxysmal nocturnal dyspnea and 2-pillow orthopnea.
His temperature is 37, heart rate 110, blood pressure 110/70, respirations 20 and saturation 95%. He has a third heart sound, but no murmurs. He has pulmonary crackles at both lung bases. His abdomen is soft and
non-tender. He has leg edema up to the knees.
Diagnosis?

Back 51

Heart failure

Front 52

Let’s assume that when his heart was healthy, years ago, his left ventricular end diastolic pressure (LVEDP) was 10 mm Hg and end diastolic volume (LVEDV) was 150 ml, of which his left ventricle ejected two-thirds with each heartbeat, making his stroke volume (SV) 100 ml and ejection fraction (EF) 67%, leaving 50 ml behind, his left ventricular end systolic volume (LVESV).
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Back 52

Answer option D has a markedly elevated LVEDP
of 40 mm Hg, markedly elevated LVEDV of
250 ml, of which only 65 ml (SV) is ejected for
an ejection fraction (EF) of 26%, leaving behind
a very large amount of blood at the end of
systole (LVESV 185 ml), which be associated
with left ventricular dilatation, but do not jump
the gun before you consider the last option.

Front 53

What is B associated with?

Back 53

Answer option B has an LVEDP of 2 mm Hg and
LVEDV of 100 ml, both lower than his previous
baseline, of which 3/4 is ejected (EF 75%),
leaving only 25 ml behind (LVESV). This would
fit much better with the clinical scenario of
someone with a normal heart and severe acute
blood volume loss without time to pull in fluid
to compensate.

Front 54

What is C associated with?

Back 54

Answer option C has a slightly higher LVEDP of
12 mm Hg and doubled LVEDV of 200 ml, of
which half is ejected (EF 50%), but that amount
(SV 100 ml) is the same as his previous normal
baseline; this would be compensated heart
failure.

Front 55

What is E associated with?

Back 55

Answer option E has the same high LVEDP of
40 mm Hg, but low LVEDV of 100 ml, of which
65% is ejected, leaving 35 ml behind (LVESV).
This would fit much better with the clinical
scenario of someone with a stiff noncompliant
heart and impaired diastolic filling

Front 56

50-year-old black male with a history of smoking, gradually progressive dyspnea, dry cough over the
past 4 years, and leg edema for the past 2 months. No orthopnea or paroxysmal nocturnal dyspnea.

Temperature is 37, HR 90, BP 90/70, respirations 30 and saturation 89%. Hands and feet are cool
to the touch. He has jugular venous distension, diffuse dry pulmonary crackles, abdominal distension with hepatomegaly and ascites, and leg edema up to the knees.

Back 56

None of the above! Left heart failure (most common cause of right heart failure)

Front 57

Jugular venous distention, hepatomegaly, ascites, and leg edema are classic findings of what?

Back 57

Right heart failure

Front 58

Patients with cor pulmonale often have dyspnea. What is the dyspnea from?

Back 58

Lung disease that caused heart failure, not the other way around.

Front 59

Pulmonary crackles could be from what?

Back 59

Idiopathic interstitial lung disease --> pulmonary hypertension --> cor pulmonale

Front 60

One thing that distinguishes right heart failure due to cor pulmonale from right heart failure due to left heart failure is that patients with cor pulmonale do not get orthopnea or paroxysmal nocturnal dyspnea; why not?
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Back 60

Orthopnea and paroxysmal nocturnal dyspnea from exacerbation of left heart failure from the increase in venous return from being recumbent.

If pulmonary hypertension is causing the right heart to fail, it does not pump that extra venous return to the left heart.

Front 61

A 30-year-old south Asian female with increasingly disabling dyspnea on exertion, fatigue, palpitations and recent episodes of mild hemoptysis.

Her temperature is 37, heart rate 90, blood
pressure 110/70, respirations 20 and
saturation 97%. Her pulse is irregular. On
cardiac auscultation, she has an opening snap
and a grade III/VI diastolic rumbling murmur.
She has no pulmonary crackles. Her abdomen
is not distended and not tender. She has no
peripheral edema.

Back 61

Mitral stenosis
=diastolic murmur, opening snap sometimes
No left heart failure findings (wet pulmonary crackles)
No right heart failure findings (jugular venous distention, hepatomegaly, ascites and lower edema)

Front 62

A 30-year-old black female food service
worker presents with increasingly disabling
dyspnea on exertion, palpitations, orthopnea
and paroxysmal nocturnal dyspnea, 3 months
after she had her third child.

Her temperature is 37, heart rate 110, blood
pressure 110/70, respirations 30 and
saturation 92%. Her skin is warm. On
auscultation, she has an S3 third heart sound
and bibasilar wet pulmonary crackles. Her
abdomen is mildly distended, but not tender.
She has no peripheral edema.

Back 62

Systolic left heart failure.

Front 63

What are classic symptoms of systolic left heart failure?

What caused her to have low sodium?
What percent of heart failure patients have this?

Back 63

Dyspnea on exertion, orthopnea, and paroxysmal noctural dyspnea

Actually retaining more water than sodium --> dilution
Syndrome of SIADH (antidiuretic hormone)
25%

Front 64

Why do people get heart failure following pregnancy?
Peripartum cardiomyopathy

Back 64

Unknown
Cardiac angiogenic imbalances from complex pregnancy-related immune system and hormonal changes play a role

Front 65

Does heart failure lead to pro-inflammatory cytokine profile?

Back 65

Yes!
TNF, IL-1, and IL-6

Front 66

What would it be?

What would your forward stroke volume be?
Would you have heart failure?

Back 66

120 mL (assuming 100 mL baseline)

60 mL
Yep!

Front 67

What is the average normal EDV?
What amount is left over from last systole?
What amount left from atrium?
Now, with your acute aortic regurgitation,
it is 170 ml (50 ml end-systolic, 60 ml back
from the aorta and only 60 ml from left atrium
instead of 100 ml). Where is the missing 40 ml?

Back 67

150 mL
50 mL
100 mL
Not being returned from the body.

Front 68

True or false.

Severe acute uncompensated aortic regurgitation is a surgical emergency.

Back 68

TRUE!

Front 69

You are a heart valve with a chronic mitral valve regurgitation of 95 mL. How do you cope?

Back 69

1. Increased stroke volume
2. Increased end-diastolic volume
3. Left ventricular dilatation

Front 70

Suppose the best you could do is double normal stroke volume and 90 mL extra end diastolic volume. What would these be?

Will that be enough to avoid heart failure?

Back 70

EDV = 240 mL
Stroke volume = 200 mL

Yes = forward stroke can fall 30 mL before getting heart failure.

Front 71

You are a heart with a mitral valve prolapse. Rupture of chordae have just caused acute regurgitation of 70 mL. How can you cope?

Back 71

1. Increased stroke volume
2. Increased end-diastolic volume

Front 72

Suppose the best you can do is 40% more stroke volume and 13% more end-diastolic volume. What will these be?

Will that be enough to avoid heart failure?

Back 72

EDV = 170 mL
SV = 140 mL

Probably no, if your baseline had been 100 mL, because only 70 mL is going forward.

Front 73

What is the threshold for reduction in forward stroke volume that will cause heart failure (when patients begin to have symptoms)?

Back 73

25% reduction in forward stroke volume