Heart Failure Patho and Patient assessment

What is the number one reason for hospital admission?

Heart Failure </3

What is the 30-day readmission rate for heart failure patients?

25%

When must HF patients be seen after hospitalization?

Within 3-7 days of discharge

If you are older than 40 what is your percent risk of developing HF?

20% risk

what is the mortality rate for HF?

50% mortality rate within 5 years of diagnosis

What is the number one cause of heart failure?

MI

What is heart failure?

A decrease in cardiac output where the heart can’t meet the demands of the body

What is cardiac output?

The amount of blood leaving your heart - CO (mL/min) = Stroke Volume (mL/beat) x HR (beats/min)

Why is cardiac output important?

Blood is the carrier of oxygen to tissues and organs which is required for them to function

Where does deoxygenated blood enter the heart?

Into the right atrium

Where does deoxygenated blood go after leaving the right atrium?

into the right ventricle

where does deoxygenated blood go after leaving the right ventricle?

The lungs

Where does blood go after getting oxygenated in the lungs?

To the left atrium of the heart

Where does oxygenated blood go after the left atrium?

the left ventricle

Where does oxygenated blood go after it leaves the left ventricle?

To the rest of the body bby !!!!

What is right-sided heart failure?

The right ventricle can’t pump enough blood to the lungs

What is left-sided heart failure?

The left ventricle can’t pump enough blood to the tissues and organs that need rest

Which type of heart failure is common? (left or right)

Left-sided heart failure

Which type of heart failure is rare?

right-sided heart failure

What is systolic dysfunction

Problem with pumping - ventricles can fill up but can’t pump (the heart muscles are weakened and can’t squeeze as well)

What is systolic dysfunction also known as?

Heart failure with reduced ejection fraction (HFrEF)

What is diastolic dysfunction?

Problem with filling - ventricles can’t fill but can pump (stiff heart muscles can’t relax normally to make room for blood)

What is diastolic dysfunction also known as?

Heart Failure with preserved ejection fraction (HFpEF)

What is an ejection fraction?

the percentage/fraction of blood that leaves your left ventricle when it contracts

What is a false yet common misconception with ejection fraction?

that all of the blood in your ventricle leaves that space when the heart contracts

What does ejection fraction really represent with blood leaving the heart?

A normal ejection fraction is ~50-70% meaning 30-50% of the blood in your ventricle remains behind after it pumps.

EF = Stroke Volume / End Diastolic Volume

What is HFrEF

Your heart pump does not work so < 40% of the blood in your ventricle leaves when it contracts.

Which type of HF has an Ejection fraction of <40%

HFrEF

What does HFmrEF stand for?

Heart failure with mildly reduced ejection fraction

What is HFmrEF

HFpEF that is getting worse or HFrEF that is getting better

Which type of HF has an ejection fraction of 40-50%

HFmrEF

What is HFpEF

The LV does not fill properly, but does contract, so the same percentage of blood leaves the ventricle but from a smaller starting volume

Which type of HF has an ejection fraction of > 50%

HFpEF

What is the amount of blood in the left ventricle after diastole called?

end diastolic volume

What is a normal end diasolic volume?

~120 mL

What is a normal amount of blood ejected from the heart?

~70 mL

What is the approximate/normal ejection fraction?

70 mL / 120 mL = ~60%

Approximate amount of blood ejected in HFrEF

~30 mL

Amount of blood in left ventricle after diastole in HFrEF

~120 mL

Amount of blood in left ventricle after diastole in HFmrEF

~100 mL

approximate amount of blood ejected in HFmrEF

~45 mL

Amount of blood in left ventricle after diastole in HFpEF

~ 80 mL

Approximate amount of blood ejected in HFpEF

~50 mL

What test is used to diagnose/determine EF?

Echocardiogram (ECHO)

What does an Echocardiogram evaluate?

Evaluates EF/wall motion abnormalities, chambers of the heart, and valves

What is hypoperfusion

Not enough oxygenated blood moving from the heart to perfuse the vital organs

What is congestion in terms of decreased cardiac output?

Blood backs up from the LV to the lungs, possible the RV, and beyond

What are the clinical presentations of decreased cardiac output

hypoperfusion and congestion

Side effects of hypoperfusion

tachycardia, fatigue, cyanosis, cold extremities, organ dysfunction (increased serum creatinine, increased LFTs, and confusion/AMs)

Side effects of congestion

weight gain, SOB, orthopnea, paroxysmal nocturnal dyspnea, pleural effusion on CXR, crackles/rales on auscultation, S3 and S4 (abnormal/additional sounds during Lub Dub), peripheral edema (pitting), B-type natriuretic peptide, jugular venous distention (JVD)

Which test estimates ejection fraction (EF) of the heart (diagnostic tool)?

Echocardiogram

Which test/lab can show cardiac enlargement, pulmonary edema, and pleural effusions?

Chest X-ray

Which test can help identify a cause for HF exacerbation such as ACS or arrhythmias?

ECG

Which labs can show hypoperfusion, hyponatremia, and anemia?

CBC/BMP (complete blood count and basic metabolic panel?)

What levels of BNP (B-type natriuretic peptide) can indicate HF?

> 100 ng/mL

What levels of NT-BNP (N-terminal pro B-type natriuretic peptide) can indicate HF?

> 300 ng/mL

What is an ACC Classification of A?

Patient is at risk for heart failure but without structural heart disease/symptoms of HF

What is an ACC Classification of B?

Structural heart disease but without signs and symptoms of HF

What is an ACC Classification of C?

Structural heart disease with prior or current symptoms of HF

What is an ACC Classification of D?

Advanced heart failure requiring specialized interventions - includes patients with severe symptoms that interfere with their daily life

What is a NYHA Classification of I?

No limitations with ordinary/physical activity - ordinary activities do not cause HF symptoms

What is a NYHA Classification of II?

Slight symptoms with activities of daily living - comfortable at rest but ordinary activity results in HF symptoms

What is a NYHA Classification of III?

Extreme symptoms/marked limitations with activities of daily living - comfortable at rest but less than ordinary activity causes symptoms

What is a NYHA Classification of IV?

Symptoms at rest :(

What do the NYHA Functional Classifications gauge?

The severity of symptoms in those with structural heart disease

Why are myocardial infarctions the most common cause of HF?

When blood supply is cut-off to the muscle so is oxygen. When this happens, the myocytes become ischemic and stunned/necrotic which leads to remodeling

What is the #1 cause of death in HF patients?

Sudden cardiac death from ventricular tachycardia/fibrillation

Why does sudden cardiac death from ventricular tachycardia/fibrillation in HF patients occur?

it increases beta-1 stimulation and ventricular remodeling leading to ventricular arrythmia and sudden cardiac death.

What does baroreceptor activation from decreased cardiac output lead to?

Catecholamine release, juxtaglomerular apparatus, sodium and water retention and alpha-1 stimulation.

What occurs from short-term catecholamine release (NE/E)?

Stimulates B-1 receptors in the heart which will increase CO

What occurs from long-term catecholamine release (NE/E)?

Apoptosis/muscle burn out and ventricular remodeling fibrosis.

• desensitize B-1 receptors

• change in beta-1 : beta-2 ratio from 80:20 to 60:40

• uncoupling of B-1 receptors (myocytes won’t contract)

All in an attempt to decrease B-1 stimulation

What occurs in juxtaglomerular apparatus

Increased renin ultimately stimulates AGII (angiotensin II) receptors

What does stimulation of AGII receptors lead to in our extremities?

vasoconstriction

What does stimulation of AGII receptors lead to in our kidneys?

Na and water retention

What does stimulation of AGII receptors lead to in our adrenals?

NE and aldosterone release - Aldosterone leads to more ventricular remodeling and promotes more K and Mg excretion

What does stimulation of AGII receptors lead to in the heart?

Stimulates abnormal growth/collagen depositions which worsens remodeling

What does stimulation of AGII receptors lead to in the posterior pituitary?

ADH release which leads to holding on to more free water

What happens when sodium and water retention increases?

Promotes K and Mg excretion - body will hang on to additional fluid which leads to an increase in preload

What happens when alph-1 receptors are stimulated?

Vasoconstriction and increase in afterload which makes it harder for the LV to pump, and overtime, muscle hypertrophies and remodels

T/F: neurohormonal responses to decreased cardiac output are detrimental in the short term as they lead to increase an in perfusion

FALSE: neurohormonal responses to decreased cardiac output are beneficial in the short term to increase perfusion but are detrimental and can lead to cardiac remodeling overtime

What is the 6-month readmission rate for patients with HF?

50%

What is an exacerbation of ADHF

rapid onset of symptoms causing clinic, ED, or hospitalization

What can cause acute exacerbations of HF?

Non-compliance to medications (especially abrupt withdrawal), Non-compliance with diets/dietary recommendations (possibly a fluid and/or salt restriction… generally 2 L and 2 g), NSAID use (leads to fluid retention), and comorbidities (A-fib, MI, infection)

Classification of ADHF (acute decompensated heart failure): Class I?

Warm (adequate) perfusion and Dry (absent) congestion

Classification of ADHF (acute decompensated heart failure): Class II?

Warm (adequate) perfusion and Wet (present) congestion

Classification of ADHF (acute decompensated heart failure): Class III?

Cold (inadequate) perfusion and Dry (absent) congestion

Classification of ADHF (acute decompensated heart failure): Class IV?

Cold (inadequate) perfusion and Wet (present) congestion