10 - Cardiac Failure

cardiac failure

inability of the heart to maintain adequate circulation

• 5-year survival: 45%

• CHF (left ventricle)

• cor pulmonale (right ventricle with pulmonary disease)

• right heart failure without pulmonary disease

risks for cardiac failure

• coronary artery disease (CAD)

• HTN

• diabetes mellitus

• smoking

• obesity

• high fat diet

• family history

• sleep apnea

other causes of cardiac failure

• idiopathic dilated cardiomyopathy

• infectious cardiomyopathy

• valvular disease

• CHD

• pulmonary disease

• drugs

• alcohol

• leukemia

• metal poisoning

• metabolic disorder

• neurological disorder

• trauma

categories of cardiac failure

• restricted filling

• pressure overload

• volume overload

• contractile disorder

• tachy-/bradycardic dysrhythmias

myocardial infarction (MI)

occlusion of one or more coronary arteries, rupture of plaque

manifestations of MI

• chest pain that may radiate

• chest tightness

• nausea, heart burn

• extreme fatigue

• SOB

• cold sweat

• may be asymptomatic

diagnosis of MI

• symptoms

• enzymes

• troponin

• ECG

treatment of MI

• MONA

  • morphine

  • O₂

  • nitroglycerin

  • aspirin

• prevent more damage

  • repurfusion (PCI, thrombolytics)

  • anticoagulants

pathophysiology of cardiac failure

• secondary right heart failure

condition that can decrease pulmonary edema

pathophysiology of cardiac failure

• myocardial performance

• ino-/chrono-/dromotropic effects

• Frank-Sterling equation

• sympathetic response

• ventricular hypertrophy

pathophysiology of cardiac failure

• circulation changes

• shunt to heart and brain (peripheral vasoconstriction)

• left heart (pulmonary edema)

• right heart

  • hepatomegaly

  • portal HTN

  • decreased lymph drain

  • fluid in joints, peritoneal cavity, and pleural space

pathophysiology of cardiac failure

• fluid and electrolyte imbalance

• sodium and water retention

• angiotensin

• edema

pathophysiology of cardiac failure

• pulmonary dysfunction

• low V/Q

• edema

• decreased FRC

• decreased C_L

• mixed acidosis

clinical findings for cardiac failure

• left heart

• dyspnea

• cough

• decreased exercise intolerance

• delirium

• anxiety

• adventitious breath sounds

• poor peripheral perfusion

clinical findings for cardiac failure

• right heart

• JVD

• distended abdomen

• peripheral edema

clinical findings for cardiac failure

• physical exam

• BP may be normal

• crackles, wheezing

• S3/S4 heart sound

• JVD

clinical findings for cardiac failure

• radiology (mild)

• pulmonary venous congestion

• wide pulmonary artery

clinical findings for cardiac failure

• radiology (moderate)

• cardiomegaly

• Kerley A/B lines

clinical findings for cardiac failure

• radiology (severe)

• symptoms from previous severities

• bat wing pattern

• pleural effusion

clinical findings for cardiac failure

• ECG

• sinus tachycardia

• PVC

• a-fib

• ischemia/infarction

clinical findings for cardiac failure

• ABG

• impaired gas exchange

• hyperventilation

• mixed acidosis

clinical findings for cardiac failure

• labs

• secondary polycythemia

• hyponatremia

• hypokalemia

• liver enzyme changes

• ANP/BNP

clinical findings for cardiac failure

• hemodynamics

• C.O. changes

• PHTN

clinical findings for cardiac failure

• other

• echocardiogram

• Doppler

• radionuclide

• stress test

• angiogram

cardiac failure classification

• ACCF/AHA

STAGE	DESCRIPTION
A	at risk without heart disease or symptoms
B	heart disease without HF symptoms
C	heart disease with prior/current HF symptoms
D	refractory HF needing interventions

cardiac failure classification

• NYHA

STAGE	DESCRIPTION
I	no limit on physical activity
II	some limit on activity; ordinary activity causes HF symptoms
III	marked limit on activity; less than ordinary activity causes HF symptoms
IV	unable to carry on activities without HF symptoms; or symptoms at rest

treatment of cardiac failure

• treat reversible causes

• educate/counsel

• lifestyle modifications

• vaccines

• medication

• procedures

medications to treat cardiac failure

• diuretics

• ACE inhibitors (-pril): vasodilation

• ARBs (-artan): vasodilation

• neprilysin inhibitors: increase vasoactive peptides

• beta blockers (-lol)

• digitalis glycoside: negative chronotrope

• hydralazine/nitrates (ie, nitroglycerin)

procedures to treat cardiac failure

• PCI (angioplasty/stents)

• surgery

  • CABG

  • valve replacement

  • heart transplant

• ECMO

• intra-aortic balloon pump

• ventricular assist

intra-aortic balloon pump

pump placed in the heart that treats issues with medications (decreased afterload, inotropes)

• suports diastolic pressure

• improves coronary artery perfusion

• decreases left ventricular work

• increases stroke volume

• optimizes O₂ demand and supply

ventricular assit device

percutaneous device that supports the heart long-term

• types: LVAD, BiVAD

treatment for acute cardiac failure

• medications

  • morphine (analgesic, vasodilator)

  • nitrates

    • nitroglycerin (venodilator)

    • nitroprusside (reduces pre- and afterload)

  • dobutamine (inotrope)

  • milirinane (inotrope, vasodilator)

• hemodynamic monitoring

RT protocol for cardiac failure

• O₂

• CPAP

• ventilation (NIV, MV, sedation [etomidate])

• suction pulmonary edema?

• bronchodilators