heart failure, hypotension + circulatory shock

heart failure

inability to provide sufficient blood to meet the body needs

consequence of underlying conditions

right-sided heart failure

failure of right heart to pump into pulmonary circulation

• RV cannot pump into the lungs

blood backs up into systemic circulation (body/tissues)

an increase in pressure → RV works harder → RV hypertrophy → decrease in filling → diastloic dysfunction

cause:

• left sided heart failure → common

• pulmonary disease

• pulmonary HTN

• tricuspid/pulmonic valve disease

• RV infarction

• cardiomyopathy

• obstruction of lung blood flow

Cor Pulmonale

• right HF due to pulmonary disease (COPD → pulmonary HTN → RV hypertrophy → decrease in SV → decrease in CO

right-sided heart failure symptoms

venous backup

peripheral edema

fatigue

increased peripheral venous pressure

ascites

enlarged spleen and liver

anorexia

GI distress

weight gain

congestion of abdominal organs

left-sided heart failure

failure to pump into systemic circulation → blood backs up into the lungs

increase pulmonary pressure → fluid leaks into lungs → pulmonary edema → decrease in gas exchange

pulmonary edema → impaired gas exchange

can lead to right HF (cor pulmonale)

left-sided heart failure symptoms

pulmonary nocturnal dyspnea

orthopnea (unable to breathe lying down)

dyspnea

tachypnea

cough

crackles

wheezes

blood-tinged sputum

fatigue

tachycardia

confusion

cyanosis

Systolic Heart Failure

inability to pump efficiently during systole

decrease in contractions

EF < 40%

causes:

• coronary heart disease

• dilated cardiomyopathy

• hypertension

• valvular heart disease

Diastolic Heart Failure

inability to fill properly

stiff/small ventricles

EF normal but decrease in output

causes:

• hypertrophic coardiomyopathy

• restrictive cardiomyopathy

• hypertension

causes of Heart Failure

cardiomyopathy → structural/functional heart muscle disease

myocarditis → inflammation of heart muscle

coronary insufficiency → reduced blood flow to the heart

Myocardial Infarction (MI) = ischemia → tissue death → scar formation

valvular disease → stenosis or regurgitation

congenital heart defects → structural abnormalities

constrictive pericarditis → restricted heart expansion

hypertension → increased workload on heart

hypermetabolic states → excessive demand on heart

volume overload → excess fluid (renal failure)

Acute MI cause → LAD blockage from spasm or atherosclerosis + clot → permanent loss of contraction

Acute Heart Failure

rapid onset (<30 days)

life-threatening

causes:

• MI

• sepsis

• Pulmonary Embolism

• valve dysfunction

• arrhythmias

• surgery

Chronic Heart Failure

long-term condition

adaptive responses may worsen Heart Failure

general symptoms of heart failure

edema

shortness of breath

fatigue

cyanosis

cachexia

jugular vein distention

diaphoresis

tachycardia

FORCED represents which type of heart failure + what it stands for

left-sided heart failure

Fatigue

Othopnea

Rales/restlessness

Cyanosis/confusion

Extreme weakness

Dyspnea

BACONED represents which type of heart failure + what it stands for

right-sided heart failure

Bloating

Anorexia

Cyanosis/cool legs

Oliguria

Nausea

Edema

Distended neck veins

acute pulmomary edema

fluid (transudate) enters alveoli → lung stiffness → decrease in expansion → decrease in gas exchange → hypoxia, cyanosis and shortness of breath

Cardiac Output

amount of blood pumped per minute

Stroke Volume

amount of blood per beat

Preload

volume at EDV

ventricular stretch

→ right sided heart failure

Afterload

resistance to ejection (TPR)

→ left sided heart failure

contractility

strength of heart muscle contraction

compensatory mechanisms

makes HF worse

Frank-starling laws

• increased EDV → increase stretch → temporary increase in SV

Sympathetic nervous system

• decrease in CO → increase in SNS response

• increase in HR, contractility and vasoconstriction

RAAS

• increase in volume, preload and BP

• fluid retention (worsens edema + HF) → increase in pressure

Natriuretic peptides

• vasoactive substances affecting fluid balance

Myocardial Hypertrophy/remodeling

• increase in BP → cardiac remodeling

• thickening of wall size → decrease in chamber size and EF

AHA stage A means?

risk factors present, no structural disease

AHA stage B means?

structural disease, no symptoms

AHA stage C means?

structural disease + symptoms

requires treatment

AHA stage D means?

refractory HF

requires devices transplant or palliative care

NYHA class I means?

no symptoms

NYHA class II means?

symptoms with moderate exertion

NYHA class III means?

symptoms with minimal exertion

NYHA class IV means?

symptoms at rest

PCWP (pulmonary capillary wedge pressure)

estimates left atrial pressure

normal: 4-12 mmHg

Killip classification → estimates 30-day mortality

treatment of HF

goals:

• relieve symptoms

• improve quality of life

• slow/reverse progression

ACE inhibitors → lowers BP, reduce workload

Beta Blockers → reduce BP and heart workload

diuretics → reduce fluid retention

calcium channel blockers → reduce afterload

vasodilators → decrease vascular resistance

lifestyle modifications → activity and diet changes

surgical/mechanical therapy → valve repair, ICD, VAD, transplant

shock (circulatory)

inadequate blood supply → cellular hypoxia → organ failure

cardiogenic shock

heart cannot pump

cause:

• MI

• arrhythmias

• valve problems

• cardiomyopathy

obstructive shock

blocked flow, inability to fill or flow outward

causes:

• pulmonary embolism

• cardiac tamponade

• pneumothorax

• atherosclerosis

distributive shock

vasodilation

• causes:

  • sepsis

  • anaphylaxis

  • neurogenic shock

hypovolemic shock

low blood, plasma or ECF volume

causes:

• bleeding

• rupture

• burns

• vomiting

• diarrhea

• dehydration

shock symptoms

hypotension

confusion

decrease in urine output

skin changes (cold or flushed)

tachycardia

tachypnea

labs: increase in lactate, creatinine, troponin

shock treatment

increase in BP

treat cause

improve cardiac output

reduce myocardial workload

increase coronary perfusion

monitor volume

complications of shock

ARDS (acute respiratory distress syndrome)

• dyspnea

• tachypnea

• hypoxia

• decrease in compliance and pO2

other complications

• renal failure

• GI issues

• DIC

• MODS

MODS = multiple organ dysfunction syndrome

multi-organ failure

• kidney

• lungs

• liver

• brain

• heart

cannot maintain homeostasis

APP (abdominal perfusion presure)

APP = MAP - IPP

negative APP = critical