CLIN PATH: EXAM #1 (CARDIO 1.B HF)

LV Failure or RV Failure?

- Dyspnea

- Orthopnea

- Paroxysmal nocturnal dyspnea

- Hemoptysis

- Occasionally chest pain

- Fatigue

- Nocturia

- Confusion

LV Failure

LV Failure or RV Failure on PE?

- Inc HR and RR

- Skin may be pale, cold, and sweaty

- Severe HF, palpation of peripheral pulse may reveal alternating strong and weak beats (pulsus alternans)

- Lungs show rales

- Bases of lung dull to percussion

- Apical impulse displaced laterally

- 3rd and 4th heart sounds can be heard

- Signs of RV HF may be present

LV Failure

In severe HF, palpation of peripheral pulse may reveal alternating strong and weak beats is called what?

pulsus alternans

LVHF can be caused by inappropriate work loads on the heart:

_____________:

- Mitral or Aortic Regurgitation

- Anemia, hyperthyroidism (high output states)

Volume overload

LVHF can be caused by inappropriate work loads on the heart:

________________:

- Systemic HTN

- AS, asymmetric septal hypertrophy

- Restricted filling of the heart

- MS, pericardial disease, amyloidosis

Pressure Overload

LVHF can be caused by inappropriate work loads on the heart:

________________:

- MI from CAD

- Connective tissue disease (SLE)

Myocyte loss

LVHF can be caused by inappropriate work loads on the heart:

___________________________:

- Poisons, infections, genetic mutations of cell architecture or sarcomere proteins

Decreased myocyte contractility

Pathophysiology of HF:

__________________:

- Decreased output (Heart failure with REDUCED ejection fraction HFrEF)

- Decreased filling (Heart Failure with PRESERVED ejection fraction HFpEF)

A. Hemodynamic Changes

B. Neuro-Hormonal Changes

Hemodynamic Changes

Pathophysiology of HF:

Hemodynamic Changes

- Decreased ____________ (Heart failure with REDUCED ejection fraction HFrEF)

A. output

B. filling

output

Pathophysiology of HF:

Hemodynamic Changes

- Decreased ___________ (Heart Failure with PRESERVED ejection fraction HFpEF)

A. output

B. filling

filling

Pathophysiology of HF:

______________________:

- Sympathetic system activation

- RAAS activation

- Vasopressin release

- Cytokine Release

A. Hemodynamic Changes

B. Neuro-Hormonal Changes

Neuro-Hormonal Changes

Pathophysiology of HF:

__________________:

- Inefficient intracellular Ca2+ handling

- Adrenergic desensitization

- Myocyte hypertrophy

- Re-expression of fetal phenotype proteins

- Cell death

- Fibrosis

A. Cellular Changes

B. Neuro-Hormonal Changes

Cellular Changes

HEMODYNAMIC CHANGES

To maintain CO, the heart responds in three compensatory ways:

1. _____________ --> inc contraction of sarcomeres (Frank-Starling) --> Inc EDV

A. Inc Preload

B. Inc release of catecholamines

Inc Preload

HEMODYNAMIC CHANGES

To maintain CO, the heart responds in three compensatory ways:

2. __________________ --> inc CO by increasing HR and shifting systolic isovolumetric curve to left

A. Inc Preload

B. Inc release of catecholamines

Inc release of catecholamines

HEMODYNAMIC CHANGES

To maintain CO, the heart responds in three compensatory ways:

3. _______________________ --> shifts diastolic curve to right

A. Hypertrophy and ventricular volume inc

B. Inc release of catecholamines

Hypertrophy and ventricular volume inc

Increased ______________ activity occurs early in the development of heart failure

A. sympathetic

B. parasympathetic

sympathetic

Elevated plasma _____________ levels cause increased cardiac contractility and an increased HR that initially help maintain CO

norepinephrine

In neuro-hormonal changes, continued increased contractility lead to increased preload (venous vasoconstriction) and afterload (arterial vasoconstriction) --> _____________________

worsen heart failure

Both angiotensin II and sympathetic activation cause ___________ glomerular arteriolar vasoconstriction --> helps maintain GFR despite a reduced CO

A. efferent

B. afferent

efferent

What are the two major groups of cytokines that may have an important pathophysiologic role in heart failure?

Interleukins (ILs) and tumor necrosis factor (TNF)

Where is Endothelin released from?

Endothelial cells

In heart failure, both delivery of Ca2+ to the contractile apparatus and reuptake of Ca2+ by the sarcoplasmic reticulum are __________

slowed

Levels of α1-adrenergic receptors are slightly ______________ (increased/decreased) in heart failure

increased

Significant b-adrenergic receptor desensitization as a result of chronic ________________ (sympathetic/parasympathetic) activation.

sympathetic

Increased a1-adrenergic receptors and b-adrenergic receptor desensitization lead to a further reduction in what?

myocyte contractility

What happens when the heart enlarges due to hemodynamic stress?

LV remodeling

Myocyte loss via apoptosis (accelerated via TNF) --> “holes” are left in the myocardium --> increased stress on myocardium --> hypertrophy --> ______________ (vicious cycle)

further apoptosis

Myocyte loss via apoptosis (accelerated via TNF) --> “holes” are left in the myocardium --> increased stress on myocardium --> _______________ --> further apoptosis (vicious cycle)

hypertrophy

Myocyte loss via apoptosis (accelerated via TNF) --> “holes” are left in the myocardium --> _______________ --> hypertrophy --> further apoptosis (vicious cycle)

increased stress on myocardium

Myocyte loss via apoptosis (accelerated via TNF) --> __________________ --> increased stress on myocardium --> hypertrophy --> further apoptosis (vicious cycle)

“holes” are left in the myocardium

___________________ (accelerated via TNF) --> “holes” are left in the myocardium --> increased stress on myocardium --> hypertrophy --> further apoptosis (vicious cycle)

Myocyte loss via apoptosis

In HF, the increase in connective tissue increases chamber stiffness and shifts the diastolic pressure-volume curve ______________.

A. to the left

B. to the right

to the left

HF is also associated with gradual dilation of the _______________.

ventricle

What three clinical manifestations do you expect to see in LVHF?

SOB, Orthopnea, PND

Edema of bronchial walls leads to small airway obstruction and produce wheezing. What is this called?

cardiac asthma

_______________ probably stimulates juxtacapillary J receptors which results in reflex shallow and rapid breathing

Pulmonary edema

Work of breathing increases as pt tries to distend stiff lungs resulting resp muscle fatigue and sensation of what?

dyspnea

Why does SOB occur in the recumbent position (orthopnea)?

Reduced blood pooling in the extremities and ABD

PND (sudden onset of severe resp distress at night) --> ___________________________ --> increase in blood return (inc preload) and normal nocturnal depression of respiratory center

reduced adrenergic support of LV function with sleep

What clinical manifestation of LVHF arises because of inability of the heart to supply appropriate amounts of blood to skeletal muscles?

Fatigue

What clinical manifestation of LVHF arises in advanced HF because of under-perfusion of the cerebrum?

Confusion

Heart failure can lead to reduced renal perfusion during the day while the patient is upright, which normalizes only at night while the patient is supine, with consequent diuresis. What clinical manifestation does this lead to?

Nocturia

If the cause of failure is coronary artery disease, patients may have what secondary to ischemia (angina pectoris)?

Chest pain

Which of the following hemodynamic parameters would classify a pt as having HFrEF?

A. Stroke Volume

B. Ejection Fraction

Ejection Fraction

Which-sided HF clinically presents as SOB, Pedal edema, abdominal pain?

A. LV Failure

B. RV Failure

RV Failure

What sided HF has PE findings including:

- Third heart sound heard best at sternal border

- Sustained systolic heave of sternum

- Elevated JVP

A. LV Failure

B. RV Failure

RV Failure

RV failure can occur as a sequela of pulmonary disease which is also known as what?

cor pulmonale

What kind of MI (ischemia) may cause RV failure?

Inferior wall myocardial infarction (IWMI)

When RV pressure increases relative to the left, what structure can bow to the left and prevent efficient filling of the left ventricle, which may lead to pulmonary congestion?

Interventricular Septum (IVS)

If LV failure, SOB is due to pulmonary edema. If RV failure, SOB is due to what?

Underlying disease (COPD, pulmonary embolus)

In RV failure, SOB is due to underlying disease (COPD, pulmonary embolus). In LV failure, SOB is due to what?

Pulmonary edema

In Elevated JVP, elevated atrial pressures indicate that the preload of the ventricle is adequate but ventricular function is ___________ (increased/decreased) and fluid is accumulating in the venous system.

decreased

Other causes of _____________ besides heart failure include pericardial tamponade, constrictive pericarditis, and massive pulmonary embolism.

elevated JVP

In elevated JVP, expansion of liver from fluid accumulation can cause distention of liver capsule with _____ abdominal pain.

A. RUQ

B. LUQ

RUQ

What does elevated right sided pressures lead to?

Increased fluid in systemic venous circulation

What causes generalized edema, ascites, and dependent edema?

Venous congestion

Pressing on liver for approx. 5 seconds can lead to displacement of blood into the vena cava; when RV cannot accommodate the extra blood, an increase in JVP is seen. What is this called?

Hepatojugular reflux

What is the most common cause of RV failure?

Left Sided HF

What are the 3 types of cardiomyopathy?

Dilate, Hypertrophy, or Restrictive

What is a physiological myocardial hypertrophy as an adaptive response?

Highly trained athletes

What are the 3 pathological myocardial hypertrophies as an adaptive response?

1. Hemodynamic overload

2. Myocardial injury

3. Valvular Insufficiency

In physiological hypertrophy (chronic exercise/pregnancy) what happens to the LV chamber size?

A. The chamber size stays the same

B. The chamber size decreases

The chamber size stays the same

In pathological hypertrophy (aortic valve stenosis/HTN) what happens to the LV chamber?

A. The chamber size stays the same

B. The chamber size decreases

The chamber size decreases

What is the primary cause behind many cases of cardiac transplants?

Idiopathic Dilated Cardiomyopathy (DCM)

What does Secondary Dilated Cardiomyopathy (DCM) results from?

Injury to cardiac myocytes

What are "toxic" to cardiac muscle cells?

Alcohol & its metabolites

There may be a ____________ component to Dilated cardiomyopathy.

genetic

Pathophys of __________________:

- The heart muscle dilates and becomes thinner

- The contractile elements do not align properly --> decreased ability to effectively contract

Dilated Cardiomyopathy (DCM)

What type of cardiomyopathy is characterized by a thickened, hyperkinetic ventricular muscle mass where the hypertrophy is not uniform throughout and the septum is most affected?

Hypertrophic Obstructive CMP (HOCM)

What type of cardiomyopathy may result in Pts having impaired systolic function and/or Sudden death can occur at any time?

Dilated Cardiomyopathy (DCM)

What type of cardiomyopathy is the #1 cause of sudden death in young athletes?

Hypertrophic Obstructive CMP (HOCM)

In this type of cardiomyopathy, a histology report states that the cells are disorganized. Appear as whorls, rather than their normal linear arrangement.

Hypertrophic Obstructive CMP (HOCM)

What cardiomyopathy is due to a ventricular outflow obstruction as a result of septal hypertrophy and leads to sudden cardiac death in young athletes?

Hypertrophic Obstructive CMP (HOCM)

What cardiomyopathy has S&S including dyspnea and angina?

Hypertrophic Obstructive CMP (HOCM)

What cardiomyopathy has Pulsus alternans?

Dilated Cardiomyopathy (DCM)

What cardiomyopathy is the rarest?

Restrictive Cardiomyopathy

What cardiomyopathy is characterized by a stiff, fibrotic/rigid, and non-compliant ventricle with impaired diastolic filling?

Restrictive Cardiomyopathy

What cardiomyopathy usually presents secondarily with infiltrative disease like Sarcoidosis, Amyloidosis, and Hemochromatosis?

Restrictive Cardiomyopathy

What cardiomyopathy has S&S including exercise intolerance, dyspnea, and weakness?

Restrictive Cardiomyopathy

Which of the following causes would be an example of physiological hypertrophy?

A. MI

B. HTN

C. Aortic Stenosis

D. Pregnancy

Pregnancy

Which of the following CMP would be described as the ventricular wall becomes thinner and can result in sudden death?

A. HOCM

B. Dilated Cardiomyopathy (DCM)

C. Restrictive CMP

Dilated Cardiomyopathy (DCM)

What type of CMP is described as a hyperdynamic LV contractility with stiff, non-compliant LV?

A. Hypertrophic Cardiomyopathy

B. Dilated Cardiomyopathy

C. Restrictive Cardiomyopathy

Restrictive Cardiomyopathy