2.2 cardiac muscle dysfunction patholphysiology

What does it mean to have acyanotic defect

still circulating oxygenated blood through arteries (just mixed)

What does it mean to have cyanotic defect

deoxygenated/venous blood is circulated throughout the body

What are the 4 types of acyanotic defects

ventricular septal defect

atrial septal defect

patent ductus arteriosus

coarctation

Describe ventricular septal defect (VSD)

hole between ventricles

describe atrial septal defect (ASD)

hole between atria

describe patent ductus arteriosus (PDA)

extra vessel connection aorta and pulmonary a never disconnects after birth

Decribe coarctation

pinch in the aorta limiting flow out of heart, but still delivers the O2 blood

Why don’t individuals usually notice coarctation until adulthood

HTN arises to compensate for resistance

What are the 3 cyanotic defects

tetralogy

transposition

truncus arteriosus

Describe tetralogy

aorta is taking blood from both ventricles due to 4 defects

What are the 4 defects that combine to lead to tetralogy

VSD

narrowing of pulm artery

aorta lies just above VSD

R ventricular hypertrophy

describe transposition

great vessels are switched

describe truncus arteriosus

aorta and pulm arteries do not fully separate

What are the most commonly occluded arteries in CAD

LAD, RCA, and left circumflex artery

Why does CAD reduce EF

once muscle is damaged a scar forms. Scar reduces contractility

How can we check for a baggy/saggy heart on a lab

check BNP levels

What is a dilated cardiomyopathy

L ventricle is stretched leading to bad contractility

What is a hypertrophic cardiomyopathy

muscle wall of L ventricle have thickened (really good contraction, much smaller volume)

What is a restrictive cardiomyopathy

walls of LV have stiffened due to a metabolic dysfunction (no stretch= smaller volume and less efficient contractility)

What is a sarcomere made up of

actin and myosin filaments

What is the frank-starling law

Changed in contractility will shift the curve in relation to SV and LVEDV leading to positive and negative inotropic effects

What is a positive inotropic effect

Low SV and a high contractility

What is a negative inotropic effect

increased SV with low contractility

What is end diastolic volume (EDV)

blood in LV at end of diastole

What is end systolic volume (ESV)

blood left in the ventricle at the end of systole

what is the equation for ejection fraction (EF)

= (EDV-ESV)/EDV

What is EF

the amount of blood pumped out of the heart with each contraction

What is a normal EF

55-70%

What does HFpEF stand for

Heart failure preserved EF

At what phase does HFpEF occur

diastolic

What does HFpEF look like

stiff and thick chambers (hypertrophic cardiomyopathy)

What causes HFpEF

heart cant fill

What does HFrEF stand for

heart failure reduced EF

At what phase does HFrEF occur

systole

What does HFrEF look like

stretched and thin chambers (dilated cardiomyopathy)

What causes HFrEF

heart can’t pump

What EF correlates with HFpEF

>40%

What EF correlates with HFrEF

<30%

New York Heart Association (NYHA) heart failure classification of I

no limitations, asymptomatic during daily activities

New York Heart Association (NYHA) heart failure classification of II

slight limitation, mild symptoms with ordinary activities

New York Heart Association (NYHA) heart failure classification of III

moderate limitation, symptoms noted with minimal activity

New York Heart Association (NYHA) heart failure classification of IV

severe limitations, symptoms at rest

How many METs can we work a class I pt on the NYHA

6-10, exercise as normal

How many METs can we work a class II pt on the NYHA

4-6, may have lab value activity

How many METs can we work a class III pt on the NYHA

2-3, min activity

How many METs can we work a class IV pt on the NYHA

less than 2

What are common symptoms of Left-sided heart failure

Paroxysmal nocturnal dyspnea

elevated pulmonary capillary wedge pressure

pulmonary congestion

restlessness

confusion

orthopnea

tachycardia

external dyspnea

fatigue

cyanosis

What is the main problem with left-sided HF

trouble with O2 due to blood backup into lungs (cyanotic)

What is the main problem with right-sided HF

swelling due to back up into body

What is right-sided HF caused by

can come from severe LS or HTN of pulmonary artery OR secondary to chronic pulmonary problems

Common side effects of right-sided heart failure

fatigue

increased peripheral venous pressure

ascites

enlarged liver and spleen

distended jugular veins

anorexia and complaints of GI distress

weight gain

Another name for right-sided HF

cor pulmonale

How does peripheral edema occur with myocardial damage

What are medical management options for HF pts

medications

AICD/pacemaker

dialysis/CRRT

intra-aortic balloon pump (IABP)

ventricular assistive device (VAD)

left ventricular muscle flaps

cardiomyoplasty

heart transplant

What are the strong CPG treatments

1. increase total daily PA

2. education on disease management

3. aerobic exercise training

4. upper and lower body resistance training

5. inspiratory muscle training (IMT)

6. neuromuscular electrical stimulation (NMES)

What are the guidelines for PA

150 mins per week of moderate intensity PA

75 mins per week of vigorous-intensity PA

How can we help educate on disease management

• daily weight management

• recognition of s/s of exacerbation

• action planning using red-green-yellow CHF tool

• following a nutrition plan

• medication management/reconciliation

What weight differences are concerning for HF

>2-3lbs in 24 hrs or 5lbs in 3 days

What are the symptoms within the green zone

• no shortness of breath

• no swelling

• no weight gain

• no chest pain

• no decrease in ability to maintain your activity

What should we do with pts when in the green zone

continue activity and therapy as tolerated

What are the symptoms within the yellow zone

• weight gain of 2-3lbs in 24 hrs

• increased cough

• peripheral edema: increased distal extremity swelling

• increase in SOB with activity

• orthopnea (increase in the number of pillows needed)

What should we do with pts when in the yellow zone

symptoms may indicate an adjustment in medications and therefore warrants communication with the physician

What are the symptoms within the red zone

• SOB at rest

• unrelieved chest pain

• wheezing or chest tightness at rest

• paroxysmal nocturnal dyspnea: requiring to sit in chair to sleep

• weight gain or loss of >5 lbs in 3 days

• confusion

What should we do with pts when in the red zone

symptoms indicate overt decompression and an immediate visit to the emergency department or physician office

What are the moderate CPG treatments

1. high-intensity interval training for selected pts

2. combined resistance and aerobic training

3. combined IMT and aerobic exercise

What pts are able to participate in CPG

NYHA class II and III

What are the time guidelines for aerobic exercise training

20-60 mins

What are the intensity guidelines for aerobic exercise training

50%-90% of peak VO2/MET or peak work

What are the frequency guidelines for aerobic exercise training

3-5 times per week

What are the duration guidelines for aerobic exercise training

at least 8 to 12 weeks

What are the mode guidelines for aerobic exercise training

treadmill or cycle ergometer or dancing

What are the time guidelines for HIIT training

>35 total mins of 1-5 mins of high intensity (>90%) alternating with 1 to 5 minutes at 40%-70% active rest intervals, with rest intervals shorter that the work intervals

What are the intensity guidelines for HIIT training

>90 of peak VO2 or peak work

What are the frequency guidelines for HIIT training

2-3 times per week

What are the duration guidelines for HIIT training

at least 8-12 weeks

What are the mode guidelines for HIIT training

treadmill or cycle ergometer

What are the time guidelines for combined resistance and aerobic training

20-30 mins of resistance training added to aerobic exercise training

What are the intensity guidelines for combined resistance and aerobic training

2-3 sets per major muscle group, 60-80% 1RM

What are the frequency guidelines for combined resistance and aerobic training

3 times per week

What are the duration guidelines for combined resistance and aerobic training

at least 8-12 weeks

What are the time guidelines for inspiratory muscle (IMT) training

30 min/day or less if using higher training intensity

What are the intensity guidelines for inspiratory muscle (IMT) training

>30% MIP

What are the frequency guidelines for inspiratory muscle (IMT) training

5-7 days/wk

What are the duration guidelines for inspiratory muscle (IMT) training

at least 8-12 weeks

What are the time guidelines for combined IMT and aerobic exercise training

30 mins/day

What are the intensity guidelines for combined IMT and aerobic exercise training

>30% maximal inspiratory pressure

What are the frequency guidelines for combined IMT and aerobic exercise training

5-7 days/wk

What are the duration guidelines for combined IMT and aerobic exercise training

at least 8-12 weeks

What are the time guidelines for NMES training

30-60 minutes per session

What are the waveform guidelines for NMES training

biphasic symmetrical pulses at 15-50 Hz

What are the intensity guidelines for NMES training

On/off time 2/5 sec

pulse width for larger LE muscles = 200-700 ms

pulse width for smaller LE muscles = 0.5-0.7 ms

20-30% of MVIC

intensity to muscle contraction

What are the frequency guidelines for NMES training

5-7 days/week

What are the duration guidelines for NMES training

at least 5-10 weeks

What other conditions can result HF 

HTN

CAD

cardiac arrhythmias

renal insufficiency

Heart valve abnormalities

cardiomyopathy

pericardial effusion

PE

pulmonary HTN

SCI

age-related changes

What is valvular heart disease

any valves could have stenosis, insufficiency, or both leading to needing a more forceful contraction which can cause hypertrophy

What are the effects of PE

can lead to R ventricular strain from high PA pressures

What should we do if pt is diagnoses with an acute PE

Emergency!! do not mobilize until pt receives medical treatment

What is pulmonary hypertension (PH)

mean pulmonary artery pressure (mPAP) >20 due to increased work to get blood from RV to lungs