Topic 5: Heart Failure_Younai

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jlyip89
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255752
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Topic 5: Heart Failure_Younai
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2014-01-11 00:05:07
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Heart Failure
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systems 1
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Younai lecture 1.4
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  1. cardiomyopathies
    A group of disorders in which the dominant  feature is the direct involvement of the heart muscle itself (which means problems with pumping)
  2. classification of cardiomyopathies
    • 1) Dilated CM
    • 2) Hypertrophic CM
    • 3) Restrictive CM
    • 4) Arrhythmogenic right ventricular CM
    • 5) Unclassified CM
    • 6) Specific CM

    *covered in class
  3. Dilated CM
    - what is it?
    - inheritance?
    - causes?
    - origin?
    - ventricular dilation in all chambers (cardiomegaly) of heart leading to enlargement, contractile and systolic dysfunction w/ signs of congestive heart failure

    -Inherited: autosomal dominant

    • - causes: occurs following inflammatory myocarditis caused by:
    • toxins (alcohol, cocaine, radiation), infections (viruses, bacteria, etc),
    • metabolic diseases (diabetes)

    • - origin: Familial (~30%), idiopathic
    • (~30%)
  4. Hypertrophic CM
    - what is it?
    - effects?
    - orgin?
    - mutations where?
    • - Increasing thickness of left ventricular walls & asymmetrical involvement of
    • IVS (interventricular septum)

    • effects:
    • - diastolic dysfunction
    • - may appear asymptomatic
    • - with progression: arrhythmia, myocardial ischemia, sudden death

    - Mostly inherited (born with this condition) but can also be due to CV diseases

    • - mutations in genes encoding sarcomere
    • proteins
  5. restrictive cardiomyopathy

    - what is it?
    - effects?
    - least common, replacement of myocardial or endocardial tissues by other tissues

    - Bi-atrial dilation, later involving left ventricle

    • effects:
    • - enlargement of both atria and left ventricle
    • - diastolic dysfxn
    • - endocardial scarring of ventricles
    • - reduced CO (due to rigidity of walls) that leads to chest pain or a-fib

    note: May not show signs of heart problems but will notice a problem when they try to exercise
  6. congestive heart failure

    - definition?
    - caused by
    - involves what kind of dysfunction?
    • The inability of the heart to supply adequate
    • oxygenated blood to meet body’s metabolic needs

    - caused by defect in myocardial contraction where an increase in hemodynamic (pump) burden or a reduction in myocardial oxygen delivery results in abnormal myocardial structure and function

    • - Most cases involve both systolic and
    • diastolic dysfunction
  7. Systolic Dysfunction

    - characterized by?
    - leads to?
    - characterized by ventricular dilatation and decreased contractility

    - Leads to reduced CO and ejection fraction



    • pDiastolic dysfunction -
    • characterized by decreased myocardial compliance but contractility is normal

    nLeads to increased diastolic pressure but cardiac output may be normal
  8. Diastolic Dysfunction

    - characterized by?
    - leads to?
    - characterized by decreased myocardial compliance (heart unable to relax) (but contractility is normal)

    - leads to increased diastolic pressure (but CO may be normal)
  9. (3) Types of adaptive mech. of the heart
    1) Short term mech.- activated within a few hours

    2) Peripheral mech. – also activated rapidly but continue over long period of time

    3) Long term mech. – develop within weeks to months
  10. Name some short term adaptive mech. of the heart
    1) Frank Starling relationship: increasing the resting muscle length --> increase blood volume-->increase preload --> increase CO

    *not the same with exercise

    2) Activation of the neurohumoral system

    - Adrenergic system - increases contractility, velocity of contraction, and increases HR

         **All will improve cardiac output**

    • - Renin-angiotensin- aldosterone system: helps to maintain arterial pressure and
    • tissue perfusion and also increases cardiac preload

    -Commands kidney to reabsorb water to raise blood volume (increasing preload)

    -Commands vasoconstriction helps raise BP
  11. Peripheral adaptive mech. of the heart (2)
    • 1)  Arteriolar constriction
    • - Causes the blood flow to be redistributed
    • - Less blood to kidneys, skin, visceral organs, and skeletal muscle
    • - Maintained blood level to brain and heart

    • 2) Increased venous tone
    • - Shifts blood from the peripheral pool to the
    • central circulation, thereby enhancing ventricular filling and helping to maintain CO
  12. Long term adaptive mech of the heart (2)
    • 1) Heart chamber dilation
    • - Chronic volume overload leads to dilation
    • of left ventricle which increases the demand on the heart!

    • - can be explained by Law of Laplace:
    • radius (R) of the ventricle increases, greater tension (T) is required in the wall to generate the same pressure (P)

    • 2) Myocardial remodeling or hypertrophy
    • - Chronic pressure overload & higher wall
    • tension leads to pathological myocardial remodeling

    - Law of Laplace: in order to reduce the wall tension (T), the wall thickness (M) increases

    - This occurs by both, increasing the size of individual muscle cells & increasing the overall muscle mass

    • - There is also fibrosis in the damaged areas
    • of the myocardium
  13. Hemodynamic consequences of adaptive mech. of the heart (5)
    • 1) ejection fraction (decrease)
    • 2) EDV and EDP (increase)
    • 3) CO (decrease)
    • 4) blood redistribution (decrease in skeletal muscles, kidney, and liver)
    • 5) edema (left: lungs, right: general edema)
  14. Etiology of left sided heart failure (4)
    • 1) Ischemic heart disease
    • 2) Valvular heart disease
    • 3) Cardiomyopathy
    • 4) Myocarditis
  15. etiology of right sided heart failure (4)
    • 1)Left sided heart failure
    • 2) Obstructive lung disease
    • 3) Pulmonary hypertension
    • 4) Pulmonary emboli
  16. Precipitating factors that effect progression of congestive heart failure (7)
    1) Inappropriate reduction of therapy (decompensation)

    2) Arrhythmias (common in pts with structural HD)

    3) Myocardial ischemia

    4) Systemic bacterial and viral infections

    5) Pulmonary embolism

    6) Stress (physical, emotional)

    7) Myocarditis (allergic, immune, infectious)
  17. Signs and symptoms of left-sided heart failure
    • 1) Pulmonary edema
    • - Dyspnea: feeling of not enough air and choking
    • - Orthopnea: difficulty in breathing while lying flat
    • - Paroxysmal nocturnal dyspnea (PND): sudden inability to breath, awakening patient during night
    • - Tachypnea:increased rate of respiration
    • - Rales: indicates fluid in alveolar spaces

    2) Gallop rhythm of the heart
  18. symptoms and signs of right sided heart failure
    • - Congestion of organs such as liver
    • - Edema of lower extremities
    • - Clubbing of the fingers and cyanosis
    • - Jugular venous distention
    • - Increased jugular vein pressure (JVP)
  19. What is pulmonary edema?

    what are some signs and symptoms
    • - Fluid moving into interstitial and alveolar
    • spaces

    • signs & symptoms:
    • - Extreme breathlessness
    • - pink frothy sputum
    • - feeling of drowning
    • - anxiousness
    • - expiratory gurgling sounds or wheezing
    • - profuse sweating
    • - cyanosis

    ***Life threatening -needs immediate treatment***
  20. causes of pulmonary edema not relating to heart failure
    • - allergic reactions to blood products or
    • medications

    - infections

    - smoke inhalation

    - high altitude

    - heroin overdose
  21. Ways to diagnose congestive heart failure
    • 1) adequate history
    • 2) lab tests
  22. what to look for in patient history to diagnose congestive heart failure
    - Family history of heart failure, cardiomyopathy, rhythm abnormalities, sudden death

    - History of alcohol, illicit drugs, chemotherapy or radiation therapy

    - Assessment of ability to perform routine and desired activities

    - Assessment of volume status, blood pressure, body mass index
  23. Types of lab tests to diagnose congestive heart failure
    1) Chest X-ray most useful - shows enlarged heart size and pulmonary congestion

    • 2) Swan-Ganz catheter - measures pressures in both right and left
    • side (with wedging)

    3) Echocardiogram - multiple uses such as etiology, differentiating between systolic and diastolic failure

    4) Radionuclide scans

    • 5) B-type natriuretic peptide (BNP) – highly elevated in CHF and useful in
    • differentiating cardiac vs non-cardiac causes of dyspnea

    • - A peptide released from ventricular myocardium in response to changes in
    • ventricular filling pressure; causes natriuresis and vasodilitation

    6) Serum electrolytes – to assess renal function
  24. congestive heart failure treatments
    - Address correctible causes

    - Decrease pre-load (diuretics and angiotensin converting enzyme inhibitors)

    • - Improve contractility (cardiac glycosides,
    • beta-blockers)

    - Reduce afterload (vasodilators): Of the many different agents used in therapy, angiotensin converting enzyme inhibitors and beta-blockers appear to prolong life

    • - Correct complicating causes:
    • * anemia - transfusion & careful monitoring
    • * rhythm problems – correct with medications
    • * heart block - may need pacemaker
    • * coronary heart disease – dilate or graft
    • vessels

    - Diet – reduce sodium and caloric intake

    - Severe cardiomyopathies require heart transplantation
  25. Dental implications of congestive heart failure
    • - Condition implies advanced heart disease:
    • * Careful assessment -  explore if patient has high blood pressure, coronary heart disease, cardiomyopathy or valvular
    • disease

    *Some patients with severely low EF may be treated in hospital setting

    - Pay attention to signs: pulmonary edema & pitting edema in extremities (i.e. ankles)

    - Cannot lay flat in a dental chair - fluid accumulation in the lungs->pulmonary edema (won’t be able to exchange O2)

    - Precautions w/ epinephrine(affects rhythm abnormalities)

    - Control levels of stress

    - Watch for medication interactions

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