Heart Failure and Cardiomyopathies

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Heart Failure and Cardiomyopathies
2015-09-13 21:47:47
Heart Failure Anesthesia

Heart Failure and Cardiomyopathies
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  1. Heart Failure Causes
    • 1.Impaired myocardial contractility secondary to ischemic heart disease or cardiomyopathy,
    • 2.Cardiac valve abnormalities
    • 3.Systemic HTN
    • 4.Disease of the pericardium
    • 5.Pulmonary HTN (for pulmonale)
  2. Heart Failure
    • Inability of the heart to fill or eject blood at a rate to meet tissue requirements. 
    • Ultimately all develop high ventricular end-diastolic pressure due to altered ventricular function and neurohormonal regulation.
  3. Systolic Heart Failure
    • More common in middle aged men due to high incidence of CAD.
    • Decreased systolic ventricular wall motion
    • S/S: S3 Gallop
  4. Diastolic Heart Failure
    • More common in elderly women due to HTN, obesity, and diabetes after menopause. 
    • Abnormal ventricular relaxation and compliance.
    • S/S: S4 gallop
  5. Low Cardiac Output Failures Causes
    • CAD
    • Cardiomyopathy
    • HTN
    • Valvular Disease
    • Pericardial Disease
  6. High Cardiac Output Failure Causes
    • Anemia
    • Pregnancy
    • Arteriovenous fistulas
    • Severe hyperthyroidism
    • Beriberi: Vitamin B deficiency 
    • Paget's Disease: Excessive breakdown and formation of bone
  7. Initiating Mechanisms of Heart Failure
    • Pressure overload: aortic stenosis, essential HTN
    • Volume Overload: mitral/aortic regurgitation
    • Myocardial ischemia/infarction
    • Myocardial inflammatory disease
    • Restriced diastolic filling: constrictive pericarditis, restrictive myocarditis
  8. Normal Cardiac Output Mechanisms
    • Frank-Starling Relationship: Increased SV accompanying an increased LVEDV
    • Activation of Sympathetic Nervous System: arterial/venous constriction to maintain BP(a) and increased central return(v), activation of renin-angiotensin-aldosterone system (RAAS) due to decreased renal flow, 
    • Alterations in the Inotropic State, HR, and afterload:Afterload is the tension needed to open the aortic/pulmonic valve and increased during systemic arteriolar constriction and HTN. SHF benefits from tachycardia and DHF benefits from rate control. 
    • Humoral-mediated responses: ANP and BNP release from the heart. Increased levels of vasopressin, endothelial dysfunction, and inflammatory mediator release.
  9. Signs and Symptoms of Heart Failure
    • Hemodynamic: decreased CO, increased LVEDP, peripheral vasoconstriction, Na and H2O retention, and decreased tissue O2 delivery with a widened a-v O2 difference. 
    • General:dyspnea, fatigue, weakness, organ system dysfunction, tachypnea, moist rales, tachycardia, S3 gallop (ventricular diastolic gallop), bilateral pitting pretibial edema 
    • LV failure: pulmonary edema
    • RV Failure: systemic venous HTN and peripheral edema.
  10. Heart Failure Diagnosis
    Echocardiography: Most useful test to assess abnormalities of the myocardium, valves, or pericardium, and can help measure Ejection Fraction.
  11. NYHA Functional Classification
    • Class I: Ordinary physical activity does not cause symptoms
    • Class II: Symptoms occur with ordinary exertion
    • Class III: Symptoms occur with less than ordinary exertion
    • Class IV: Symptoms occur at rest
  12. American College of Cardiology (ACC)/American Heart Association (AHA) Classification
    • Stage A: Patients at high risk of heart failure without structural disease or symptoms
    • Stage B: Patients with structural disease without symptoms
    • Stage C: Patients with structural disease with previous/current symptoms of heart failure
    • Stage D: Patients with refractory heart failure requiring specialized interventions
  13. Management of Heart Failure
    • RAAS Inhibitors: ACEi, ARB, aldosterone antagonist
    • B-Blockers: 
    • Diuretics: thiazide, loop, K-sparing,
    • Digoxin/Digitalis
    • Vasodilators
    • Statins
    • Diastolic Heart failure is best treated by prevention
  14. Acute Heart Failure
    • Hemodynamics: high ventricular filling pressures, low CO, and hyper/hypo-tension
    • Therapy: diuretics, vasodilators, inotropics, mechanical assisted devices, cardiac surgery, calcium sensitizers (levosemindan), exogenous BNP (nesiritide), NO synthase inhibitors
  15. Preoperative Evaluation and Management
    • Discontinue: Diuretics, ARBs, and ACEIs prior to surgery
    • Maintain: B-Blocker therapy, Digoxin until the day of surgery
  16. Intraoperative Management of Anesthesia
    • All types of GA may be used. 
    • Opioids effective for inhibiting adrenergic system (delta receptor)
    • PPV and PEEP: decrease pulmonary congestion and improve arterial oxygenation
    • Fluid overload: will worsen heart failure. 
    • Cardiac Transplant patients: Increase in HR can only occur with direct B-agonists (NOT anticholinergics such as atropine).
  17. Postoperative Management of Anesthesia (HF)
    Aggressively treat postoperative pain to prevent hemodynamic complications
  18. Cardiomyopathies
    • Heterogenous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction. 
    • Usually exhibit inappropriate hypertrophy or dilation. 
    • Due to a variety of causes (often genetic).
    • Either confined to the heart or are a part of generalized systemic disorders. 
    • Divided into primary or secondary cardiomyopathies.
  19. Primary Cardiomyopathies
    • Exclusively or predominantly confined to the heart muscle.
    • Can be acquired, genetic, or mixed.
  20. Secondary cardiomyopathies
    Involvement of the heart in the context of a multiorgan disorder.
  21. Hypertrophic Cardiomyopathy
    • Primary Cardiomyopathy: most common genetic CV disease. LV hypertrophy in the absence of other cardiac disease capable of inducing ventricular hypertrophy. 
    • Path: Myocardial hypertrophy, LV outflow tract (LVOT) obstruction, systolic anterior movement of the mitral valve/ regurgitation, diastolic dysfunction, myocardial ischemia, and dysrhythmias
    • S/S: angina often relieved by lying down, fatigue, syncope, double apical impulse, gallop rhythm, cardiac murmur/thrills
    • ECG: LV hypertrophy, high voltage QRS, ST segment and T wave alterations, abnormal Q waves, and LA enlargement
  22. Treatment of Hypertrophic cardiomyopathy
    • B-blockers
    • Ca Channel Blockers
    • Diuretics used cautiously due to the need for high ventricular filling pressures. 
    • High risk require amiodarone and/or ICD. 
    • AFib is likely and can be treated with amiodarone.
  23. Hypertrophic Cardiomyopathy Anesthesia
    • Minimize LVOT obstruction: decreased contractility, increased preload/afterload
    • Avoid: sympathetic stimulation, hypovolemia, and vasodilation
  24. Hypertrophic Cardiomyopathy Preoperative
    • Updated cardiac evaluation
    • Continue B-Blockers and Ca Channel Blockers
    • ICD turned off
    • Questions regarding family history of cardiac disease/ sudden death
    • Preoperative medications to decrease anxiety and possible SNS activation
    • Expansion of intravascular volume may be beneficial.
  25. Hypertrophic Cardiomyopathy Intraoperative
    • Avoid sudden decrease in SVR: IV induction acceptable
    • Modest myocardial depression is acceptable
    • Volatile anesthetic or B-blocker can blunt sympathetic response to DL. 
    • Use smaller tidal volumes and higher RR: PPV can decrease preload and predispose a hypovolemic patient to LVOT obstruction
    • Insufflation should be done slowly: can cause preload reduction and severe hypotension. 
    • Volatile anesthetics often used in moderate doses: mild depression of myocardial contractility and minimal preload/afterload effects. 
    • Hypotension: Treated with phenylephrine (NOT drugs with B-agonist effects due to increased contractility&HR-ephedrine, dopamine, dobutamine)
    • Vasodilators should NOT be used to lower BP due to decreased SVR
    • Maintain normal sinus rhythm.
  26. Dilated Cardiomyopathy
    • Primary cardiomyopathy: LV or biventricular dilation, systolic dysfunction, and normal LV wall thickness. Mixed causes with 30% familial. Most common type of cardiomyopathy and the 3rd most common cause of heart failure, and the most common indication for cardiac transplant
    • S/S: Embolization common
    • ECG: ST segment and T wave abnormalities and LBBB, cardiac dysrhythmias common
    • Treatment: Anticoagulation, medical management of chronic heart failure, 
    • Anesthesia: Same as heart failure
  27. Dilated Cardiomyopathy Anesthesia
    • All types of GA may be used. Opioids effective for inhibiting adrenergic system (delta receptor)
    • PPV and PEEP: decrease pulmonary congestion and improve arterial oxygenationFluid overload: will worsen heart failure. 
    • Cardiac Transplant patients: Increase in HR can only occur with direct B-agonists (NOT anticholinergics such as atropine).
  28. Peripartum Cardiomyopathy
    • Primary Cardiomyopathy: Acquired and rare. During 3rd trimester to 5mo after delivery. 
    • S/S: Dyspnea, fatigue, and peripheral edema
    • Tx: diuretics, vasodilators, and digoxin. ACEIs are teratogenic but can be used following pregnancy. IV Immunoglobulin may be used. Anticoagulation is often recommended.
  29. Secondary Cardiomyopathies with restrictive physiology
    • Info: Due to systemic diseases that produce myocardial infiltration and diastolic dysfunction (Amyloidosis is the most common). 
    • S/S: LV and RV failure may be present, no cardiomegaly, AFib is common
    • ECG: conduction abnormalities
    • Tx: similar to DHF. Diuretics, digoxin, maintain normal sinus rhythm. Anticoagulation w/ low CO or AFib. NO cardiac transplantation. 
    • Anesthesia: Same as cardiac tamponade. Maintain normal sinus rhythm and avoid a significant decrease in HR. Maintain venous return and IV fluid volume.
  30. Cor Pulmonale
    • Info: RV enlargement (hypertrophy/dilation) that may progress to RV failure. Caused by diseases that induce pulmonary HTN (COPD, restrictive lung, respiratory insufficiency)
    • S/S: Peripheral edema, dyspnea, diastolic murmur due to tricuspid regurgitation
    • ECG: RA and RV hypertrophy. RA hypertophy has peaked P waves in leads II, III, and aVF. Right axis deviation and RBBB. 
    • Tx: Decrease pulmonary vascular resistance and pulmonary artery pressure. Supplemental oxygen. Diuretics and digitalis. Possible lung transplant due to cardiorespiratory failure.
  31. Cor Pulmonale Preoperative
    • 1. Eliminate and control acute and chronic pulmonary infection
    • 2. Reverse bronchosapsm
    • 3. Improve Clearance of airway secretions
    • 4. Expand collapsed or poorly ventilated alveoli
    • 5. Hydration
    • 6. Correct nay electrolyte imbalance
    • Consider antibiotic prophylaxis for valvular disease
  32. Cor Pulmonale Intraoperative
    • Induction: any method or drug
    • Intubation: Ensure adequate depth of anesthesia to prevent bronchospasm
    • Maintenance: typically volatiles with other drugs. Avoid large amounts of opioid due to ventilatory depression in postoperative period. 
    • Muscle relaxants: avoid histamine release
    • PPV: improves oxygenation