Heart Failure

Question 1

Definition of heart failure

Answer 1

Pump failue - heart has a hard time pumping - impaired cardiac output in relation to demand

• A clinical syndrome with varied signs + symptoms caused by structural or functional cardiac abnormalities
• diagnosis of heart failue is restricted to the stage at which symptoms are present and cardiac dysfunction meets threshold criteria

Question 2

Heart failue epidemiology

Answer 2

• 2% of adults have chronic HF (2-8% comes from age range of 65-69 but as we age, 85yrs, it becomes more prevalanet and increses the risk
• Ppl 40 yrs have a 25% risk of getting HF
• 50% of people die within 5 years of diagnosis so the prognosis is not great

Question 3

How does a heart failue diagnosis occur

Answer 3

Signs and symtoms on their own can be misleading as they are non specific
- use an** assessment tool** looking at clinical history in terms of things like history of hypertension, exposure to drugs, radiation diuretics, dyspnoea, CAD.
- Physical examination like ankle oedema, heart murmur, venous dialation, rales, apical beat.
- ECG - Any Abnormality
- After looks at the natriuretic peptides (BNP) which essentiall signal the load of heart and the amount of stretch it has (on its own this doesnt indicate much as it flucauates a lot (EX), but it does indicate the chronic load of the heart
- finally look at echocardiography (video ultrasound to look at heart, critical to look at strutcure, size, volume, how it pumps etc…)

Question 4

What is ejection fraction?

Answer 4

Ejection fraction - Percent of blood ejected from the heart in a beat (efficiency)

Question 5

Heart failure 2 types

Answer 5

Heart failure with presevered ejection fraction
Heart failue with reduced ejection fraction
Difference - HRrEF = less than 40% based on the left ventricle, HRpEF = greater than 50% based on the left ventricle

Classification based on ejection fraction critical for identifying causes and recommending treatments

Question 6

HFpEF / Diastolic heart failure

Answer 6

Typically occurs when the ventricle(s) lose ability to relax and fill normally

• Stiffer ventricle, slower contraction and slower early diastolic “untwisting“.
• Lower intraventricular pressure and pressure gradients.
• Reduced elastic recoil.
• Filling becomes dependent on high atrial pressure to actively push blood into the ventricle.

Question 7

HFrEF / Systolic heart failure

Answer 7

typically occurs when the heart is weakened and ventricle(s) lose ability to contract normally.
- loss of contraction strength

Question 8

Heart failure can present on both sides of the heart.

Answer 8

• Right-side heart failure occurs if the heart can’t fill and pump enough blood to the lungs to pick up oxygen.
• Left-side heart failure occurs if the heart can’t pump enough oxygen-rich blood to the rest of the body.
• CV circuit is closed, deficiency on one side will often affect the other

Question 9

Heart failue - Stages

Answer 9

A - high risk for HF, no structural heart disease or symtoms for HF
B - structural heart disease, no symptoms or signs of HF
C - sturtcural heart disease with prior or current symtoms of HF
D - refractory HF requireing intervention unstable

Question 10

Heart falue - classifications

Answer 10

Class 1 - no limitation of PA, does not cause undue breathlessness, fatiuge or palpitations
Class 2 - slight limitation of PA, results in breathlessness, fatiuge or palpitations
Class 3 - Marked limitations of PA Comfortable at rest, but less then ordinary pa = breathlessness, fatiuge, palpitations
Class 4 - unable to carry on any physical activity without discomfort. Symtoms at rest can be present. If PA is undertaken, discomfort is increased

Question 11

Stages + class - HF

Answer 11

line up - at risk doesn’t have a classification, no symtoms
- structural heart disease without sign and symotms line up with class 1
- structural heart disease with prior or surrent can be anything any class
Eg. patient has stage c class 2

Question 12

Congestive heart failure

Answer 12

blood backing up into — or congesting — the liver, abdomen, lower extremities and or lungs

Results in edema.

Not all heart failure is congestive and congestion can occur in individuals with HFpEF and HFrEF

Question 13

Pulmonary Heart Disease

Answer 13

• Right sided heart failure
• Associated with right ventricular hypertrophy
• Caused by pulmonary hypertension or elevated pulmonary resistance

Question 14

Heart Failure – Causes (Aetiology)

Answer 14

Myocardial Insult
Abnormal Loading
Conduction Abnormalities

Question 15

Review Slide 21!

Question 16

Heart failue - Diseased myocardium

Answer 16

Heart attack or CAD
- vascualr insufficiency - something wrong with blood vessesls not getting enough oxygen and blood to the cadium itself
- tissue ischemia - not getting enough oxygen
- = scarring cardiac, tissue cells death
can occur in a number of different ways
- Toxicity, Infection, Metabolic Disturbances, Genetics, etc
- some of these causes can be reversed in the short term and you can have acute heart failue that can be reversed if treated properly
- Some causes will damage cardiac tissue irreversibly

Answer 17

pumps against a resistence blood pressure can have overtrianing
high blood pressure (hypertension)
reason its a problem is because heart builds pressure eventually high enough overcomes aortic pressure opening valve to ejection but in hypertension heart has to generate more pressure to overcome aortic becuase that aortic pressure pushing back is higher then after it does overcome it it shuts it earlier in teh cuycle cant get all of the blood out shifted curve to right more voluem in the heart and has to generate more pressure all the time
valve insufficiency
2 types mitral - have blood enter venticle generstr systolic pressure ejectied into aorta mital valve closed but if mitral valve is bad and the valve opens with low pressure part of the blood is going to be ejected back into the atrium so not as much blood can be ejected into the aortic cuz cant generate the pressure and part of teh blood going back to atrium incresed pressure in left atrium not deisgned to have those higher pressures overtime remodelling
problem with aortic valve - as soon as heart relaxes blood flows back into ventricle from aorta pressure to achive to eject blood peak systolic pressure mainatined during relaxation because blood is now being oushed back into the ventricle it doesnt get to relax end up with higher pressures and then left artium has to generate more pressure to get blood into ventiricle

Question 18

Heart failue - conduction abnormalities

Answer 18

preventicular contraction affects loading conditions contactility start higher voumes anythign thatt affects an electircal ciruclity within the heart will affect the efficiency of the heart

Question 19

Heart failue - causes and comorbidities

Answer 19

Advanced age
Arterial hypertension / fibrilation
Kidney dysfunction
Sleep Apnea
Obesity
Femal
Pulmonary disease
etc…

Question 20

Stress Test

Answer 20

• Some heart problems are easier to diagnose when your heart is working hard and beating fast. Stress tests, make your heart work hard and beat fast.
• Can walk or run on a treadmill or pedal a bicycle. Can’t exercise = given meds to raise your heart rate.
• Heart tests, (nuclear heart scanning and echo), often are done during stress testing.
• Tests cardiac function by increasing HR and myocardial contractility
• Exercise for stress test allows us to measure factors that impact cardiac output
  
  • Cardiac factors (HR and Myocardial contractility)
  • Coupling Factors (Pre and After Load)

Question 21

Exercise in HF diagnosis - stress tests - what is it

Answer 21

No difference between groups at rest but when exercised there was a difference between NCD group, and early stage HFpEF group, so exercise can help with early diagnosis

Question 22

Goals of exercise in individuals with HF:

Answer 22

1) Improve clinical status (NYHA Functional
Classification)
2) Improve Functional Capactity
3) Improve Quality of Life
4) Prevent hospital administration (stabilization)
5) Reduce mortality (prolong life)
Treatment

Question 23

HF Treatment

Answer 23

Primary prevention, treatment and management of hypertension includes the treatment of underlying CVD risk factors.

Advanced age
Arterial hypertension / fibrilation
Kidney dysfunction
Sleep Apnea
Obesity
Femal
Pulmonary disease
etc…

Question 24

HF - EX Treatment

Answer 24

Standard recommendations for EX training in patients with HF are similar to those with other known CVD
It is generally well tolerated and safe.

Question 25

Exercise recommendations for HF

Answer 25

similar for those patients with other known CVDs ex training in patients with HF is generally well tolerated and safe - shown by the studies where they looked at event rates. only 1 dead from 5000 people start sig high intensity activity is safe and well tolerated in all capacities some situations might need more surveillance or if condition is deteriating as its hard to move that line once it becomes end stage - so speciifc methods for increasing is importan,t how much can they take stress testing for developing the program

Question 26

Contraindications to EX - HF

Answer 26

Despite safety there are specific contraindications for exercise testing and training. Uncontrolled/worsening condition. Severe Ex Intolerance. Some patient deemed “high risk” may require specific medical supervision

Question 28

Pre-training Stress Test - Information gained - Hemodynamic:

Answer 28

- Maximum heart rate - Maximum systolic blood pressure - Rate-pressure product (HR x systolic BP) – surrogate of cardiac oxygen demand - Exercise-induced hypotension - Chronotropic incompetence

Question 29

Pre-training Stress Test - Information gained - Hemodynamic:

Answer 29

Symptoms of angina or severe shortness of breath Time to exercise-induced angina Time to exercise-induced shortness of breath - Use of angina scale (Borg Dyspnea)

Question 30

Stress test - How often, and Use

Answer 30

- annual “checkup” or “physical” used for screening for physician clearance. - Prognostic: assessing patients with risk factors. - Diagnose: coronary artery disease & symptoms such as chest pain, shortness of breath or lightheadedness. - Functional: To assess a procedure that may be used to improve coronary artery circulation. - Functional: To Determine a safe level of exercise for rehab or daily living

Question 31

HF and FITT Principle

Answer 31

- No changes needed for the principle

Question 32

HIIT for HF?

Answer 32

- Guidelines don't change for exercise in people with HF - Their capaicty changes so normal HIIT exercise (sprinting or running) would = mowing the lawn = their maximum heart rate or met capacity depends on the individual n = 1 - Even just doing basic chores around the house is difficult so difference isnt in the intensity but the functional activity Importance of those intensities and knowing when arrythmias show up

Question 33

HF - EX Intensity

Answer 33

Training HR should be set 10 bpm below signs or symptoms of ischemia or onset of arrhythmia, BP limit of 250/115. RPE may be used to guide intensity.

Question 34

Exercise Considerations

Answer 34

(β)Beta and Funny Channel (If) Blockers Lesser increase in EX HR Reduced maximal HR ACE Inhibitors and ATII Blockers May blunt EX BP response – be aware of hypotension - Overall, pay attention to meds, can impact how body reacts, HR if used to measure intensity

Question 35

Exercise considerations of HF - pacemakers and ICDs

Answer 35

Pacemakers may sense movement and ventilation to adjust HR – upper limit also adjustable. Upper limit usually set ~10 bpm below ischemic limit. EX intensity should be set 10 bpm below ICD shock threshold.

Question 36

LVADs

Answer 36

Heart rate may be difficult to assess. Blood pressure may be difficult to assess. Perceived exertion (Borg 11-13) may be more appropriate for assessing intensity.

Question 37

Heart Transplantation

Answer 37

Denervation, immunosuppressive therapy Higher BP Higher Resting HR (often >90 bpm) Smaller increase in EX HR Lower max HR (and stroke volume) Prolonged Recovery