Heart Failure 8, Clinical features, acute and chronic

so we're still thinking about the features of heart failure but I wanted to differentiate between acute and chronic because this sometimes causes a bit of confusion so acute means of recent onset so acute means it's of recent onset it's just started it's an acute heart failure and we first of all looking at acute left heart failure acute left heart failure now very often here there's a history of an acute cardiac event so the times I've seen this most commonly is after myocardial infarction so there's a myocardial infarction that occludes the blood supply to part of the left ventricle part of the left ventricle dies so there's a disconnect or an akinetic segment in the left ventricle basically a bit that's not contracting properly and that's going to reduce the pumping efficiency of the heart and of course that's going to lead to dis me now dyspnea means shortness of breath difficulty breathing dys dis dis means difficulty Pinilla means to do with air or breathing so like paneer is like new a pneumatic tire that's where we get the word from so dis Mira's difficulty breathing and of course this makes perfect sense because we know that with a left ventricular failure there we're going to get a damming back of blood to the lungs leading to pulmonary edema and there can be acute dyspnea and it can develop into severe respiratory distress and the dis Mir will be present even at rest of this is bad and as well as that you can get um pink frothy sputum occurring if it's a severe case of acute left heart failure because in the alveoli in the lungs which are surrounded by lots of little blood vessels very rich blood supply to the alveoli the alveoli are basically surrounded in capillaries but of course these capillaries need to drain into a branch of the pulmonary vein and if the pom Nevada is congested is going to be a back pressure at blood that's going to increase the pressure of blood in the capillaries that surround the alveoli and some of them are simply burst and you'll get mixing of the blood with the mucus so you'll get some blood going up to be coughed out from the respire to tract but because that mixing occurs slowed down by the time the blood's coughed out and we see it it's all very well mixed so it makes the sputum look pink and it's frothy because it's mixed with air as well so this pink frothy sputum in what is severe respiratory distress this can be very distressed patients and there's orthopnea now author actually means straight so orthopedics originally meant straight children it was just straightening children's bones and we see the pannier part again that the breathing posture the orthopnea is difficulty breathing lying down so what happens here is the when the patient's lying flat the fluid goes all over the lung fields so in the patients lying down flat and the lying flat the light our flap the pulmonary oedema goes all over the lung fields and in him it's breathing altogether but then when we sit the patient up the pages in an upright position like this then what happens is the gravity effect means that the fluid accumulates mostly at the bottom of the lungs now that's bad for the bottom of the lungs but of course what that does is it leaves the top of the lungs clear and the patient can breathe through the upper parts of the lungs and that leaves the dis Mia so that is orthopnea so orthopnea a shortness of breath when lying down relieved by sitting up and when the patients can't breathe the ratchet ated the pale and clammy and the pale and clammy because of the sympathetic activity so sympathetic activity activity of the sympathetic nervous system is going to cause peripheral vaso constriction making the patient's appear pale they will have what we call power and the clamminess is caused by the stimulation of sweating and the tachycardia is also a feature of the sympathetic attempted compensation occasionally they can be ran in appropriate bradycardia which is a very poor prognostic refuge' the blood pressure will be raised again due to sympathetic activity but of course the proviso here is in severe cases the patient will go into shock called cardio genic shock so shock is when the blood pressure is too low to perfuse the tissues of the body cardio is heart and genic means genesis that's where who began so a shock that begins with the heart to cardiogenic shock there'll be some increase in jugular venous pressure due to the backlog food to the systemic circulation now this is worse if the patient's fluid overloaded if we've given them too much fluid we've mentioned the pulmonary edema really and the Pony edema will cause their crepitations as well and if you listen to the heart auscultation if there's a power failure yield but valvular failure you'll hear a murmur and acute left are failures also associated with with what's called in a triple gallop rhythm of the heart so that's an acute situation and this can develop over a very short period of time attention potentially well it was very severe instantly or potentially just minutes after myocardial infarction it can develop over an hour or so quite rapidly or a very distressing severe condition so that's kind of the thick features of cute and again they do make sense in terms of our diagram that we hopefully know already now now thinking now about chronic heart failure now chronic just means the condition is established the condition is being going on for a lot of a while so chronic is the converse of acute is the converse of acute and very often in chronic heart failure is a bit relapsing and remitting so the condition never goes away but as the patient compensates the features remit and then they'll have episodes such as intercurrent infection which we'll call will cause a relapse and some decompensation when the patient becomes more much more but much more symptomatic so for example if the patient has a myocardial infarction or the ischemia becomes worse or they develop a atrial fibrillation or they have a pulmonary embolism or anaemia will make it worse by increasing the the the the required workload of the heart because of the patient's anemic and the blood has to be pumped and quicker but then we have to be very careful in healthcare pick with patients with controlled or compensated heart failure for example if we give them too much fluid we can send them into failure early if we check if we reduce their therapy that can send them into failure or we give negative inotropic drugs such as too much beta blockers Pizza blockers have to be titrated very carefully in heart failure well there's other drugs such as non-steroidal anti-inflammatory drugs or corticosteroids that will encourage fluid overload so these patients are kind of delicately compensated and lots of the time you have to be careful not to decompensate them now thinking about left ventricular failure now in the more chronic patient we know there's a reduced cardiac output so there's reduced cardiac output from the left ventricle as we know and that's going to lead to pulmonary edema as we've covered so the low cardiac output is actually going to cause the crepitations because the low cardiac output means us the damming back of blood from the left ventricle to the left atrium through the formerly veins into the lungs the fatigue what happens here is the patients are very tired because blood is diverted to the essential organs to maintain the essential organs so there's less blood available for perfusion of the the muscles peasants become very fatigued and that's why they have weakness and the low cardiac output causes general listlessness as well these these patients are quite uncomfortable and agitated sometimes of course the left ventricle cants increases workload significantly because it's diseased it's failed so they have extreme exercise intolerance these patients are remarkably unfit and unable to increase their exercise tolerance and again this idea of keeping the blood supply for the essential organs means that this off often cold peripheries cold hands and feet and as the patient's decompensate the blood pressure is going to drop if the blood pressure drops that means the kidneys are not going to be well perfused and we can get all the urea olek means few urea means urine so the volumes of urine are going to drop and if the volumes of urine drop then the water-soluble urea is not adequately removed from the blood than these patients are at risk of becoming you remake increase in the amount of urea in the blood so these are what we see commonly in hospital when we get patients admitted especially in the emergency department as they have one of these things like the mi the ischemia the infections the AF the anemia or the 'true genic inappropriate management that leads to D compensation and then these features are exacerbated to them that made worse now right ventricular failure we should also think about again thinking more from there the chronic situation and here we have a high jugular venous pressure jvp so when the right ventricle is failing the right ventricle is not ejecting the blood the blood is damming back to the right atrium that means that blood cannot drain adequately from the systemic veins and of course the jugular veins are systemic veins so they become congested raised jugular venous pressure the liver of course is part of the body so that becomes congested hepatic congestion and this is what pathologists call out a meatloaf liver the livers become very congested and look like meatloaf and the peripheral edema is dependent now a dependent means it's affected by gravity so there's going to be the backlog into the systemic circulation that's going to increase the pressure in the systemic capillaries that means the tissue fluid is not going to be adequately reabsorbed at the venous end of the capillary so remember that normally the tissue fluid is formed in the arterial end of the capillary because the hydrostatic pressure that is the blood pressure is greater than yours molten pressure and normally the tissue fluid is reabsorbed at the venous end of the capillary because the osmotic pressure is greater than the now reduced hydrostatic pressure at the venous end of the capillary but because the pressure is increased in the venous end of the capillary the tissue fluid is not reabsorbed and we're left with the edema if you want to go over that physiology there is a series on purple areas on competition where we do that in in great detail also we notice the ascites which is the collection of fluid ascites really is just the edema but in the peritoneal sac between the visceral and the parietal peritoneal membranes there's a site ease and fluid in the abdominal cavity and the back pressure can also lead to pleural effusions now the pleural effusions are more really associated with left heart failure but we do see the minim we do see a fusions into the pleural space in right heart failure as well even louis lesce corn so unwell patients raise gvp jvp eventually reduced into the function swelling swelling difficulty breathing as well here now the other thing that these patients sometimes get and again we do see this the weight loss is sometimes called cardiac cachexia now the cachexia is a term we usually use in association with cancer patients become cachectic when they have this appalling weight loss due to the release of inflammatory cytokines in cancer but we can also get cardiac cachexia cardiac of course means to do with the heart though these patients can become emaciated and wasted and this is because the congestion because of course the gastrointestinal tract is part of the body isn't it as part of the systemic circulation so it's good that there's going to be congestion here and that can lead to anorexia anorexia means the patient doesn't feel hungry and they Rexy just means loss of appetite and the congestion in the organs of the gastrointestinal tract can impair absorption of food from the gastrointestinal tract so there's reduced absorption of nutrients into the blood because of the GI a congestion and the weight loss is also exacerbated by loss of skeletal muscle because muscle of course is much heavier than fat and this loss of skeletal muscles fetal muscle atrophy as a result of the immobility so useful to think about the chronic and the acute and the chronic thinking about the compensated and decompensated heart failure trying to prevent decompensation episodes if we can with good management early recognition of infection early recognition of anemia and correction of such correct all conditions good management's of other ischemic heart disease problems so thinking about not causing preventing D compensations certainly us not causing D compensations and correcting the underlying cause quickly when it occurs but also thing the amalgams between the acute in the chronic but also remembering of course all the time as we've seen in the previous video in detail that the left ventricular failure will lead to right ventricular failure the right to the left so the two tend to develop together in longer term conditions but we do sometimes see this acute so-called de novo presentation or of the left ventricular failure with those features that we've considered and of course that is a medical emergency

Channel: Dr. John Campbell

Views: 37,334

Keywords: heart, cvs, cardiovascular, heart failure, pathophysiology, disease, medical, nursing, NCLEX, signs, clinical features

Id: KAJLQKBLua0

Length: 17min 49sec (1069 seconds)

Published: Mon Mar 04 2019