Risk and protective factors & Psychosocial Aspects

Risk Factors:
Age
Smoking
Alcohol abuse
Cocaine
Physical inactivity
Obesity
Hypertension
High cholesterol levels / low HDL cholesterol
Diabetes (Type 1 & 2)
Previous heart attacks
Arrhythmia
Coronary heart disease
Heart valve disease (especially of the aortic and mitral valves)
Cardiomyopathy
Congenital heart defects

Protective Factors:
Supportive daughter (Lina)
Social life (?)
Vitamin D


Psychosocial Aspects:
Economics – medication and treatment may be expensive (but husband still works)
Emotional – add to the depression she’s already facing
Her kids are away, she feels lonely
Her husband is having an affair
Social support – chats online (?)
– goes out often to play mahjong which may be beneficial
– but drinks a lot at the club
Exercise/Work – less due to fatigue & weakness
Lifestyle changes – it is not easy to change one’s lifestyle
– she has to stop consuming alcohol and smoking
– may need to control her diet as well

P.S. please feel free to add anything to the psychosocial aspects if you have any views of it that you might want to share, either on the blog or during PCL

(posted by: Vivian)

cardiomyopathy - types and causes

Cardiomyopathy (types and causes)

Definition - Cardiomyopathy is a weakening of the heart muscle or a change in heart muscle structure. The heart muscle becomes inflamed and doesn’t work as well. As a result, it is often associated with inadequate heart pumping or other heart function abnormalities and diseases associated with other organs as well.

Causes (general):
Cardiomyopathy can be caused by viral infections, heart attacks, ALCOHOLISM, long-term, severe high blood pressure, nutritional deficiences (particularly selenium, thiamine, and L-carnitine), systemic lupus erythematosus, celiac disease, and end-stage kidney disease.

Types:
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy

Dilated Cardiomyopathy
This is the most common form, usually idiopathic myocardial disorder characterized by a marked enlargement and inadequate function of the left ventricle. Most patients develop CONGESTIVE HEART FAILURE. Arrhythymias and disturbances in the heart’s conduction system may also occur.

Blood flows more slowly in an enlarged heart so blood clots easily form. Complications:
- Thrombus and mural thrombi
- Embolus (pulmonary, cerebral, renal, peripheral, coronary artery)

A complication known as Barth’s syndrome (genetically linked cardiac disease) can cause dilated cardiomyopathy.

If the heart is significantly stretched, the mitral and tricuspid valves may not be able to close properly resulting in murmers. Blood pressure may increase because of increased sympathetic activity. Sympathetic nerves can also cause arteries to narrow. That’s why some people have high blood pressure readings.

Dilated cardiomyopathy accounts for over 10,000 deaths each year. Nearly 50,000 people a year are hospitalized due to this condition. The condition may not produce symptoms in some people, or it may be so severe that heart failure develops, which may require a heart transplant.

Dilated cardiomyopathy includes many conditions:
Causes (specific):

• Ischemic cardiomyopathy: This is caused by heart attacks, which leave scars in the heart muscle (myocardium).
• Idiopathic cardiomyopathy: The term "idiopathic" means that the cause is unknown.
• Hypertensive cardiomyopathy: This is seen in people who have high blood pressure for a long time, particuarly when it has gone untreated for years.
• Infectious cardiomyopathy: HIV, Lyme disease, Chagas disease, viral myocarditis, and other infections have been linked to dilated cardiomyopathy.
• Toxic cardiomyopathy: In additional to alcohol, cocaine use, and some chemotherapy drugs can also produce dilated cardiomyopathy.
• Peripartum cardiomyopathy: This type appears in women during the last trimester of pregnancy or after childbirth.
• Tachycardia mediated cardiomyopathy: This occurs in people who have an abnormally fast heart rate.
• Alcoholic cardiomyopathy:
o This type of dilated cardiomyopathy usually begins about 10 years after sustained, heavy alcohol consumption.
o It can occur with both typical signs of heart failure, as well as with atrial fibrillation or other heart rhythm problems.
In severe cases, the lack of blood flow affects all parts of the body, damaging multiple tissues and organ systems. Also damages the liver.

Other types:
• Hypertrophic cardiomyopathy: This occurs when the left and right heart muscles grow to be different sizes. In up to 70% of cases, there is a family history of this condition.
• Restrictive cardiomyopathy: This disorder affects the heart muscle's ability to relax between contractions. The heart cannot relax adequately after each contraction (systole), which prevents it from filling with enough blood.

~Shantz

Sources: www.americanheart.org/presenter.jhtml?identifier=4468
http://nlm.nih.gov/medlineplus/ency/article/001105.htm

CHF: Prognosis and Management

CHF: Prognosis

Poor. 5-year survival around 50%. About 20% survive longer than 8-12 years.
5-year survival rate for Congestive Heart Failure: Half of the patients diagnosed with CHF will be dead within 5 years. (Source: excerpt from NHLBI, Congestive Heart Failure Data Fact Sheet: NHLBI)
Results of a new study published in the March 7 issue of Archives of Internal Medicine suggest that heart failure survival after 6 years in adults 67 years and older on Medicare is very low and may be worse than the prognosis for most types of cancer. (Source: excerpt from Facts About Heart Failure in Older Adults: CDC-OC)
This condition carries a reduced life expectancy. Many forms of heart failure can be controlled with medication, lifestyle change, and correction of any underlying disorder. Heart failure is usually a chronic illness, and it may worsen with infection or other physical stressors.
Estimated mortality rate for Congestive Heart Failure from prevalence and deaths statistics:
Deaths: 50,824 (USA annual deaths calculated from this data: 50,824 deaths (NHLBI 1999); about 260,000 deaths a year (CDC-OC))
Incidence: 4,800,000 (USA prevalence calculated from this data: 4.8 million Americans (NHLBI); 2% age 40-59; 5% age 60-69; 10% over 70's
1.1% (ratio of deaths to prevalence).
Estimated mortality rate for Congestive Heart Failure from incidence and deaths statistics:
Deaths: 50,824 (USA annual deaths calculated from this data: 50,824 deaths (NHLBI 1999); about 260,000 deaths a year (CDC-OC))
Incidence: 400,000 (USA annual incidence calculated from this data: 400,000 new cases annually
12.7% (ratio of deaths to incidence).

Naturally, such forecast issues are by their nature unpredictable.


Management for CHF

Medications
ACE inhibitors such as captopril and enalapril -- these medications open up blood vessels and decrease the work load of the heart.
Diuretics -- there are several types including thiazide, loop diuretics, and potassium-sparing diuretics; they help rid your body of fluid and sodium.
Digitalis glycosides -- increase the ability of the heart muscle to contract properly; prevent heart rhythm disturbances
Angiotensin receptor blockers (ARBs) such as losartan and candesartan which, like ACE inhibitors, reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors
Beta-blockers -- this is particularly useful for those with a history of coronary artery disease
Inotropic agents help improve the heart's ability to pump blood. Such drugs include dobutamine and milrinone. They are given intravenously.


Diet Modification

Look for foods that are labeled “low-sodium,” “sodium-free,” “no salt added,” or “unsalted.” Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you how to understand these labels. Don’t cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate, MSG). Avoid foods that are naturally high in sodium, like anchovies, meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami), nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese. Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese. Use oil and vinegar, rather than bottled dressings, on salads. Eat fresh fruit or sorbet when having dessert.

Other lifestyle modifications
Don’t smoke.
Stay active..exercise. Your doctor can provide a safe and effective exercise plan based on your degree of heart failure and how well you do on tests that check the strength and function of your heart. DO NOT exercise on days that your weight has gone up from fluid retention or you are not feeling well.
Lose weight if you are overweight.
Get enough rest, including after exercise, eating, or other activities.

posted by Chris

Investigation of Congestive Heart Failure by Chest X-ray and Echocardiogram

Peribronchial cuffing
Cardiothoracic Ratio ( abnormal >0.50)
Normal Chest X-Ray


For Heart Failure, Chest X-ray is helpful,but they are quite hard to be interpreted

Classic finding of congestive heart failure on CXR:

1. Increase heart size (cardiomegaly) -cardiothoracic ratio > 0.50
2. Large hila with indistinct margin - hilum is a depression on the medial surface of the lung that form the opening through which bronchus, blood vessels and nerve pass by. Hilum is enlarged due to increase of pulmonary venous pressure
3. Prominent of superior pulmonary vein ; cephalization of flow ( happens when the pulmonary venous pressure is about 15-20mmHg) Cephalization of flow is the redistribution of blood flow to the upper lung field and a sign of pulmonary odema.
   
4. Fluid in interlobar fissures
5. Pleura effusion- a collection of fluid in the pleural space
6. Kerley B lines (several fine horizontal lines of few centimetres above the angle in the CXR that is made by the recess between the ribs and lateral most portion of diaphragm)
7. Alveolar oedema
8. Pericardial cuffing

Echocardiogram with Doppler examination

• provide an objective assessment of cardiac structure and function
• calculation of LV ejection fraction (EF) can be obtained. This is the stroke volume (EDV-ESV) expressed as percentage of the LV EDV

What is Doppler examination?

• assessment of the blood flow (direction and velocity) while M-mode & 2D Echocardiogram only evaluate the size,thickness and movement of HF (chamber,valve etc.)

Info from Echocardiogram and Doppler examinaton

1. Size of chambers(volume of the cavity & thickness of the wall) -when LV pump function is reduced in patient with HF,LV & RV tends to dilate or enlarge. Severity of enlargement can be diagnosed.
2. Pumping function -can assess if the pumping power is reduced to a mild or severe degree.This measure is known as Ejection Fraction. Normal EF (55-65%) while EF less than 45% represents some decrease in EF. EF<>
3. Valve function-Echocardiography identifies the structure, thickness and movement of each heart valve. It can help determine if the valve is normal, scarred from an infection or rheumatic fever, thickened, calcified (loaded with calcium), torn, etc. It can also assess the function of prosthetic or artificial heart valves.
   Doppler is also very useful in diagnosing the presence and severity of valve stenosis (pronounced stee-no-sis) or narrowing. Remember, unlike echocardiography, Doppler follows the direction and velocity of blood flow rather than the movement of the valve leaflets or components. Thus, reversed blood direction is seen with leakages while increased forward velocity of flow with a characteristic pattern is noted with valve stenosis.
   
4. Volume Status- inferior vena cava is distended or increase in size in patient with HF
   

http://www.heartsite.com/html/echocardiogram.html (echocardiogram)
www.postgradmed.com/issues/1997/01_97/bales.htm


Lawrence Oh

Investigations leading to the diagnosis of Cardiac Heart Failure (CHF)

CHF is a grouping of clinical findings rather than a specific diagnosis or a single disease. CHF can be considered a symptom of impairment of the pumping action of the heart that is caused by an underlying disease.

The diagnosis of CHF is based on knowledge of the patient's pertinent medical history, a careful physical examination, and selected laboratory tests. These investigations are carried out to find evidence of cardiac dysfunction and to establish the underlying cause of heart failure.

A thorough patient history may disclose the presence of one or more of the symptoms of CHF (e.g. dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, fatigue). In addition, a history of significant coronary artery disease, myocardial infarction, hypertension, diabetes, or significant alcohol use can be clues.

The physical examination is focused on detecting the presence of extra fluid i.e. oedema in the body. Pulmonary oedema can be detected by listening to the breathing sounds of the lungs (crackles and wheezes), and central cyanosis (bluish discoloration of the lips). Peripheral oedema is marked by swelling in the ankle or leg and peripheral cyanosis (bluish discoloration of the extremities). Jugular venous pressure is also checked to detect for any abnormal elevation. The heart is also examined (heart size – estimated with the position of the apical impulse, pulse, heart sounds, and murmurs). In addition, blood pressure is also measured to check for hypotension that maybe due to decreased cardiac output.

The first few diagnostic tests to order for a patient with suspected CHF include the electrocardiogram (ECG) and chest x-ray to explore the possibility of previous myocardial infarctions, arrhythmia, heart enlargement, and fluid in and around the lungs.

Blood tests are used to evaluate kidney and thyroid function as well as to check cholesterol levels, cardiac enzymes and the presence of anemia. Anemia is a blood condition that occurs when there is not enough hemoglobin (the substance in red blood cells that enables the blood to transport oxygen through the body) in a person's blood.

B-type Natriuretic Peptide (BNP) blood test. BNP is a substance secreted from the ventricles in response to changes in blood pressure that occur when heart failure worsens. BNP blood levels increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable. The BNP level in a person with heart failure -- even someone whose condition is stable -- is higher than in a person with normal heart function.

Echocardiogram uses ultrasound to image the heart muscle, valvular structures, and blood flow patterns. The echocardiogram is very helpful in diagnosing heart muscle weakness. In addition, the test can suggest possible causes for the heart muscle weakness (e.g., prior heart attack, severe valvular abnormalities). Virtually all patients in whom the diagnosis of CHF is suspected should ideally undergo echocardiography at some point.

Cardiac catheterization: The arteries to the heart are visualized with coronary angiography (using dye inside of the blood vessels that can be seen using x-ray methods). During catheterization the pressures in and around the heart can be measured and the heart's performance assessed.

Other diagnostic tests include:
Nuclear medicine studies (radionuclide angiography)
Cardiac Biopsy: In rare cases (e.g. amyloidosis - an infiltrative disease)
Cardiac MRI: Only used if other tests do not provide satisfactory diagnosis.

The choice of tests depends on each patient's case and is based on the suspected diagnoses.

Contributed by John Lee

causes,signs and symptoms of congestive heart failure

Congestive heart failure/congestive cardiac failure (CCF)/ biventricular cardiac failure

CCF results from the failure of the heart to eject blood effectively, thus it is the most common manifestation of heart failure. It is clinically useful to divide the heart failure into the syndromes of left and right cardiac failure, but it is rare for any part of the heart to fail in isolation.

Most commonly, there is a pre-existing Left heart failure followed by Right heart failure.

Left heart failure

Causes include:
*ischaemic heart disease: causing infarction of the heart walls, such as the myocardium hence the ventricles cannot contract efficiently thus reducing cardiac output.
*systemic hypertension: the heart has to pump harder to overcome the arterial pressure thus increases the afterload resulting in hypertrophy of the heart thus leading to CCF.
*mitral and aortic valve disease: incompetent valves leads to the heart having to pump harder, leading to hypertrophy of heart. i.e in mitral regurgitation, there is excessive preload
*Cardiomyopathy: can cause dilation and failure of the heart

Symptoms
*Fatigue (due to inadequate systemic perfusion, or lack of sleep because of paroxysmal dyspnoea)
*exertional dyspnoea ( breathlessness)
orthopnoea ( shortness of breath when lying down due to fluid in the chest cavity. this is relieved by sitting up.)
*paroxysmal nocturnal dyspnoea ( sudden breathlessness at night)
*wheeze
*nocturnal cough with or without pink sputum

Signs
*LV third or fourth heart sound ( S3 and S4)
*Tachycardia
*Crackles are heard at lung bases( pulmonary oedema)
*Peripheral cyanosis ( due to insufficient cardiac output leading to poor circulation in the peripheries)








Right heart failure

Causes include:
*left heart failure and others


symptoms
*fatigue
*peripheral oedema (the left ventricle is pumping more blood than the right heart can handle on return thus there is an accumulation of fluid in the peripheries)
*nausea
*anorexia
*pulsation in neck and face (raised right heart pressure)


signs
*jugular venous distension
*ascites ( development of abdominal fluid, systemic oedema)




Other causes of CCF also include

Drugs
beta blockers causing inadequate heart rate
negatively inotropic ( decrease heart contractility) drugs
excessive alcohol intake resulting in high BP leading to cardiomyopathy

Congenital defects in cardiac structure

Right-sided HF vs. Left-sided HF vs. Congestive HF

Classifications of Heart Failure

1. Systolic vs. diastolic
2. High output vs. low output
3. Acute vs. chronic
4. Right sided vs. left sided
5. Forward vs. backward

In this case, we are simply going to talk about Right sided vs. left sided heart failure, and after learning others' research, we will be able to compare these 2 conditions with congestive heart failure. For more info on the other classifications, you may visit: http://www.medscape.com/viewarticle/535310

Right-sided Heart Failure

Definition: The inability of the right side of the heart to adequately pump venous blood into the pulmonary circulation.

Pathophysiology: Usually due to an abnormality or condition that affects the flow of blood through the right ventricle, causing pressure in the blood vessels to increase and fluid to be forced from the blood vessels into body tissues, as the fluid cannot be pumped to the lungs at an efficient rate, and hence backs up in the veins, leaks out of capillaries and accumulates in tissues.

Causes: Most cases, lung disease, most commonly chronic obstructive lung disease. The right side of the heart suffers increased stress as it pumps blood into a diseased lung. The end result is a large heart (enlargement of the right atrium and ventricle) and fluid backing up in the systemic venous system.

Left-sided heart failure can also cause right-sided heart failure.

Symptoms: Due to the back-up of fluid in the body, swelling, oedema (peripheral), bloating, occasionally abdominal discomfort and ascites (fluid within the abdomen). Dyspnoea in the presence of right heart failure is most commonly due to the underlying lung disease, not the heart failure.

Treatment: Treatment is that of the underlying lung condition, since any improvement in lung function will help relieve stress on the right side of the heart. When hypoxemia is present, oxygen is the best single treatment. Diuretics are also frequently used to help mobilize the excess fluid.

Left-sided Heart Failure

Definition: The inability of the left side of the heart to pump into the systemic circulation.

Pathophysiology: When the left ventricle cannot adequately pump blood out of the left atrium, or when one or more of the heart valves becomes leaky or narrowed (stenotic),blood can "back up" into the lungs. When this occurs, the lungs become congested with fluid (called pulmonary oedema), interfering with the movement of oxygen from the lungs into the bloodstream.

Causes: Often due to primary heart disease, usually of the coronary artery blood vessels or of the left heart valves (aortic or mitral valves). Another common cause of left heart failure is severe high blood pressure.

Symptoms: Back-up behind the left ventricle causes accumulation of fluid in the lungs (pulmonary oedema), dyspnoea, fatigue (due to low oxygen).

Treatment: Of underlying heart condition or of hypertension.

Sources:

http://www.heartfailure.org/eng_site/hf.asp
http://heart-disease.health-cares.net/congestive-heart-failure.php
http://www.lakesidepress.com/pulmonary/books/breathe/Sectm.htm

Effects of increased venous pressure in CCF

My explanation ( LOTS OF POSTULATIONS, ERRORS WILL BE CORRECTED AFTER PCL IF THERE IS ANY)
Increased venous pressure ( a compensatory response to reduced cardiac output) will directly cause the right atrium pressure to elevate since the preload is high. But as time goes by, the compensatory mechanism will cause the myocardium to hypertrophy and stiffens, compromising the heart’s ability to function normally. High venous pressure will increase the hydrostatic pressure of plasma at the venule ends of the capillaries and thus reducing the reabsorption of the filtered fluid from the interstitium. Accumulation of fluid outside plasma in the ECF will result in peripheral oedema as what Rosalyn is experiencing.

As you all know, venous pressure is governed by two factors – volume of blood in the veins as well as the distensibility of the vein walls controlled by smooth muscle. The built up of pressure in the veins will be indicated by jugular venous pressure. An elevated JVP is the classic sign of venous hypertension (e.g. right-sided heart failure). The paradoxical increase of the JVP with inspiration (instead of the expected decrease) is referred to as the Kussmaul sign, and indicates impaired filling of the right ventricle.

****************************Addendum*****************************
Expert’s view:
In RV failure, systemic venous pressure increases, causing fluid extravasation and consequent edema, primarily in dependent tissues (feet and ankles of ambulatory patients) and abdominal viscera. The liver is affected most, but stomach and intestine also become congested; fluid accumulation in the peritoneal cavity (ascites) can occur. RV failure commonly causes moderate hepatic dysfunction, with usually modest increases in conjugated and unconjugated bilirubin, PT, and hepatic enzymes (eg, alkaline phosphatase, AST, ALT). The impaired liver breaks down less aldosterone, further contributing to fluid accumulation. Chronic venous congestion in the viscera can cause anorexia, malabsorption and protein-losing enteropathy (characterized by diarrhea and marked hypoalbuminemia), chronic GI blood loss, and rarely ischemic bowel infarction.
Cardiac response: If ventricular function is impaired, a higher preload is required to maintain CO. As a result, the LV is remodeled over time: It becomes less ovoid and more spherical, dilates, and hypertrophies. Initially compensatory, these changes eventually increase diastolic stiffness and wall tension, compromising cardiac performance, especially during physical stress. Increased wall stress raises O2 demand and accelerates apoptosis (programmed cell death) of myocardial cells.
http://www.merck.com/mmpe/sec07/ch074/ch074b.html

10:14pm/14Mar

Murmurs and Heart Sounds in Congestive Heart Failure

Pan-systolic murmurs are murmurs that are heard throughout systole of the ventricles.

Causes:

- Mitral regurgitation
- Tricuspid regurgitation ( usually difficult to detect)
- Ventricular Septal Defect
- Pulmonary stenosis
- Aortic stenosis

Pan-systolic murmurs heard in patients with congestive heart failure may be indicative of the causes of the heart failure. These murmurs may prove that there is insufficiency of the AV valves, a stenosis in the semilunar valves or a ventricular septal defect which led to the development of a heart failure.

There are other types of murmurs that may be heard in a patient with congestive heart failure. These can be grouped under diastolic murmurs. As the name suggests, these murmurs are heard during the diastole of the ventricles. They are caused by aortic regurgitation or pulmonary regurgitation (usually difficult to detect).

A physician should be alert for murmurs in patients with congestive heart failure as they can provide information about the cause of heart failure and also aid in the selection of therapy.

Third and Fourth Heart Sounds

As discussed in the previous PCL, 3rd and 4th heart sounds are detected in the presence of diseased valves. Hence in patients with congestive heart failure caused by diseased valves, S3 and/or S4 can be heard.

A point to note:
A third heart sound is not sensitive (24 percent) for heart failure, but it is highly specific (99 percent).

Contributed by John Lee