CARDIAC RESERVE and HEART FAILURE CARDIAC RESERVE = maximal CO / resting CO CORONARY RESERVE = maximal CF / resting CF CHRONOTROPIC RESERVE = maximal HF / resting HF VOLUME RESERVE = maximal SV / resting SV 4 - 7 3,5 3 - 5 1,5 CARDIAC RESERVE CO (l/min) WORKLOAD (W/kg) ATHLETHS HEART PHYSIOLOGICAL RESPONSE HEART FAILURE 1 2 3 4 10 30 20 HEART FAILURE The heart is not able pump sufficient amount of blood into periphery at normal venous return. MOST OFTEN CAUSES: • Severe arrhythmias • Overload – volume (aortal insufficiency, a-v shunts) or pressure (hypertension and aortal stenosis – left overload, pulmonary hypertension and stenosis of pulmonary valve – right overload) • Cardiomyopathy SYMPTOMS: fatigue, oedemas, venostasis, dyspnoea, cyanosis ACUTE x CHRONIC. COMPENSATED x DECOMPENSATED. ACUTE FAILURE CARDIOGENIC SHOCK COMPENSATION CHRONIC FAILURE SUDDEN DEATH DECOMPENSATION GRADUAL LOSS OF CARDIAC RESERVE COMPENSATION HEART FAILURE CAUSES MECHANICAL MYOCARDIAL DYSHRYTHMIAS •Pressure overload (valvular stenosis, hypertension) •Volume overload (valvular insufficiency, water retention) •Aneurysma •Dyssynergy •Endo-myocardial restriction •Cardiomyopathy •Myocarditis •Metabolic disorders •Loss of myocardial mass •Tachyarhythmias •Bradyarhythmias •Fibrillation •Blocks CIRCULATORY FAILURE •The main function of circulation is keep a good organ and tissue perfusion • • BP = CO x TPR •Circulatory failure is a generalized inadequate blood flow in the body that causes tissue damage due to reduced blood flow - reduced transport of oxygen (and other nutritional factors). The cardiovascular system itself (cardiac muscle, vascular walls, vasomotor system, and other parts of circulation) worsens when coming „circulatory shock“ CIRCULATORY FAILURE • BP = CO x TPR •CO decrease: ülower volume in circulation – lower venous return •decrease of filling pressure and by Frank- Starling principle decrease of CO •Clinical: e.g. hemorrhagic shock, hypovolemic shock •Therapy: infusion (e.g. of physiological solution) CIRCULATORY FAILURE • BP = CO x TPR •CO decrease: üvasodilatation of venous system - sudden periphery vasodilatation – e.g. sudden loss of vasomotor tone : vasomotor syncope (neurogenic shock-brain damage, deep anesthesia) üemotional activation of parasympathetic signals to slow the heart and also activation of inverse sympathetic signals to dilate the peripheral vasculature : vasovagal syncope (emotional disturbance-fainting in young people) CIRCULATORY FAILURE • BP = CO x TPR •CO decrease: ülower pumping function of the heart •e.g. myocardial infarction, severe dysfunction of the heart valves, cardiac arrhythmias •Result: cardiogenic shock •= circulatory shock, which results from the weakened ability of the heart as a pump; (85% of people who develop a cardiogenic shock will not survive) CIRCULATORY FAILURE •BP = CO x TPR •Circulatory shock without the change of CO •Abnormal increase in metabolic demands of the organism (so great that physiological CO is insufficient) •Abnormal tissue perfusion – e.g. septic shock (blood poisoning) •(inadequate supply of nutrients or inadequate production of waste substances from tissues) • CIRCULATORY FAILURE • BP = CO x TPR •TPR decrease: ütoxic vasodilatation (by histamin-allergy) – anaphylactic shock - sting by a bee ü üDysbalance of autonomy nervous system – sympathetic part – decrease of sympathetic tone of vessels vegetative collapse - dysbalance of the autonomic nervous system (decrease in the influence of sympathetic to the vascular tone – everything is related to the situations described in vasodilation of the venous system) ü ü NYHA classification Clipboard07.bmp •SYNCOPE - a manifestation of brain ischemia that arises with a sudden drop in blood pressure due to failure in circulation - if the lying - consciousness returns quickly - within one minute • Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery •If the pressure drops for several hours, they are metabolic changes in the ischemic organs and developing „a shock“ •SHOCK = is acute circulatory insufficiency syndrome with manifestations of tissue ischemia in a different areas of the body EXAMINATION TECHNIQUES IN CARDIOLOGY •Non-invasive methods • • • •Invasive methods • •(by puncture needle or catheter) NON – INVASIVE METHODS Basic – used together with examination of patients Inspection Palpation Percussion Auscultation •PHONOCARDIOGRAPHY S1 S2 S3 S1 S2 S3 X-ray RTG Helán Chest x-ray provides useful information about cardiac size and shape, as well as the state of the pulmonary vasculature, and may identify noncardiac causes of the patient´s symptoms ELECTROCARDIOGRAPY •A routine 12-lead ECG •The major importance of the ECG is to assess cardiac rhythm and determine the presence of left ventricle hypertrophy or prior myocardial infarction or QRS width •Normal ECG excludes left ventricle dysfunction Clipboard04.bmp ELECTROCARDIOGRAPY •HOLTER MONITORING • 24-hour ECG record • • ü estimation of heart rate variability § time analysis § spectral analysis • C:\Documents and Settings\ja2\Dokumenty\Přednášky medici\HRV002.jpg ELECTROCARDIOGRAPY •HOLTER MONITORING • ülate potencials C:\Documents and Settings\ja2\Dokumenty\Přednášky medici\late potencial001.jpg Reveal - implantable recorder reveal & act white carelink_pgmr §small device, without electrodes §recorder of ECG during syncope - activation by patients - or autoactivation §continuously monitoring 36 month, 42 min episodes at memory §simple implantation, simple evaluation. Patient Activator and Reveal® Plus ILR Medtronic CareLink® Programmer BLOOD PRESSURE MEASUREMENT AUSCULTATORY METHOD OSCILOMETRIC METHOD BLOOD PRESSURE MEASUREMENT •AMBULATORY BLOOD PRESSURE MONITORING - ABPM • img010.jpg BLOOD PRESSURE MEASUREMENT •continuously beat-to-beat measurement •Peňáz principle - photopletysmography • IMG_0869 •We need than pressure in the cuff corresponded to the pressure of the digital artery •Method: photopletysmography •Recorded photoelectric plethysmogram •The new term: Transmural pressure – Pt (the pressure across the wall of the artery) •BP, Pc (pressure in cuff), Pt •We estimated: BP=Pc - - - Pt=0 - - - photoplethysmogram registered the highest amplitude of oscilation --- we measure the MAP •Step by step increase of Pc, in the moment of the highest amplitude – feed-back loop started for obtained(keeping) the constant volume of the finger ECHOCARDIOGRAPHY most widespread methods img004.jpg img004.jpg APICAL VIEW img005.jpg PARASTERNAL LONG-AXIS VIEW img006.jpg COMPUTED TOMOGRAPHY •CT is a fast, simple, noninvasive technique that provides images of the myocardium and great vessels; •CT uses x-rays to create tomographic slices of objects-this is acomplished by rotating an x-ray bea around the object and measuring the trasmission of x-rays through the object at many angles,called projections • Clipboard03.bmp aorta Left anterior descending artery left atrium Left circumflex •Based on the magnetic properties of hydrogen nuclei •Used to quantify accurately EF, ESV, EDV, cardiac mass •Without the need for ionizing radiation • • MAGNETIC RESONANCE IMAGING Clipboard02.bmp NUCLEAR CARDIOLOGY •Nuclear (or radionuclid) imaging requires intravenous administration of isotopes •Single photon emission computed tomography SPECT and positron emission tomography PET Clipboard01.bmp INVASIVE TECHNIQUES •CARDIAC CATHETERIZATION •Right heart catheterization – uses a balloon-tipped flotation catheter that is inserted into the femoral or jugular vein. Using fluoroscopic guidance, the catheter is advanced to the right atrium - right ventricule – pulmonary artery and pulmonary wedge position (as a surrogate for left atrial pressure = wedge pressure) INVASIVE TECHNIQUE •CARDIAC CATHETERIZATION •Left heart catheterization – with the aid of fluoroscopy, the catheter is guided to ascending aorta – across the aortic valve into left ventricule (inserted into a.femoralis,a.axillaris, a.brachialis) •A needle-tipped catheter to puncture the atrial septum during right heart catheterization •+ coronary angiography img007.jpg INVASIVE TECHNIQUE •How do we use cardiac catheterization? • üPressure measurement üBlood flow measurement üBiopsy of tissue üBlood samples for oxygen-saturation analysis to screen for intracardiac shunts üElectric potentials measurement • Intracardiac Echocardiography Is an intravascular ultrasound modality that provides diagnostic imaging of cardiac structures from within the heart. The first catheters used high frequency tranducers (20-40 MHz) containing a single ultrasound crystal that rapidly rotated at the end of catheter C:\Documents and Settings\ja2\Dokumenty\Přednášky medici\intrakardiální echo007.jpg INVASIVE TECHNIQUE •ELECTROPHYSIOLOGY EXAMINATION img009.jpg img009.jpg C:\Documents and Settings\ja2\Dokumenty\Přednášky medici\aktivační mapa003.jpg C:\Documents and Settings\ja2\Dokumenty\Přednášky medici\propagační mapa004.jpg Activation map - Activation map of right atrium in left sloping projection - Sinus rhythm Activation propagation map - propagation of left ventricular map C:\Documents and Settings\ja2\Dokumenty\Přednášky medici\voltážová mapa005.jpg C:\Documents and Settings\ja2\Dokumenty\Přednášky medici\sítová mapa006.jpg Voltage map – red color – places with a lower voltage, violet – healthy myocardium Voltage map in network design – visibility of the catheter Kombinace elektrody v hrotu PK a anteriorní větvi CS - LVAT 150 ms Apex PK LK Poloha elektrody v PK na midseptu - LVAT 82 ms Apex PK LK Electrodes for cardiostimulation Electrode in right atrium and auricle Electrode in right ventricle Electrodes for cardiostimulation Resynchronization therapy