1b// Structural heart disease and Heart failure Flashcards
what is structural heart disease?
defects affecting the valves and chambers of the heart and aorta
What are 6 congenital structural heart diseases you need to know?
- Atrial septal defect (ASD)
- Ventricular septal defect (VSD)
- Coarctation of aorta
- Patent foramen ovale (PFO)
- Patent ductus arteriosus (PDA)
- Tetralogy of Fallot (TOF)
Label.
What is the innermost, middle and outermost layer of the heart wall?
endocardium
it lines the cavities and valves of the heart
it regulates contractions of the heart
myocardium
composed of cardiac fibres
responsible for contraction of the heart
epicardium
aka visceral pericardium
thin layer of connective tissue and fat
What are pectinate muscles?
- Pectinate muscles are muscular ridges located in the atria of the heart
- Specifically in the right atrium and auricle
- They help increase the SA in the right atrium
What are chordae tendinea?
- Chordae tendinea are tendons that connect papillary muscles to tricuspid valve and mitral valve in the heart
- They help prevent the valve from prolapsing during the ventricular systole
What are trabeculae carneae?
** - They are irregular muscular columns
- They project from the inner surface of the right and left ventricles of the heart
- The provide additional support to ventricular valves
- They help maintain stroke volume and cardiac output
**
What are papillary muscles?
- Papillary muscles are small, cone-shaped muscles located in the ventricles of the heart
- They attach to the cusps of the atrioventricular valves via chordae tendineae
- They contract to prevent inversion or prolapse of these valves on systole (or ventricular contraction)
How do you calculate cardiac output?
heart rate (HR) x (stroke volume)
How do you calculate stroke volume?
end diastolic volume (EDV) - end systolic volume (ESV)
How do you calculate mean arteriole pressure?
(cardiac output(CO)) x Systemic vascular resistance (SVR))+ central venous pressure (CVP)
or
DP + 1/3(SP-DP)
How do you calculate ejection fraction?
SV/ EDV x100
How do you calculate ejection fraction?
SP-DP
What is mean arteriole pressure?
The mean arterial pressure is an average arterial blood pressure throughout a single cardiac cycle of systole and diastole. In health, a MAP >65 mmHg represents the pressure necessary to adequately perfuse the body organs. The estimation of MAP is useable at rest but during exertion (at high heart rate) MAP moves more closely toward an average of SP and DP.
What are the normal and abnormal heart sounds you can hear?
S1 and 2= normal
S3 and S4= abnormal
What is heart sound S1?
- The first sound S1 is caused by the closure of the mitral and tricuspid valves, which occurs when the ventricles contract to pump blood into the pulmonary artery and aorta .
What is heart sound S2?
The second sound S2 is caused by the closure of the aortic and pulmonic valves, which occurs when the ventricles relax to receive blood from the atria after pumping blood.
What is heart sound S3?
The third sound (S3) is a low-frequency sound that occurs in early diastole, produced by rapid filling and expansion of ventricles. The most common cause of pathological S3 is congestive cardiac failure.
What is heart sound S4?
- The fourth sound (S4) is a low-frequency sound that occurs in late diastole, produced by forceful atrial contractions forcing blood into stiff ventricles. Unlike S3, S4 is always pathological. It usually indicates atrial hypertrophy (seen in AS) or stiff ventricles ( systemic hypertension, hypertrophic cardiomyopathy, and ischemia)
What causes a heart murmur? And what are the types of murmurs?
A heart murmur is caused by the turbulent blood flow through the heart valves and is generally blowing, whooshing, or rasping sound heard during a heartbeat. There are 3 types of murmurs:
systolic, diastolic, continuous murmur
When does a systolic, diastolic and continuous murmur occur?
Systolic murmur: This type of murmur occurs when the heart is pumping blood to the rest of the body.
Diastolic murmur: This type of murmur occurs when the heart relaxes between beats to fill up with blood.
Continuous murmur: This type of murmur occurs throughout the heartbeat
What are the diseases that cause murmurs? (5)
aortic stenosis
mitral regurgitation
aortic regurgitation
mitral stenosis
patemnt ductus arteriosus
What is stenosis and what is aortic stenosis’ murmur?
stenosis means that valve is tight and not very flexible, and when the blood rushes through it during systole it has to gush through a tight opening
ejection systolic murmur
What is aortic regurgiation and what is its murmur?
valve leaflets are floppy they are not closed tightly when the valve is supposed to close after the systole is finished so there is a backflow of blood, simply can say leakage of blood back intop the ventricle from aorta.
diastolic murmur
What is patent ductus arteriosus and what is its murmur?
hole in the heart: PDA occurs when the opening between the aorta and the pulmonary artery does not close as it should. so there is mixing of blood and free flow of blood between lungs, aorta and pulmonary artery.
continuous murmur
What is mitral regurgitation and what its murmur?
floppy valves causing leaking of blood even when the valve is supposed to be closed i.e., during systole
holosystolic/ systolic murmur
What is mitral stenosis and what is its murmur?
stenosis means the valve is tight and whard for blood to flow through
mid-diastolic rumble
What is cardiac output?
the volume of blood the heart pumps in 1 minute. frequently given in L/min
What is VSD/ ASD?
- Ventricular is when the wall between the 2 ventricles doesn’t fully develop
Atrial is where there is a hole in the wall between the atria
so there is mixing of oxygenated and deoxygenated blood
ventricular/ atrial septal defect
What happens to a baby with VSD/ ASD?
baby will turn blue due to mixing of blood
- as deoxygenated bloof is being pumped from the left ventricle to the body
- aka cyanosis (blue tinge of lips and nails)
what is the tetralogy of fallot?
combination of 4 congenital heart defects…
VSD, pulmonary stenosis, overriding aorta, hypertrophy of the right ventricle
What is meant by overriding aorta?
The aorta, which is the artery that carries oxygen-rich blood to the body, is out of place and rises above both ventricles. As a result, the body gets too much oxygen-poor blood.
What is meant by hypertrophy of the right ventricle?
The right lower chamber of the heart is bigger or thicker than normal, making it harder for blood to go through the pulmonary valve.
what is a coarctation of the aorta and what does it cause and increase the risk of?
narrowing of aorta at downward arc
causes hypertension
risk of heart attack and stroke
blood struggles to push through, may develop HF
what are the 4 valvular/ structural defects?
aortic and mitral stenosis
aortic and mitral regurgitation
what is the epidemiology of mitral valve disease? And the other valve diseases?
greatest rates in 70+ and females
major point is the prevalence increases dramatically from 60+
mild mitral regurgitation is the most common
what is aortic stenosis commonly preceded by?
aortic sclerosis (aka aortic valve thickening withoutr flow limitation)
when is aortic stenosis/ sclerosis often suspected? And how is it confirmed?
the presence of early peaking, systolic ejection murmur
- echocardiograph
how does aortic stenosis cause abnormal physiology?
long-standing pressure overload leads to left ventricular hypertrophy in order to maintain normal afterload
as stenosis worsens, adaptive mechanism fails and LV wall stress increases, declines systolic function
results in systolic heart failure
What are risk factors for aortic stenosis?
- Hypertension
- LDL levels
- Smoking
- Elevated C-reactive protein
- Congenital bicuspid valves
- Chronic kidney disease
- Radiotherapy
Older age **
What are pathologies that cause aortic stenosis?
- Rheumatic heart disease
- Congenital heart disease
Calcium build up
- Congenital heart disease
what type of murmur is an S4 sound and what pathology?
ejection systolic
aortic stenosis
what does an aortic stenosis murmur sound like?
crescendo decrescendo
loudest over aortic area
radiates to carotid
ejection systolic (between lub and dub)
what does a mitral stenosis murmur sound like?
loudest over apex
and in expiration
lub-dub-whoooosh
mid diastolic murmur
what does an aortic regurgitation murmur sound like?
loudest at sternal edge
and when leaning forward
after dub
eARly diastolic murmur
what does a mitral regurgitation murmur sound like?
loudest over mitral area, radiates to axilla (left)
high pitched whistling
lub-whistle-dub
pansystolic murmur
what valve is open in systole?
aortic
what valve is open in diastole?
mitral
what are the investigations for valvular defects?
CXR
ECG
Transthoracic echocardiography
pos cardiac catheterisation, cardiac MRI/CT
basic pathophysiology of aortic stenosis
abnormal blood flow/trigger initiates inflammatory process similar to athersclerosis
damages valvular endocardium, leads to aortic sclerosis - leaflet fibrosis and calcium deposition
obstructs left ventricular emptying, increases pressure in left ventricle
compensatory left ventricular hypertrophy
How may someone present with aortic stenosis?
- Presentation may look like…
- Exertional dyspnoea and fatigue
- Chest pain, angina
- Syncope
- Heart failure
- Ejection systolic murmur
- Rheumatic fever
High lipoprotein and LDL and CKD
What is essential to diagnose aortic stenosis?
doppler echo
What is the management of aortic stenosis?
Aortic valve replacement (AVR):
* Treatment of severe aortic stenosis…
- Transcatheter valve replacement
- Surgical valve prosthesis
*choice of intervention should be a shared discussion making process, taking account of lifetime risks and benefits associated with the type of approach (transcatheter versus surgical) and type of valve (mechanical vs bioprosthetic)
what is aortic sclerosis
asymptomatic/pre-stenosis stage of aortic valve calcification
management of asmymptomatic aortic stenosis
observe only
management of symptomatic aortic stenosis
valve replacement
management of asymptomatic but less than 50% ejection fraction aortic stenosis
valve replacement
what is the option of treatment for aortic stenosis when not fit for surgery?
TAVI - trans-catheter aortic valve replacement
what is the trigger for aortic stenosis in rheumatic fever patients?
streptococcal infection triggering autoimmune reaction
symptoms of coarctation of aorta?
pale skin
irritability
sweating
difficulty breathing
management of coarctation of aorta?
surgery immediately
pathophysiology of coarctation of aorta
wall narrowing blocks normal blood flow
backflow to left ventricle, it works harder
LV hypertrophy
eventual heart failure
pathophysiology of atrial septal defect
hole between atria
blood flows from left-right
more blood goes to lungs, so lungs and heart work harder
symptoms of atrial septal defect
asymptomatic
or signs of reduced HF - SOB, murmurs, palpitations, oedema
symptoms of ventricular septal defect
murmurs
breathlessness
failure to thrive
or asymptomatic
symptoms of tetralogy of fallot
cyanosis
SOB
systolic murmur
pathophysiology of tetralogy of fallot
VSD
pulmonary stenosis
overriding aorta - enlarged, sits over VSD so blood from both ventricles enters
right ventricular hypertrophy as a result
lack of oxygenation as blood goes from right - systemic circulation, bypassing lungs
pathophysiology of mitral stenosis
acute insult leads to formation of multiple foci and infiltrates in endo/myocardium, valve walls
thickens and calcifies leading to stenosis
blood struggles to pass from left atrium - ventricle
increased left atrial pressure, enlargement
increased LA pressure leads to pulmonary hypertension, congestion and right sided dysfunction
common cause of mitral stenosis
rheumatic fever/ heart diseasew
symptoms of mitral stenosis
palpitations angina orthopnoea exertional dyspnoea paroxysmal nocturnal dyspnoea - wakes up short of breath
What are causes of mitral stenosis?
- Rheumatic fever
- Carcinoid syndrome
- Use of ergot/ serotonergic drugs
- SLE
- mitral annular calcification due to aging
- Amyloidosis
- Rheumatoid arthritis
- Whipple disease
Congenital deformity of the valve
What is mitral stenosis?
- Obstruction to the left ventricular inflow at the level of mitral valve due to structural abnormality of the mitral valve
- As disease progresses it leads to pulmonary hypertension and right heart failure occur
What are the clinical findings of mitral stenosis?
management of mild mitral stenosis
observation
management of severe asymptomatic mitral stenosis
balloon valvotomy
management of severe symptomatic mitral stenosis
beta blockers
diuretics
balloon valvotomy
valve replacement
What are investigations for mitral stenosis?
- ECG
- Chest x ray
Transthoracic echocardiography
- Chest x ray
What is the presentation of someone with mitral stenosis?
- H/0 of rheumatic fever
- Dyspnoea
- Mid diastolic murmur
- Opening snap/ loud S1 in early stages
- Dysphagia
- Atrial afibrillation
- Haemoptysis
pathophysiology of chronic aortic regurgitation
valvular incompetence leads to reflux from aorta into left ventricle
increased volume and pressure in left ventricle - LV hypertrophy
eventual reduced ejection fraction and end systolic volume increases
eventual dyspnoea and ischaemia
**aortic regurgiation is hte diastolic leakage of blood from the aorta into the left ventricle
- it occurs due top the imcompetence of valve leaflets resulting from ewither intrinsic valve disease or dilation of the aortic root
Is acute or chronic aortic regurgirtation a medical emergency?
- It can be acute–> medical emergency, presenting with sudden onset of pulmonary oedema and hypotension or cardiogenic shock
It can be chronic–> culminate into congestive cardiac failure
pathophysiology of acute aortic regurgitation
inc end systolic LV volume end diastolic pressure increases increase in pulmonary venous pressure dyspnoea and pulm oedema heart failure and cardiogenic shock
what are the main differences beyween acute and chronic aortic regurgitation
chronic allows for compensatory mechanisms - hypertrophy
symptoms of acute aortic regurgitation
cardiogenic shock tachycardia cyanosis pulmonary oedema austin flint murmur
symptoms of chronic aortic regurgitation
wide pulse pressure
corrigan pulse/traube sign (booming pulse)
management of acute aortic regurgitation
treat underlying cause
ionotropes
vasodilators
valve replacement
management of mild chronic aortic regurgitation
reduction of afterload - diuretics, vasodilators
management of severe aortic regurgitation
valve replacement
What are the causes of congenital and acquired aortic regurgitation?
- Rheumatic heart disease
- Infective endocarditis
- Aortic valve stenosis
- Congenital heart defects
Congenital bicuspid valves
What are the causes of aortic root dilation aortic regurgitation?
- Marfan’s syndrome
- Connective tissue disease/ collagen vascular diseases
- Idiopathic
- Ankylosing spondylitis
Traumatic
Describe the pathyphysdiology of aortic regurgitation (IC).
pathophysiology of mitral regurgitation following infective endocarditis
abcess formation, vegetations, rupture of chorade tendinae and valve perforations
leads to blood leakage LV-LA
*in general mitral regurg is the reversal of blood flow from the LV to the LA
pathophysiology of chronic mitral regurgitation
reflux from LV to LA
increased LA pressure, inc pulmonary pressure
congestion by fluid buildup - congestive heart failure
common cause of acute mitral regurgitation
- Mitral valve prolapse ?**
- Rheumatic heart disease
- Infective endocarditis
- Following valvular surgery
Prosthetic mitral valve dysfunction
*it is caused by the disruption in any part of the mitral valve apparatu
common causes of chornic mitral regurgitation.
- Rheumatic heart disease
- SLE
- Scleroderma
- Hypertrophic cardiomyopathy
Drug related
symptoms of mitral regurgitation
dyspnoea
orthopnoea
chest pain
fatigue
holosystolic murmur
S3 heart sounds
signs of congestive heart failure
What are investigations for mitral regurg?
- Transthoracic echocardiograph
- ECG
- Chest x ray
Cardiac MRI/ CT scan
management of acute mitral regurg
nitrates, diuretics, ionotropes,
intra-arotic balloon counterpulsation
management of acute mitral regurg with severe regurg
surgery
- prosthetic ring can be inserted to reshape the valve
management of severe chronic assymptomatic and chronic symptomatic mitral regurg
asymptomatic= watchful waiting or surgery
symptomatic= 1st surgery plus medical treatment
What are cardiomyopathies and what are the main types?
disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body
- it can lead to heart failure
the main types are…
- dilated
- hypertrophic
- restrictive
pathophysiology of dilated cardiomyopathy
ventricles stretch and thin
ventricular enlargement
ventricular systolic dysfunction
heart failure
progressdive, usually iireversible disease cuases systolic dysfunction with heart failure
What is the hallmark gross finding at autopsy for dilated cardiomyopathy?
left ventricular dilation usually more than 4cm
cause of dilated cardiomyopathy
genetic 1/3 (25%, primary withouyt family history is idiopathic) myocardial ischaemia/ heart valve disease child birth myocarditis alcoholism drug use autoimmune thyroid hypertension/diabetes
symptoms of dilated cardiomyopathy
- Dyspnoea, cold clammy extremities
- Low cardiac output leading to insufficient tissue oxygenation
- Displaced apex beat
- Enlarged left ventricle
- Fatigue
- Low cardiac output and decrease organ perfusion
- Angina
- Low coronary perfusion
- Pulmonary congestion
- Diffuse crackles
- Peripheral oedema
- Heart failure
- Sudden cardiac death
What are investigations for dilated cardiomyopathy?
- ECG
- Chest x ray
- Cardiac catheterisation
- Cardiac MRI/ CT scan
- Echocardiography
- Genetic testing
Viral serology
management of dilated cardiomyopathy
fluid and sodium restrictions
treat underlying cause
heart failure management - diuretics, beta blockers, ACEi
What is hypertrophic cardiomyopathy?
- Hypertrophic cardiomyopathy is a genetic cardiovascular disease
- It is defined by an increase in left ventricular wall thickness that is not solely explained by abnormal loading conditions
- Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death on preadolescent and adolescent children
- Familial hypertrophic cardiomyopathy occurs as an autosomal dominant in approximately 50% of cases
- Most patients with HCM are asymptomatic
- Unfortunately, the first clinical manifestation of the disease in such individuals may be sudden death, likely from ventricular tachycardia or fibrillation
pathophysiology of hypertrophic cardiomyopathy
genetic AD
abnormal increase of left ventricular wall
LV outflow obstruction, heart less able to fill, diastolic dysfunction
cause of hypertrophic cardiomyopathy
familial or sporadic mutations
symptoms of hypertrophic cardiomyopathy
S4
- Forceful atrial contraction into a hypertrophied left ventricle
Syncope - Reduced cardiac output to the peripheries and head Fatigue - Low cardiac output and decrease organ perfusion Angina - Low coronary perfusion Pulmonary congestion and oedema - Diffuse crackles Systolic murmur - Due to passage of blood through the narrow outflow Sudden cardiac death
management of hypertrophic cardiomyopathy
HCM w symptoms–> beta blockers, if contraindicated B=Verapamil
If refractory and drugs fail–> mechanical therapy with pacemaker or surgery (septal myectomy or ablation)
What are investigations for hypertrophic cardiomyopathy?
- Echocardiography
- Chest x ray
- Cardiac MRI
What is restruictive cardiomyopathy?
- Less well-defined cardiomyopathy as its diagnosis is based on establishing the presence of a restrictive ventricular filling pattern
- RCM accounts for approximately 5% of all cases of diagnosed cardiomyopathies
It may be idiopathic, familial (has been related to troponin I or desmin mutations, the latter often in association with a skeletal myopathy), or associated with various systemic disorders, such as haemochromatosis, amyloidosis, sarcoidosis, Fabry’s disease, carcinoid syndrome, scleroderma, anthracycline toxicity, or previous radiation.
pathophysiology of restrictive cardiomyopathy
ventricles become rigid, restricted from stretching/filling with blood
diastolic dysfunction
reduced cardiac output
causes of restrictive cardiomyopathy
idiopathic
familial
assoc. with systemic disorders
symptoms of restrictive cardiomyopathy
Ascites and pitting oedema in peripheries
- Increase venous pressure leads to right sided heart failure
Hepatomegaly - Hepatic congestion due to RHF S4 heart sound - Atrium contracts into still ventricle Increase in jugular venous pressure - Due to right heart failure Easy bruising, weight loss - Heart failure
management of restrictive cardiomyopathy
underlying cause
* Heart failure medication - Guideline-directed medical therapy for heart failure - Including angiotensin-converting enzyme inhibitors or angiotensin receptor II blockers, diuretics - and aldosterone inhibitors should be initiated in patients with reduced LV * Antiarrhythmic therapy * Immunosuppression- steroids * Pacemaker Cardiac transplantation
What are investigatyions for restrictive cardiomyopathy?
- CBC
- Serology
- Amyloidosis check
- Chest x ray
- ECG
- Echocardiography
- Catheterisation
MRI/ Biopsy
what is infective endocarditis
multisystem disease
infection of heart valves +/- adjacent endocardium
bacteria enters bloodstream, forms vegetations (bacteria, platelets, fibring)
an infection of the endocardium or vascular endothelium of the heart
- Typically affecting heart valves
- Result of bacteria entering blood stream forming a vegetation
- Causes fever, malaise, sweats and weight loss, heart murmur, blood tests= anaemia and raised markers of infection
what are vegetations
bacteria
platelets
fibrin
common cause of infective endocarditis
streptococci
symptoms of infective endocarditis
Cardiac decompensation symptoms…
- Shortness of breath
- Frequent coughing
- Swelling of the legs and abdomen
- Fatigue
- Raised JVP (jugular venous pressure)
- Lung crackles
- Oedema
who are at increased risk of infective endocaridtis?
- Increased drug users are at increased risk of infective endocarditis due to repeated injection
- Potentially exposing their bloodstream to bacteria on the surface of the skin or use of non-sterile needles
It is also more common in people who are immunosuppressed or have congenital heart defects leading to damaged endocardium
- Potentially exposing their bloodstream to bacteria on the surface of the skin or use of non-sterile needles
process of diagnosising of infective endocarditis
DUKES criteria
- Fever, malaise, sweats and unexplained weight loss are common symptoms
- There may be a new heart murmur on examination
- Blood tests show anaemia and raised markers of infection
- Blood cultures may isolate a microorganism
- Echocardiogram can show a vegetation, abscess, valve perforation and/or new
dehiscence of prosthetic valve. Often there is regurgitation of the affected valve - Transoesophageal echo has higher sensitivity compared with transthoracic
most commonly affected valves of IE and why?
aortic then mitral then right sided
The formation of a vegetation at the valves of the heart either results in changes to their thickness or a failure in their ability open and close appropriates. It is more common for bacteria to attach to the endocardium if underlying damage is present, and this occurs more frequently at sites of turbulent blood flow such as the valves of the heart.
except IV drug users - tricuspid as infection enters intravenously usually
symptoms of cardiac decompensation
SOB
frequent coughing
swelling of legs, abdomen
fatigue
clinically - raised JVP, lung crackles and oedema
complications of IE
vascular/embolic phenomena - stroke, Janeway lesions, splinter/conjunctival haemorrhage
immunological phenomena - Oslers nodes, Roth spots
what is cardiac decompensation
inability of heart to maintain adequate circulation (leading to end organ damage)
What is dilated cardiomyopathy?
dilated cardiomyopathy is characterised by dilated and thin-walled cardiac chambers with reduced contractility
Dilation of the chambers leads to reduced contractility. Echo shows a dilated left ventricle with reduced systolic function (ejection fraction) and typically global hypokinesis
What are the commonest causes of dilated cardiomyopathy?
Idiopathic, genetic, toxins (alcohol, cardiotoxic chemotherapy), pregnancy (peripartum cardiomyopathy), viral infections (myocarditis), tachycardia-related cardiomyopathy, thyroid disease, muscular dystrophies
How is dilated cardiomyopathy managed?
Medical heart failure therapy - ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists Diuretics for fluid overload
Anticoagulation for atrial fibrillation
Cardiac devices – cardiac resynchronisation therapy and/or implantable cardioverter defibrillator Transplant
What will be the implications on this gentleman in the future?
The gentleman is at risk of heart failure hospitalization, cardiac arrhythmias, sudden cardiac death due to ventricular arrhythmia, and reduced survival
What is the difference between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction?
HF with preserved ejection fraction: EF greater than 50%. Presence of diastolic or right heart dysfunction. Diastolic dysfunction leads to an increased reservoir of blood in the pulmonary veins, leading to increased pulmonary hypertension and pulmonary oedema.
HF with reduced ejection fraction: EF less than 50%. Impaired left ventricular systolic function leading to pulmonary oedema secondary to impaired systolic function and flow of blood via the aorta. This leads to the backflow of blood into the pulmonary veins and lungs (leading to pulmonary oedema).
What are the clinical signs and symptoms of heart failure and how does it differ between left and right heart failure?
Right heart failure – peripheral oedema e.g. leg swelling, raised jugular venous pressure
Left heart failure – pulmonary oedema
What medications are used to treat heart failure?
Heart failure with preserved ejection fraction: Diuretics and SGLT2 inhibitors.
Heart failure with reduced ejection fraction: ACE inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) – e.g. preformulated in Entresto. Beta blockers. Mineralcorticoid receptor antagonists, SGLT2 inihbitors, diuretics.
How is heart failure monitored?
Clinical signs and symptoms of fluid overload: E.g. shortness of breath, leg swelling, orthopnoea (needing an extra pillow at night), reduced exercise tolerance due to shortness of breath.
Observations: Low oxygen saturation
Biomarkers: NT-proBNP
Imaging: Echocardiogram
Overview of both dialted cardiomyopathy and infective endocarditis.
