2 - Heart Failure and Valvular Heart Disease Flashcards
What is the definition of heart failure and what are some causes of this?
Cardiac output is inadequate for the body’s requirements
- Ischaemic heart disease
- HTN
- Valvular heart disease (rheumatic fever in elderly)
- AFib
- Chronic lung disease
- Cardiomyopathy (hypertrophic, post viral, post partum)
- Previous chemo drugs
- HIV
What are the different symptoms in left and right heart failure?
Left: pulmonary oedema causing dyspnea, fatigue, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, pink frothy sputum, nocturia
Right (caused by LHF/Lungdisease): peripheral oedema, raised JVP, ascities, nausea, anorexia
When a patient has heart failure, what are some signs they may have?
- Raised JVP
- Displaced apex beat due to LV hypertrophy
- Peripheral oedema (ankles and sacrum)
- Bibasal crepitations
- Murmurs
- Decreased BP
- Narrow pulse pressure
How can we classify heart failure based on the output of the ventricles?
HFrEF: Ejection fraction is less than 40%, issues with ventricles contracting so systolic failure. Caused by MI, cardiomyopathy, IHD
HFpEF: Ejection fraction is more than 40%, issue with the ventricles relaxing so diastolic failure. Caused by ventricular hypertrophy, constrictive pericarditis, tamponade
Most patients have HFrEF but some have heart failure with normal ejection fraction. What types of patients tend to have HFpEF?
- Elderly
- Overweight
- HTN
- Afib
What are some causes of high output heart failure?
High-output cardiac failure is a less common form of heart failure, and although it may sound contradictory at first, in the simplest form, it is still the heart’s inability to provide sufficient blood for the body’s demand. Most patients with heart failure are either classified as a systolic or diastolic dysfunction with increased systemic vascular resistance, however, patients with high output cardiac failure have normal cardiac function and decreased systemic vascular resistance
How do we classify heart failure into groups?
New York classification
What are some poor prognostic factors for people with heart failure?
- Severe fluid overload
- Very high NT-proBNP
- Severe renal impairment
- Advanced age
- Multimorbidity
- Frequent admissions with heart failure
How is heart failure diagnosed in general terms?
- Symptoms of failure
- Objective evidence of cardiac dysfunction e.g ECHO
Can use Framingham criteria if suspect congestive heart failure
What tests are ordered when you suspect a patient has heart failure?
- Bloods: FBC for anaemia, U+Es, LFTs for hepatic congestion, TFTs, ferritin and transferrin for HH
- NT-proBNP
- CXR
- ECG
- ECHO
What is the most important investigation for heart failure and what may you find on investigation?
ECHO as can confirm heart failure, look for cause and see if LV dysfunction
Possible findings: dilated poorly contracted left ventricle (systolic dysfunction), stiff poorly relaxing small diameter left ventricle (diastolic dysfunction), valvular heart disease, pericardial disease
What other investigation apart from an ECHO can assess LV function and help to find a cause for heart failure?
Cardiac MRI
ECHO may miss right ventricle
What is the sensitivity and specificity of the BNP test?
- It is highly sensitive, if <100ng/L rules out heart failure
- However if raised it is not specific. Could be faised due to any cardiac chamber stress like AFIB
- Higher the BNP the worse the heart failure
What is the physiological role of natriuretic peptides ANP and BNP?
They help the stretched atria and ventricles by increasing GFR and decreasing Na resorption so decreases fluid load and therefore pre-load
What may a CXR show in heart failure?
ABCDE
- Alveolar oedema
- Kerly B Lines
- Cardiomegaly (PA film)
- Dilated prominent upper lobe vessels
- Pleural effusions
- Fluid in the fissures
- Air bronchograms
How is acute heart failure managed?
What are the principles of managing chronic heart failure?
- Lifestyle modification
- Treat the cause e.g valvular heart disease
- Avoid and treat exacerbating factors e.g any drugs making worse like verapamil (-ve inotrope)
- Annual flu vaccine and one off pneumovax
- Medications
What are some lifestyle modifications people with chronic heart failure can make to improve their condition?
- Smoking cessation
- Reduce alcohol consumption
- Salt restriction
- Optimise weight, weigh everyday to see if fluid accumulation. If so can fluid restrict
OFFER ALL HEART FAILURE PATIENTS A PERSONALISED CARDIAC REHABILATATION PROGRAMME
What medications do you need to start a patient with HFpEF on?
- Stop any medication worsening
- Loop diuretic e.g Furosemide
- Consider antiplatelet and statin
- Control any HTN, diabetes, AF etc
What medications do you need to start a patient with HFrEF on?
- Loop diuretics
- ACEi (ARB if not tolerated) and BB (if already on then switch to one for heart failure)
- Aldosterone antagonist (e.g spironolactone/epleronone) if symptoms persist
- Other vasodilators (e.g hydralazine/isosorbibe mononitrate) with specialist advice
All patients with heart failure are started on diuretics. Why is this the case and which diuretics are used?
Helps symptom control, does not improve survival
1st Line:
- Loop diuretic like Furosemide IV/Bumetanide PO
- Need to monitor U+Es as can cause HypoK and renal impairment.
- If hypoK+ consider adding spironolactone
2nd Line:
- Add thiazide to loops for refractory oedema e.g bendroflumethiazide
- Metolazone for dramatic diuresis
How do you start a patient with HFrEF on their first line drugs of ACEi and BB? Give some examples of drugs for each category.
- Start with one drug at a time, START LOW GO SLOW WITH BB
- Both reduce mortality
ACEi: Used if diabetic, fluid overloaded or hypertensive. e.g ramipril
BB: For more angina symptoms. Safe to start only if SBP>100, HR>60 and no postural hypotension e.g carvedilol, bisoprolol
If a HFrEF patient cannot tolerate both ACEi or ARBs, what medication can you put them on to reduce mortality?
Combination of hydralazine and isosorbide mononitrate
Particularly good in Afro-Caribbean patients
Can be used in resistant CCF if already on ACEi/ARB
If a patient with HFrEF is stil symptomatic after an ACEi and BB and spironolactone, what can you add next?
- Can switch ACEi to ARNI
- Can add ivabradine if EF<35% and HR>75
- Can add nitrates and hydralazine
- Can consider digoxin
What is an ARNI, what are some examples of this drug class, and when are they used in heart failure?
Angiotensin Receptor Neprilysin Inhibitor
Valsartan/Sacubitril stop degradation of ANP/BNP by neprilysin
Used for symptomatic chronic HFrEF <35% in NYHA II to IV who are already on stable doses of ACEi and BB
If a patient with HFrEF is already on ACEi, BB, MRA and is still having a resting heart rate >75bpm, what extra medication can you give them. What is the benefit of this drug and what drugs can it not be used in combination with?
Ivabradine
Need to be in sinus rhythm for it to be useful. Good to be used when blood pressure low as doesn’t impact bp
Avoid using with diltiazem and verapamil
If a patient with HFrEF has maximum medical therapy and is taking all of their medications, what else can we offer them?
- Cardiac resynchronisation pacemaker
- ICD to prevent sudden cardisc death. Can be primary or secondary prevention in cardiac arrest survivors
