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Y3 Medicine > 2 - Heart Failure and Valvular Heart Disease > Flashcards

2 - Heart Failure and Valvular Heart Disease Flashcards

1
Q

What is the definition of heart failure and what are some causes of this?

A

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
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2
Q

What are the different symptoms in left and right heart failure?

A

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, hepatosplenomegaly

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3
Q

When a patient has heart failure, what are some signs they may have?

A
  • Raised JVP
  • Displaced apex beat due to LV hypertrophy
  • Peripheral oedema (ankles and sacrum)
  • Bibasal crepitations
  • Murmurs
  • Decreased BP
  • Narrow pulse pressure
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4
Q

How can we classify heart failure based on the output of the ventricles, what are some causes?

A

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

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5
Q

Most patients have HFrEF but some have heart failure with normal ejection fraction. What types of patients tend to have HFpEF?

A
  • Elderly
  • Overweight
  • HTN
  • Afib
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6
Q

What are some causes of high output heart failure?

A
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7
Q

How do we classify heart failure into groups?

A

New York classification

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8
Q

What are some poor prognostic factors for people with heart failure?

A
  • Severe fluid overload
  • Very high NT-proBNP
  • Severe renal impairment
  • Advanced age
  • Multimorbidity
  • Frequent admissions with heart failure
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9
Q

How is heart failure diagnosed in general terms?

A
  • Symptoms of failure
  • Objective evidence of cardiac dysfunction e.g ECHO

Can use Framingham criteria if suspect congestive heart failure

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10
Q

What tests are ordered when you suspect a patient has heart failure?

A

- Bloods: FBC for anaemia, U+Es, LFTs for hepatic congestion, TFTs, ferritin and transferrin for HH

- NT-proBNP (400< specialist advice)

- CXR

- ECG

- ECHO

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11
Q

What is the most important investigation for heart failure and what may you find on investigation?

A

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

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12
Q

What other investigation apart from an ECHO can assess LV function and help to find a cause for heart failure?

A

Cardiac MRI

ECHO may miss right ventricle

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13
Q

What is the sensitivity and specificity of the BNP test?

A
  • 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
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14
Q

What is the physiological role of natriuretic peptides ANP and BNP?

A

Released due to cardiac distension, they help the stretched atria and ventricles by increasing GFR and decreasing Na resorption so decreases fluid load and therefore pre-load

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15
Q

What may a CXR show in heart failure?

A

ABCDE

  • Alveolar oedema
  • Kerly B Lines
  • Cardiomegaly (PA film)
  • Dilated prominent upper lobe vessels
  • Pleural effusions
  • Fluid in the fissures
  • Air bronchograms
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16
Q

How is acute heart failure managed?

A
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17
Q

What are the principles of managing chronic heart failure?

A
  • 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
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18
Q

What are some lifestyle modifications people with chronic heart failure can make to improve their condition?

A
  • 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

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19
Q

What medications do you need to start a patient with HFpEF on?

A
  • Stop any medication worsening

- Loop diuretic e.g Furosemide

- Consider antiplatelet and statin

- Refer the patient to a specialist if there is no response to diuretic therapy. Dapagliflozin is recommended by NICE

  • Control any HTN, diabetes, AF etc
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20
Q

What medications do you need to start a patient with HFrEF on?

A

- 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

NOTE: ARNI = Sacubitril + Valsartan

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21
Q

All patients with heart failure are started on diuretics. Why is this the case and which diuretics are used?

A

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

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22
Q

What do you need to monitor when starting a patient with heart failure on diuretics?

A
  • Monitor weight and urine output daily to assess response
  • Need to measure U+Es as long term diuretics can cause hypoK+. If potassium falling add K+ sparing diuretic spironolactone or epleronone

U+Es!!!!!

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23
Q

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.

A
  • 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

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24
Q

Some people cannot tolerate ACEi due to the cough. What can they use instead?

A

ACEi also have risk of hyperK+

Use an ARB and titrate up slowly e.g valsartan and candesartan

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25
What is the main side effect of hydralazine?
Drug induced lupus
26
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
27
If a patient with HFrEF is stil symptomatic after an ACEi and BB, what can you add next?
- MRA aldosterone antagonist like Spironolactone
28
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
29
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
30
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
31
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
32
What are the benefits of using nitrates in treatment of HFrEF and when should caution be taken using these?
**_Benefits_** - Reduce preload - Reduce pulmonary oedema - Reduce ventricular size - Can relieve orthopnea and exertional dyspnea **_Caution_** - Aortic and mitral stenosis - HOCM - Pericardial constriction
33
What are some palliative treatment options for heart failure patients?
- Good nutrition (allow alcohol) - Opiates for pain - O2 for dyspnea - Treat comorbidities - Treat any depression
34
What class of drugs should you avoid in HFrEF?
Rate limiting CCBs like diltiazem and verapamil as they decrease cardiac contractility
35
In general what is the issue with leaving valvular heart disease unmanaged?
- Irreversible ventricular dysfunction - Pulmonary hypertension
36
What are the signs of aortic stenosis?
**- Angina** **- Heart failure** **- Syncope** First presenting symptom is often decrease in exercise tolerance or syncope on exertion
37
What are some signs on examination of aortic stenosis?
**- Ejection systolic murmur** radiating to carotids - Aortic thrill/heave **- Slow rising pulse** with **narrow pulse pressure**
38
What is the most common cause of aortic stenosis and what are some other causes?
**- Age related calcification** - Congenital bicuspid valve - CKD - Previous rheumatic fever
39
What type of murmur is heard in aortic stenosis and where?
**Ejection systolic murmur** radiating to carotids Best heard in aortic area (2nd intercostal space to right of sternum) as crescendo-decresencdo Between S1 and S2
40
How do you assess aortic stenosis and diagnose it?
**- ECG** **- ECHO:** used for diagnosis and can see the severity of stenosis and look at the rest of the heart
41
If aortic stenosis is left untreated without surgery the prognosis is poor and has a high mortality. What are some indications for surgery with aortic stenosis?
- Done for everyone with symptoms of Aortic Stenosis - Anyone found to have it asymptomatically will also need treatment
42
What surgery is done for aortic stenosis?
**- Valve replacement:** old valve removed **- TAVI:** in older patients with comorbidities, placed through femoral artery. New valve placed inside old valve
43
What are the symptoms of aortic stenosis?
- Often **asymptomatic** for years until LV hypertrophy and heart failure **- Exertional breathlessness** and **decreased exercise tolerance** are the first symptoms - Orthopnea and PND
44
What are some signs of aortic regurgitation?
- Early diastolic murmur - Collapsing Warhammer pulse - De Mussett's sign (Headbobbing) - Quincke's sign (Capillary pulsation in nail bed) - Corrigan sign (Carotid pulsation)
45
What type of murmur is heard in aortic regurgitation and where is it best heard?
**High pitched early diastolic murmur** Best heard in left lower sternal edge 3rd/4th intercostal space with patient leaning forward in forced expiration
46
What are some causes of aortic regurgitation?
**Acute:** infective endocarditis, aortic dissection, chest trauma **Chronic:** - Idiopathic dilatation of aorta pulling valve apart - Congenital bicuspid valve - Calcific degeneration - Rheumatic disease - Marfans
47
How do you assess and diagnose aortic regurgitation?
**- ECG:** LVH **- CXR:** cardiomegaly **- ECHO:** diagnostic and can diagnose seveity of regurgitation and look at rest of heart
48
How is aortic regurgitation managed?
**- ACEi:** reduce afterload by lowering systolic bp to slow rate of ventricular hypertrophy **- Monitor with ECHO** every 6-12 months **- Valve replacement**
49
What are some indications for surgery in aortic regurgitation?
- Symptomatic severe AR - Asymptomatic severe AR with evidence of early LV systolic dysfunction (EF\<50%) - Asymptomatic AR of any severity with aortic root dilatation e.g Marfan's
50
What are the symptoms of mitral regurgitation?
- Often **asymptomatic** for years - Fatigue - Exertional dyspenea and decreased exercise tolerance are first signs - Palpitations
51
What are some signs of mitral regurgitation?
- Pansystolic murmur at apex radiating to axilla - Displaced apex beat - AF
52
What type of murmur is heard in mitral regurgitation and where is it heard best?
**Pansystolic murmur** Best heard over 5th ICS midclavicular line radiating to axilla
53
What are some causes of mitral regurgitation?
**- Mitral valve prolapse** - Connective tissue disorders e.g Marfan's - Rheumatic heart disease - Infective endocarditis - Ruptured chordae or papillary muscles
54
Mitral regurgitation can be acute or chronic. What are the differences between the two?
55
How do you assess and diagnose mitral regurgitation?
**- ECG:** may show AF **- CXR** **- ECHO:** can be transoesophageal, to look for LV dysfunction and decide whether repair or replacement
56
How is mitral regurgitation managed?
**- Diuretics** - If LV systolic dysfunction then **ACEi and Betablockers** like bisoprolol or Carvedilol **- Valve repair or replacement.** Repair has lower mortality so try this if suitable
57
What are some indications for surgery in mitral regurgitation?
- Symptomatic patients - Asymptomatic patients with mild-moderate LV dysfunction (EF 30-60%)
58
What are the signs and symptoms of mitral stenosis?
**Signs:** malar flush on cheeks, rumbling mid-diastolic murmur and opening snap **Symptoms:** breathlessness and haemoptysis due to pulmonary hypertension, dysphagia, odynphagia, fatigue, palpitations
59
Where is a murmur in mitral stenosis best heard?
Mid diastolic murmur heard best when patient lying on left in expiration
60
What is the management of mitral stenosis?
- If in AF rate control and anticoagulate **- Diuretics** to reduce preload and pulmonary venous congestion **- Balloon valvuloplasty, open mitral vavotomoy or valve replacement**
61
What causes pulmonary regurgitation?
Any cause of pulmonary hypertension
62
What two cardinal symptoms would make you strongly suspect infective endocarditis?
- Fever - New murmur This is infective endocarditis until proven otherwise!
63
What are some risk factors for developing infective endocarditis?
- Mitral valve prolapse - Presence of prosthetic material (not stents but prosthetic valves) - Bicuspid aortic valve - Congenital heart disease (e.g VSD, PDA) - IVDU - Immunosuppressed - Poor dental hygeine
64
What are the most common causative organisms of infective endocarditis in the following scenarios: - Native valve - IVDU - Prosthetic valve
**Native:** viridans streptococci and Staph.Aureus **- IVDU:** Staph Aureus **- Prosthetic Valve:** early up to 1 year coagulase negative staphylcocci (e.g S.Epidermidis), or late over 1 year is staph aureus OR strep viridans
65
Enterococcus endocarditis could be an indication of what disease?
GU or Lower GI infection
66
What are the causative organisms in fungal endocarditis and who is at risk of developing this?
**- Candida** or **Aspergillus** **- Risk factors:** IVDU, immunosuppressed, prolonged exposure to antimicrobial drugs, IV feeding
67
Some patients with infective endocarditis have negative blood cultures. Why is this?
- Recent exposure to antimicrobial drugs - Infection is with slow growing or fastidious organisms (HACEK)
68
What causes mortality in infective endocarditis?
- Heart failure - CNS emboli - Uncontrolled infection Mortality is highest with fungal (50%), then staph aureus, then viridans streptococci (4-16%)
69
What are some signs of infective endocarditis?
- Fever, night sweats, weight loss, anaemia - Sepsis - New murmur as vegetations can destroy vavles - Immune complex deposition (vasculitis, Roth spots, Splinter haemorraghes, glomerulonephritis - Emboli (Janesway lesions and Osler nodes)
70
What routine investigations should you do for suspected infective endocarditis and what are the two key diagnostic investigations?
BLOOD CULTURES x3 AND ECHOCARDIOGRAM (trans-oesophageal)
71
What will routine investigations show in infective endocarditis?
- Normocytic anaemia - Raised WCC - High CRP/ESR - Rheumatoid factor positive - Haematuria on urinalysis - Cardiomegaly and Pulmonary oedema on CXR
72
How do you take blood cultures for infective endocarditis?
- At least 3 (preferably 6) from different sites over several hours - Take before antibiotics - If still negative grow in special media for fastidious organisms
73
How does (trans oesophageal echo) TOE diagnose infective endocarditis?
Looks for presence of vegetations, detects more than a transthoracic echocardiography Best at looking at mitral and prosthetic valves
74
What is the diagnostic criteria for infective endocarditis called and how many criteria have to be fulfilled for a diagnosis?
**Modified Duke's criteria** - 2 major criteria - 1 major and 3 minor criteria - 5 minor criteria
75
What are the major criteria for diagnosis of infectious endocarditis?
76
What are the minor criteria for diagnosing infectious endocarditis?
77
What is the antibiotic management for infective endocarditis?
Often good to use tunnelled central venous line as prolonged IV antibiotics (4 weeks native, 6 weeks prosthetic) **Streptococci:** benzylpenicillin (vancomycin if allergic) + gentamicin **Enterococci:** amoxicillin (vancomycin if allergic) + gentamicin **Staphylococcus:** flucloxacillin (vancomycin if allergic or MRSA) + gentamicin
78
How do you check a patient is responding to antibiotic therapy for infective endocarditis?
**- ECHO:** once a week to check vegetation size and any valve complications **- ECG:** twice a week to check for conduction disturbances which could mean aortic root abscess **- Blood tests:** twice weekly ESR, CRP, FBC, U+Es
79
When should you consider surgery to treat infective endocarditis?
- Severe valvular incompetence - Aortic abscess (often indicated by a lengthening PR interval) - Infections resistant to antibiotics/fungal infections - Cardiac failure, refractory to standard medical treatment - Recurrent emboli after antibiotic therapy
80
What heart valve is most likely to be affected in infective endocarditis in an IVDU?
Tricuspid valve Tend not to have embolic features (e.g Janesay lesions) as right sided
81
What is rheumatic fever?
**Inflammation in heart, joints, skin or CNS that occurs 2-4 weeks after inadequately treated strep throat or scarlet fever** Caused by Group A Beta Haemolytic streptococci Antibody to the streptococcus cross reacts with body's normal tissue e.g heart valve
82
How is rheumatic fever diagnosed?
**Jones Criteria** (need evidence of recent strep infection plus 2 major criteria or 1 major and 2 minor)
83
Which heart valves does rheumatic fever tend to affect?
Always affects left sided heart valves - Mitral stenosis - Aortic regurgitation - Mitral regurgitation - Aortic valve stenosis
84
What is this and what is it caused by?
**Erythema Marginatum** Rash with raised edges and clear centre usually on trunk, arms and thighs. Happens in rheumatic fever
85
What is the management for rheumatic fever?
- Bed rest until CRP normal (2weeks-3months) **- Penicillin V** **- NSAIDs** for carditis/arthritis - Immobilise arthritis joints - Haloperidol or Diazepam for chorea
86
Why do patients with heart failure have ankle oedema?
- Increased venous pressure due to defective pumping. This leads to an increased hydrostatic pressure that pushes intravascular fluid into the tissues. - Poor renal perfusion will lead to RAAS activation which causes more fluid retention.
87
What are some complications of aortic stenosis?
- Heart failure - Stroke - Arrhythmias
88
What arrhythmia do mitral stenoses patients usually have?
AFib
89
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