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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
Q

What is the main side effect of hydralazine?

A

Drug induced lupus

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26
Q

If a HFrEF patient cannot tolerate both ACEi or ARBs, what medication can you put them on to reduce mortality?

A

Combination of hydralazine and isosorbide mononitrate

Particularly good in Afro-Caribbean patients

Can be used in resistant CCF if already on ACEi/ARB

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27
Q

If a patient with HFrEF is stil symptomatic after an ACEi and BB, what can you add next?

A
  • MRA aldosterone antagonist like Spironolactone
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28
Q

If a patient with HFrEF is stil symptomatic after an ACEi and BB and spironolactone, what can you add next?

A
  • Can switch ACEi to ARNI
  • Can add ivabradine if EF<35% and HR>75
  • Can add nitrates and hydralazine
  • Can consider digoxin
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29
Q

What is an ARNI, what are some examples of this drug class, and when are they used in heart failure?

A

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

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30
Q

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?

A

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

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31
Q

If a patient with HFrEF has maximum medical therapy and is taking all of their medications, what else can we offer them?

A

- Cardiac resynchronisation pacemaker

- ICD to prevent sudden cardisc death. Can be primary or secondary prevention in cardiac arrest survivors

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32
Q

What are the benefits of using nitrates in treatment of HFrEF and when should caution be taken using these?

A

Benefits

  • Reduce preload
  • Reduce pulmonary oedema
  • Reduce ventricular size
  • Can relieve orthopnea and exertional dyspnea

Caution

  • Aortic and mitral stenosis
  • HOCM
  • Pericardial constriction
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33
Q

What are some palliative treatment options for heart failure patients?

A
  • Good nutrition (allow alcohol)
  • Opiates for pain
  • O2 for dyspnea
  • Treat comorbidities
  • Treat any depression
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34
Q

What class of drugs should you avoid in HFrEF?

A

Rate limiting CCBs like diltiazem and verapamil as they decrease cardiac contractility

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35
Q

In general what is the issue with leaving valvular heart disease unmanaged?

A
  • Irreversible ventricular dysfunction
  • Pulmonary hypertension
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36
Q

What are the signs of aortic stenosis?

A

- Angina

- Heart failure

- Syncope

First presenting symptom is often decrease in exercise tolerance or syncope on exertion

37
Q

What are some signs on examination of aortic stenosis?

A

- Ejection systolic murmur radiating to carotids

  • Aortic thrill/heave

- Slow rising pulse with narrow pulse pressure

38
Q

What is the most common cause of aortic stenosis and what are some other causes?

A

- Age related calcification

  • Congenital bicuspid valve
  • CKD
  • Previous rheumatic fever
39
Q

What type of murmur is heard in aortic stenosis and where?

A

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
Q

How do you assess aortic stenosis and diagnose it?

A

- ECG

- ECHO: used for diagnosis and can see the severity of stenosis and look at the rest of the heart

41
Q

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?

A
  • Done for everyone with symptoms of Aortic Stenosis
  • Anyone found to have it asymptomatically will also need treatment
42
Q

What surgery is done for aortic stenosis?

A

- Valve replacement: old valve removed

- TAVI: in older patients with comorbidities, placed through femoral artery. New valve placed inside old valve

43
Q

What are the symptoms of aortic stenosis?

A
  • Often asymptomatic for years until LV hypertrophy and heart failure

- Exertional breathlessness and decreased exercise tolerance are the first symptoms

  • Orthopnea and PND
44
Q

What are some signs of aortic regurgitation?

A
  • Early diastolic murmur
  • Collapsing Warhammer pulse
  • De Mussett’s sign (Headbobbing)
  • Quincke’s sign (Capillary pulsation in nail bed)
  • Corrigan sign (Carotid pulsation)
45
Q

What type of murmur is heard in aortic regurgitation and where is it best heard?

A

High pitched early diastolic murmur

Best heard in left lower sternal edge 3rd/4th intercostal space with patient leaning forward in forced expiration

46
Q

What are some causes of aortic regurgitation?

A

Acute: infective endocarditis, aortic dissection, chest trauma

Chronic:

  • Idiopathic dilatation of aorta pulling valve apart
  • Congenital bicuspid valve
  • Calcific degeneration
  • Rheumatic disease
  • Marfans
47
Q

How do you assess and diagnose aortic regurgitation?

A

- ECG: LVH

- CXR: cardiomegaly

- ECHO: diagnostic and can diagnose seveity of regurgitation and look at rest of heart

48
Q

How is aortic regurgitation managed?

A

- ACEi: reduce afterload by lowering systolic bp to slow rate of ventricular hypertrophy

- Monitor with ECHO every 6-12 months

- Valve replacement

49
Q

What are some indications for surgery in aortic regurgitation?

A
  • 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
Q

What are the symptoms of mitral regurgitation?

A
  • Often asymptomatic for years
  • Fatigue
  • Exertional dyspenea and decreased exercise tolerance are first signs
  • Palpitations
51
Q

What are some signs of mitral regurgitation?

A
  • Pansystolic murmur at apex radiating to axilla
  • Displaced apex beat
  • AF
52
Q

What type of murmur is heard in mitral regurgitation and where is it heard best?

A

Pansystolic murmur

Best heard over 5th ICS midclavicular line radiating to axilla

53
Q

What are some causes of mitral regurgitation?

A

- Mitral valve prolapse

  • Connective tissue disorders e.g Marfan’s
  • Rheumatic heart disease
  • Infective endocarditis
  • Ruptured chordae or papillary muscles
54
Q

Mitral regurgitation can be acute or chronic. What are the differences between the two?

A
55
Q

How do you assess and diagnose mitral regurgitation?

A

- ECG: may show AF

- CXR

- ECHO: can be transoesophageal, to look for LV dysfunction and decide whether repair or replacement

56
Q

How is mitral regurgitation managed?

A

- 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
Q

What are some indications for surgery in mitral regurgitation?

A
  • Symptomatic patients
  • Asymptomatic patients with mild-moderate LV dysfunction (EF 30-60%)
58
Q

What are the signs and symptoms of mitral stenosis?

A

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
Q

Where is a murmur in mitral stenosis best heard?

A

Mid diastolic murmur heard best when patient lying on left in expiration

60
Q

What is the management of mitral stenosis?

A
  • If in AF rate control and anticoagulate

- Diuretics to reduce preload and pulmonary venous congestion

- Balloon valvuloplasty, open mitral vavotomoy or valve replacement

61
Q

What causes pulmonary regurgitation?

A

Any cause of pulmonary hypertension

62
Q

What two cardinal symptoms would make you strongly suspect infective endocarditis?

A
  • Fever
  • New murmur

This is infective endocarditis until proven otherwise!

63
Q

What are some risk factors for developing infective endocarditis?

A
  • 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
Q

What are the most common causative organisms of infective endocarditis in the following scenarios:

  • Native valve
  • IVDU
  • Prosthetic valve
A

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
Q

Enterococcus endocarditis could be an indication of what disease?

A

GU or Lower GI infection

66
Q

What are the causative organisms in fungal endocarditis and who is at risk of developing this?

A

- Candida or Aspergillus

- Risk factors: IVDU, immunosuppressed, prolonged exposure to antimicrobial drugs, IV feeding

67
Q

Some patients with infective endocarditis have negative blood cultures. Why is this?

A
  • Recent exposure to antimicrobial drugs
  • Infection is with slow growing or fastidious organisms (HACEK)
68
Q

What causes mortality in infective endocarditis?

A
  • Heart failure
  • CNS emboli
  • Uncontrolled infection

Mortality is highest with fungal (50%), then staph aureus, then viridans streptococci (4-16%)

69
Q

What are some signs of infective endocarditis?

A
  • 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
Q

What routine investigations should you do for suspected infective endocarditis and what are the two key diagnostic investigations?

A

BLOOD CULTURES x3

AND

ECHOCARDIOGRAM (trans-oesophageal)

71
Q

What will routine investigations show in infective endocarditis?

A
  • Normocytic anaemia
  • Raised WCC
  • High CRP/ESR
  • Rheumatoid factor positive
  • Haematuria on urinalysis
  • Cardiomegaly and Pulmonary oedema on CXR
72
Q

How do you take blood cultures for infective endocarditis?

A
  • 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
Q

How does (trans oesophageal echo) TOE diagnose infective endocarditis?

A

Looks for presence of vegetations, detects more than a transthoracic echocardiography

Best at looking at mitral and prosthetic valves

74
Q

What is the diagnostic criteria for infective endocarditis called and how many criteria have to be fulfilled for a diagnosis?

A

Modified Duke’s criteria

  • 2 major criteria
  • 1 major and 3 minor criteria
  • 5 minor criteria
75
Q

What are the major criteria for diagnosis of infectious endocarditis?

A
76
Q

What are the minor criteria for diagnosing infectious endocarditis?

A
77
Q

What is the antibiotic management for infective endocarditis?

A

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
Q

How do you check a patient is responding to antibiotic therapy for infective endocarditis?

A

- 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
Q

When should you consider surgery to treat infective endocarditis?

A
  • 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
Q

What heart valve is most likely to be affected in infective endocarditis in an IVDU?

A

Tricuspid valve

Tend not to have embolic features (e.g Janesay lesions) as right sided

81
Q

What is rheumatic fever?

A

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
Q

How is rheumatic fever diagnosed?

A

Jones Criteria (need evidence of recent strep infection plus 2 major criteria or 1 major and 2 minor)

83
Q

Which heart valves does rheumatic fever tend to affect?

A

Always affects left sided heart valves

  • Mitral stenosis
  • Aortic regurgitation
  • Mitral regurgitation
  • Aortic valve stenosis
84
Q

What is this and what is it caused by?

A

Erythema Marginatum

Rash with raised edges and clear centre usually on trunk, arms and thighs. Happens in rheumatic fever

85
Q

What is the management for rheumatic fever?

A
  • Bed rest until CRP normal (2weeks-3months)

- Penicillin V

- NSAIDs for carditis/arthritis

  • Immobilise arthritis joints
  • Haloperidol or Diazepam for chorea
86
Q

Why do patients with heart failure have ankle oedema?

A
  • 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
Q

What are some complications of aortic stenosis?

A
  • Heart failure
  • Stroke
  • Arrhythmias
88
Q

What arrhythmia do mitral stenoses patients usually have?

A

AFib

89
Q

Complete the following table.

A

Y3 Medicine (24 decks)

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