53. Oedema Flashcards
Causes oedema
Congestive cardiac failure (ischaemic, valvular, myopathic, copulmonale, hypertensive)
Hypoproteinaemia (liver disease, nephrotic syndrome, malnutrition)
Pre-eclampsia
Venous stasis (varicose veins, DVT, inferior vena cava obstruction)
triggers acute left ventirucalr failure
Decompensated chronic heart failure
Iatrogenic eg aggressive IV fluids
MI
Arrhythmias
Sepsis
HTN emergency
signs o/e acute left ventricualr fialure
Signs: type 1 resp failure, raised RR, reduced O2 sats, tachycardia, 3rd heart sound, bibasal crackles, hypotension in cardiogenic shock
If they also have right-sided heart failure, you could find:
Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck
Peripheral oedema of the ankles, legs and sacrum
symptoms acute left ventricualr failure
Symptoms: acute SOB, feeling unwell, pink/white frothy sputum
Approach to assessing acute left venticualr failure
ABCDE approach
A
B - o2, cxr, ABG. bloods fbc, u&e, lfts, troponin, tft, d-dimer, glucose, hba1c
C - ECG
D
E
Further: echo
BNP in GP
Acute management left ventriucalr failure
S – Sit up
O – Oxygen
D – Diuretics (IV furosemide)
I – Intravenous fluids should be stopped
U – Underlying causes need to be identified and treated (e.g., myocardial infarction)
M – Monitor fluid balance
Specialist input
Hypotension: inotropes/vasopressors
Hypertension: GTN or IV nitrates
xray findings congetsive hf
Alveolar oedema (bat wing opacities)
kerley B lines
Cardiomegaly (cardiothoracic ratio > 0.5)
upper lobe blood Diversion
pleural Effusions (bilateral blunting of costophrenic angles)
Fluid in the horizontal fissure
causes chronic heart failure
Ischaemic heart disease
Valvular heart disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)
Cardiomyopathy
what is ejection fraction?
The ejection fraction is the percentage of blood in the left ventricle squeezed out with each ventricular contraction. An ejection fraction above 50% is considered normal.
pathophysiology hf with preserved ejection fraction
Heart failure with preserved ejection fraction is when someone has the clinical features of heart failure but an ejection fraction greater than 50%.
This is the result of diastolic dysfunction, where there is an issue with the left ventricle filling with blood during diastole (the ventricle relaxing).
waking up at night, symptom called?
Paroxysmal nocturnal dyspnoea
symptoms chronic heart failure
Breathlessness, worsened by exertion
Cough, which may produce frothy white/pink sputum
Orthopnoea, which is breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use)
Paroxysmal nocturnal dyspnoea (more detail below)
Peripheral oedema
Fatigue
general/holistic management heart fialure
offer annual influenza vaccine
offer one-off pneumococcal vaccine
Consider antiplatelet for atherosclerotoc disease
Consider if statin therapy is indicated
Ensure that any causes, comorbidities, and precipitating factors are optimally managed.
Ensure drugs which may cause or worsen heart failure are reviewed and stopped if appropriate.
Screen for depression and anxiety
If suitable, ensure the person has been offered referral to a supervised exercise-based group rehabilitation programme for people with heart failure.
who needs pneumococcal every 5 years
asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years
Management of confirmed heart failure with preserved ejection fraction
- Loop diuretic up to 80 mg furosemide
- Refer for specialist management if no response to loop diuretic. SGLT-2 may be used for symptomatic w normal EF or mildly reduced ejection fraction eg dapagliflozin
Management of confirmed heart failure with reduced ejection fraction
+ if fluid overload- loop diuretic
1. ACEi and BB
(Use clinical judgement to decide which drug to start first)
2. Mineralocorticoid receptor antagonist (MRA) eg spironolactone
3. Specialist advice
when not to offer acei first for hf?
if there is clinical suspicion of hemodynamically significant valve disease, until the valve disease has been assessed by a specialist
diabetes / fluid overload, first drug to start hf
ACEi
Acronym for chronic heart fialure management
ABALS
ACE inhibitor or ARB
Beta blocker eg bisoprolol
Aldosterone antagonist (spironolactone, eplerenone)
Loop diuretic (furosemide)
Sodium-glucose co-transporter 2 (SGLT2) inhibitor
Specialist Drugs: Ivabradine, digoxin
Causes of high output HF?
anaemia, thyrotoxicosis, pagets disease, arteriovenous malformations
Explain the significance of the BNP/proBNP blood result?
high negative predictive value.
Normal = unlikely to be heart failure.
However isn’t diagnostic as other things can cause a high BNP such as ACS, myocarditis, PE,renal or liver impairment). low BNP can occur in end-stage HF, flash pulmonary oedema or right sided HF.
ECG cor pulmonale?
Tall peaked p waves
why check lfts heart dialure
often elevated due to reduced CO and increased venous congestion. abnormal liver tests are associated with worse prognosis
why should you check ecg heart fialure
to look for life-threatening cause such as ACS
when to refer probnp?
if levels are ‘high’ >400 arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
if levels are ‘raised’ >100-400
arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
