9. Congestive Heart Failure Flashcards
What is chronic heart failure caused by and what does an impaired left ventricular function result in
either impaired left ventricular contraction (systolic heart failure) or left ventricular relaxation (diastolic heart failure)
a chronic back pressure of blood trying to flow into and through the left side of the heart
Define Dyspnoea and what is it associated with
Difficult or laboured breathing
increase in the work of breathing which is associate d with reduced lung compliance (stiff lung) or increased RR
Name some common causes of dysponea
asthma
heart failure
chronic obstructive pulmonary disease (COPD), interstitial lung disease
pneumonia
psychogenic problems that are usually linked to anxiety (can also occur with severe anaemia)
Define orthopnoea
SOB when lying flat
Often a symptom of of left ventricular failure and/or pulmonary oedema
Name some of the features that patients with chronic heart failure present with
Breathlessness worsened by exertion Cough- may produce frothy white/pink sputum Orthopnoea Paroxysmal nocturnal dysponoea Peripheral oedema Loss of energy/tiredness
What is Paroxysmal Nocturnal Dyspnoea (PND)
describes the experience that patients have of suddenly waking in the night with a severe attack SOB and cough
Name the mechanism behind why people with heart failure suffer from Paroxysmal Nocturnal Dyspnoea (PND)
- Fluid is settling across a large surface area of the lung when they sleep flat (so when sit up fluid sinks to the bottom)
- During sleep the respiratory centres in the brain become less responsive so RR and effort don’t increase in response to reduced oxygen sats (develop significant pulmonary congestion and hypoxia before waking up)
- There is less adrenalin circulating during sleep (means that myocardium is more relaxed which worsens cardiac output
Why does the fact that during sleep the respiratory centres are less responsive and less circulating adrenalin factor into someone with cardiac failure suffer from Paroxysmal Nocturnal Dyspnoea (PND)
- less responsive so RR increased and efforts don’t increase in response to reduced O2
- less adrenalin means myocardium is more relaxed which worsens cardiac output
Hear failure symptoms are defined by the new York heart association
What does NYHA 1-4 mean
NYHA 1: No symptoms and no limitation in ordinary physical activity
NYHA 2: Mild symptoms and slight limitation during ordinary activity
NYHA 3: Marked limitation in activity due to symptoms, even during less than ordinary activity (such as walking to the kitchen)
NYHA 4: Severe limitations, experiences symptoms even while at rest
What are the clinical signs of heart failure (signs not symptoms)
Pulmonary oedema/pleural effusion Raised JVP Pitting Oedema Ascites (and hepatomegaly) Tachycardia S3 gallop bibasal crepitations
What 3 features are needed in order to be able to confidently diagnose heart failure
symptoms typical of heart failure
signs typical of heart failure
objective evidence of structural or function cardiac abnormality at rest
Name some Objective evidence of structural or functional cardiac abnormality at rest
Cardiomegaly on CXR
S3 gallop
echocardiographic abnormality
What specific blood test would you do if you suspect heart failure (describe what it is too)
BNP - brain natriuretic peptide
secreted by the ventricles in response to excessive stretching of heart muscle cells
normal levels would rule out heart failure
(they also use Nt-proBNP)
o BNP less than 100 ng/litre
o NT proBNP less than 300 ng/litre.
What investigations would you carry out if you suspect heart failure
- CXR
- ECG
- ABG
- Bloods (FBC, U&E, Trop I, LFT, BNP )
- Echocardiography
Why would you order the following blood tests;
- FBC
- U&E
- TFT
- TROP I
- LFT
- FBC as anaemia can be a cause of heart failure as well as B12 deficiency
- U&E as often patients also have impaired renal function
- abnormal TFT can affect the heart
- TROP I or T to rule out an MI
- LFT as pulmonary congestive is associated with liver congestion
What could you see on a CXR if someone is presenting with signs of heart failure
increased cardiac size
presence of pleural effusion or pulmonary odema
could also have heavy calcification of the pericardium or the valves
What numerical value can be obtained from an echocardiogram
The ejection fraction which is a measurement % of how much blood the left ventricle pumps out with each contraction
On an echocardiograph what would you see if someone has had a previous myocardial infarction
akinetic/hytpokinetic areas where the previous MI has thinned the wall
What is the normal ejection fraction of the LV and what can patients with heart failure be subdivided into based on their ejection fraction %
approx 60%
heart failure with impaired systolic function (EF below 45%)
Heart failure with preserved LV function (greater than 45%)
On an ECG what can left ventricular hypertrophy indicate
hypertension
aortic stenosis
HOCM - hypertrophic obstructive cardiomyopathy
What are the main 4 causes of heart failure
Ischemic heart disease (accounts for 40% of all causes of heart failure in the UK eg coronary artery disease and acute MI)
valvular heart disease (commonly aortic stenosis)
hypertension
arrhhytmias (commonly AF)
In the following categories of causes of heart failure, give some examples;
- structural causes
- congenital heart disease
- Rate related causes
- pulmonary causes
- aortic regurgitation, aortic stenosis, mitral regurgitation, mitral stenosis
- ASD, VSD, inherited cardiomyopathies
- uncontrolled AF, thyrotoxicosis and anaemia (causing high output state), heart block (causing low output state)
- COPD, pulmonary fibrosis, recurrent pulmonary emboli, primary pulmonary hypertension (can cause right sided heart failure)
in the following categories of causes of heart failure, give some examples
- ischemic causes
- infective causes
- toxins
- other medical
- coronary artery disease, AMI
- chronic pericarditis (caused by TB, lupus and viruses), autoimmune such as amylooidosis and sarcoid, viral myocarditis
- alcohol, certain drugs such as doxorubicin which is a cancer drug)
- hyper tension, diabetes (due to CAD or diabetic cardiomyopathy), phaeochromocytoma (adrenal tumour)
What non-pharmacological things would you do in the management of heart failure
yearly flu and pneumococcal vaccine
stop smoking
optimise treatment of co-morbidities
exercise at tolerated
Careful discussion and explanation of the condition
heart failure specialist nurse init for advice and support
refer to special if NT-proBNP is greater than 2000 ng/litre
NICE guidelines question for stabilising a patient
- What therapy would you give to someone with acute heart failure
- What parameters do you need to measure when starting this treatment
- What other medication are not used routinely but are an option in certain circumstances
- IV diuretic therapy and if already on a diuretic then increase dose unless there is a concern with patients adherence
- monitor renal function, weight and urine output
- severe hypertension or aortic/mitral valve disease offer IV nitrates, reversible cariogenic shock offer sodium nitroprusside or inotropes or vasopressors (increase contractility and vasoconstriction
What is the first line medical treatment for heart failure
ABAL
Ace inhibitor (eg ramipril titrated as tolerated up to 10mg once daily) Beta Blocker (eg bisoprolol titrated as tolerated up to 10mg once daily) Aldosterone antagonist when symptoms not controlled with A and B (spironolactone or eplerenone) Loop diuretics improves symptoms (eg furosemide 40mg once daily)
what medicine can be prescribed if an ACEi is not tolerated and give an example
angiotensin receptor blocker (ARB) eg candesartan
What medication should you avoid in patients with valvular heart disease until indicated by a specialist
ACE inhibitor
under what circumstances should an aldosterone antagonist be used
when there is a reduced ejection fraction and symptoms are not controlled with ACEi and beta blocker
which 3 medications cause electrolyte disturbances and so U&E need to be closely monitored
diuretics
ACEi
aldosterone antagonists
NICE guideline question;
if a patient is already on a beta blocker then this should be continued unless ………….
the HR is below 50
they are in 2nd/3rd degree heart block
AV block or in shock
Name some co-morbiites that need to be treated as the underlying cause in someone with heart failure with a preserved ejection fraction
rapid AF uncontrolled hypertension critical coronary artery disease significant valvular disease uncontrolled DM thyrotoxicosis
What heart failure treatment inhibits left ventricular hypertrophy and remodelling of the heart
ACEi
name some common ACEi
Ramipril Lisinopril Captopril Enalapril Perindopril Quinapril
as well as inhibiting left ventricular hypertrophy and remodelling of the heart, what else do ACEi cause and why
decreased water and salt retention (stimulates ADH secretion)
Name some common beta blockers and name the one that is NOT licenced to treat heart failure
Atenalol is NOT licensed
Bisoprolol
carvedilol
Nebivolol
metoprolol (MR)
ARB auch as eplerenone and spironolactone are used in treatment of severe LV dysfunction which is defined as an EF of less than ____% and NYHA ___
35%
NYHA II
note that this drug also has anti-fibrotic effects
under what circumstance would someone be fitted with a cardiac resynchronisation therapy device (CRT)
patients with HF that have significant electrical and mechanical desynchrony
- ie the left and right ventricle may contract at slightly different times or
- the left ventricle may contract in segments instead of as one unit
Name the 3 leads that a CRT device has
Atrial lead
RV lead
LV lead which passes through the coronary sinus and into one of the vessels of the outside lateral wall of the heart
in what circumstances with an implantable cardiac defibrillation (ICD) be used
patients with HF and EF of less than 35%
what is the use of ICD devices
they can attempt to overdrive pace VT and deliver an electrical shock to cardiovert VT/VF
what is cardio version
is a medical procedure by which an abnormally fast heart rate or other cardiac arrhythmia is converted to a normal rhythm using electricity or drugs
name some clinical signs of right sided heart failure
bibasal crepitations
name some clinical signs of left sided heart failure
ankle oedema, hepatomegaly and elevated JVP
what risk factors should you ask about
Coronary artery disease including previous history of myocardial infarction, hypertension, atrial fibrillation, and diabetes mellitus.
Drugs, including alcohol.
Family history of heart failure or sudden cardiac death under the age of 40 years.
apart from heart failure, what other conditions could cause ankle odema
Prolonged inactivity or venous insufficiency causing dependent oedema.
Nephrotic syndrome.
Drugs (for example dihydropyridine calcium-channel blockers, nonsteroidal anti-inflammatory drugs).
Hypoalbuminaemia (from renal or hepatic disease).
Pelvic tumour.
what advise should you give in regards to driving and chronic heart failure
For group 1 entitlement (cars, motorcycles): driving may continue, provided there are no symptoms that may distract the driver’s attention. The DVLA need not be notified.
(different for lorries and buses)
