Acute-on-Chronic Breathlessness Flashcards by Jessica Lake

What signs can help distinguish between right and left heart failure?

Ankle oedema, hepatomegaly and elevated JVP suggest right heart failure.
Bibasal crepitations suggest left heart failure.

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What type of medication does NICE recommend to help treat fluid on the lungs due to heart failure?

A diuretic, such as frusemide.

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What will a chest x-ray show in cases of heart failure? (3)

Bilateral effusions, Kerley B lines and upper lobe diversion.

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What biomarker is often used as a prognostic marker in chronic heart failure?

BNP

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What is jugular venous pressure (JVP) an indirect measure of?

The central venous pressure, and thus the pressure in the right atrium.

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Give five causes of an elevated JVP.

Right ventricular failure
Tricuspid regurgitation or stenosis
Pericardial effusion or constrictive pericarditis
Superior Vena Cava obstruction
Volume overload (can be due to many different pathologies)

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How are murmurs classified based on intensity?

Grade 1: the murmur is only heard on listening intently for some time.
Grade 2: a faint murmur that is heard immediately on auscultation.
Grade 3: a loud murmur with no palpable thrill.
Grade 4: a loud murmur with a palpable thrill.

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What are the ABCDEs of chest x-ray findings in heart failure?

A: Alveolar oedema (bat-wing opacity)
B: kerley B lines
C: Cardiomegaly
D: Dilated upper lobe vessels
E: pleural Effusion (often bilateral)

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What does the Frank-Starling curve represent?

The relationship between the preload and the stroke volume of the heart (i.e as venous return (preload) increases, the left ventricle increases the force of contraction, augmenting the stroke volume to compensate for the increased workload).

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What is left ventricular ejection fraction (EF)?

Left ventricular ejection fraction is a measurement of how much blood is being pumped out of the heart with each beat. It is expressed as a percentage of the LV end diastolic volume (immediately before systole) that is ejected out of the ventricle and into the aorta.

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What is a normal volume for left ventricular ejection fraction (LVEF)?

55-70%

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What are four causes of mitral regurgitation?

Rheumatic heart disease
Ischaemic heart disease – relating to leaflet tethering or papillary muscle dysfunction
Valvular vegetations - as in patients with endocarditis
Functional mitral valve regurgitation due to dilated left atrium or ventricle

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What blood tests should be done in a patient with new onset atrial fibrillation to investigate underlying aetiology?

Thyroid function, electrolytes and inflammatory markers.

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What are the classical symptoms and associated signs of heart failure? (6)

Symptoms: breathlessness, fatigue, ankle swelling.
Associated signs: raised JVP, pulmonary crackles, peripheral oedema.

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How are heart failure patients divided based on left ventricle ejection fraction (LVEF)?

HF with preserved LV function (EF>45%)
HF with LV systolic dysfunction (EF<45%)

[The group the patient is in will ultimately affect management.]

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After treating the underlying cause, how should heart failure with impaired systolic function be managed? (5)

Diuretics
ACE inhibitors
Beta-blockers
Aldosterone receptor antagonists
Devices (such as pacemakers)

After treating the underlying cause, how should heart failure with preserved left ventricle function be managed? (2)

Diuretics
Management of co-morbidities (i.e hypertension, diabetes mellitus)

What is the mechanism of action of ACE inhibitors?

Inhibition of angiotensin converting enzyme (ACE), blocking the conversion of angiotensin I to II and subsequently preventing the effects of angiotensin II on the body.

What is first line treatment for patients with heart failure?

ACE inhibitors (i.e captopril, cilazapril, enalapril) alongside beta-blockers (although not all beta blockers are licensed for heart failure).

What are the main beta-blockers licensed for heart failure? (4)

Bisoprolol
Carvedilol
Nebivolol
Metoprolol (modified release)

Name two aldosterone receptor antagonists used in the treatment of heart failure with severe left ventricular dysfunction (EF<35%).

Eplerenone and spironolactone.

What is the CHADS2VASc Score used for?

Predicting the risk of stroke in patients with atrial fibrillation.

What are the 7 risk factors taken into account in a CHADS2VASc Score?

C - congestive heart failure
H - hypertension
A - age (75 or over = highest risk)
D - diabetes
S - stroke/TIA/VTE
S - sex (female = higher risk)
VASC - vascular history (i.e previous MI, peripheral vascular disease or aortic plaque)

Where are blood clots most likely to form during atrial fibrillation?

A pocket-like structure called the left atrial appendage (LAA).

Why does duration of an atrial fibrillation effect it’s treatment?

If a patient has been in atrial fibrillation for greater than 48 hours, they should not be cardioverted (unless life saving) because if normal sinus rhythm is restored, clots that have potentially formed could be dislodged and there is therefore a risk of causing an embolism stroke.

What would be the safest approach to treating an atrial fibrillation which has had a duration longer than 48 hours, or has an unknown time of onset?

Control the heart rate with appropriate medication (rather than controlling rhythm via cardioversion) and anti-coagulate the patient for 4 weeks. (If appropriate, cardioversion can be attempted at a later date, once the patient is fully anticoagulated and an echocardiogram has excluded the presence of thrombi.)

What are five classic peripheral signs of infective endocarditis?

Petechiae Subungual (splinter) haemorrhages Osler nodes Janeway lesions Roth spots

What are petechiae?

Tiny spots of bleeding under the skin or in the mucous membranes.

What are Osler nodes?

Tender subcutaneous nodules usually found on the distal pads of the digits.

What are Janeway lesions?

Non-tender maculae on the palms and soles.

What are Roth spots?

Retinal haemorrhages with small, clear centres (these are a very rare sign).

What diagnostic criteria is used to make a diagnosis of infective endocarditis?

The Modified Duke Criteria: for diagnosis, the patient must have either 2 of the major clinical criteria, 1 major and 3 minor clinical criteria, or 5 minor clinical criteria.

What are the major and minor criteria involved in the Modified Duke Criteria for infective endocarditis? (7)

Major: 1. Blood culture positive for IE. 2. Evidence of endocardial involvement. Minor: 1. Predisposition (predisposing heart condition, injection drug use) 2. Fever 3. Vascular phenomena 4. Immunologic phenomena 5. Microbiological evidence (that does not meet major criterion above)

What are the most common presenting symptoms of people with symptomatic aortic stenosis? (3)

Symptomatic fluid overload (SOB/orthopnoea/peripheral oedema) Exertional syncope Chest pain

What CHADS2VASc Score would indicate anticoagulant consideration?

A score of 1 or above for men, or 2 or above for women.

What is an S3 gallop heart sound?

An additional sound heard after the second heart second, resulting from rapid ventricular filling causing the chordae tendineae to pull to their full length and ‘twang’ like a guitar string.

What is a fourth heart sound?

A rare sound heard directly before S1, indicating a stiff or hypertrophic ventricle and caused by turbulent flow from that atria contracting against the non-compliant ventricle.

What is one of the main causes of mitral valve stenosis?

Rheumatic heart disease.