C34. Heart Failure Flashcards
what is Heart failure
impaired ventricular filling or ejection fraction. The state in which the heart is unable to pump blood at a rate commensurate with the requirements of the tissues or can do so only at high pressures
what happens when there is impairment of left ventricular filling
in diastole, the left ventricular walls relax to allow filling of the LV cavity.
Without proper LV relaxation, the volume of blood filling the cavity is reduced thus reducing stroke volume and the blood ejected with each contraction
what happens of there is LV wall damage
due to LV wall damage, the LV may have reduced ability to pump or eject the blood aka impaired ejection of blood
what are the steps for the diagnostic evaluation of new onset heart failure
- determine the type of cardiac dysfunction (systolic vs diastolic)
- determine aetiology and treat potentially reversible causes
- define prognosis
-guide therapy
what are some of the aetiology examples of Heart Failure
coronary heart disease (MI)
Hypertension
dilated cardiomyopathy
Valve disease
tachycardic arrhythmias
HFFpEF
what are some of the classic symptoms of heart failure
SOB, Orthopnea, Paroxysmal nocturnal dyspnoea, reduced exercise tolerance, fatigue, tiredness, ankle swelling
what is the new york heart association functional classification
1-4
1 - no limitation of physical activity
2- slight limitation
3- marked limitation
4- unable (symptoms at rest)
what examination techniques would you use for heart failure
- neck exam - looking for elevated JVP
- Auscultation of the lungs - rales or crackles
- Auscultation of the heart - looking for 3rd or 4th heart sounds (S3/S4)(gallop rhythm) or murmurs
- Oedema - in sacrum, feet, ankles or lower legs
what diagnostic tests can you do for heart failure
ECG - arrhythmias, past MI, LVH
Chest X ray - size/shape of heart or fluid accumulation in the lungs
Echocardiography - Transthoracic echocardiography TTE
Doppler
MRI
Angiogram
BNP (plus full blood tests)
in heart failure what do you see on the x ray
enlarged cardiac silhouette
peripheral congestion
Kerley B lines
fluid in inferior accessory fissure
guidelines recommend which diagnostic test as the most useful for HF
Echocardiography
what do Echocardiographys show
- chamber size
- right and left ventricular function
- regional wall motion abnormalities
- impaired LV filling (stiffness) a feature of diastolic dysfunction
- valvular heart disease
- diseases of the pericardium
- ejection fraction
what is ejection fraction
the percentage of blood that is pumped out of the heart during each beat
what is a normal EF
> 50%
Heart failure with an EF of 40% is known as what?
HFrEF heart failure reduced ejection fraction
what is heart failure reduced ejection fractions percentage EF
<40 %
Heart failure when ejection fraction is normal aka >50% is know as what?
HFpEF Heart Failure preserved ejection fraction
what is the equation to work out ejection fraction
amount of blood pumped out of the ventricle ////////////over total amount of blood in the ventricle
what is HFrEF
LV unable to eject and adequate amount of blood during systole
what is HFpEF
less blood ablw to fill the LV in diastole due to myocardial stiffness thus LV has less blood to eject during systole
what is BNP
it’s a hormone produced by your heart. When your heart has to work harder than usual, it releases more BNP into your blood. (ventricular hormone)
what is ANP
is a hormone produced by the heart, specifically by the atria
what scans/imaging techniques can you use
PET
Echo
Cardiac MRI
TI-1201
TC-99 SPECT
what does Late Gadolinium Enhanced Cardiac MRI show you?
This is a specific technique used within a CMR scan. After injecting a gadolinium-based contrast agent, LGE highlights areas of the heart muscle that are damaged or scarred. It helps differentiate between healthy and non-viable (damaged) heart tissue. It looks at size of LGE % and Wall thickness too
what lifestyle restrictions would you advise for a patient with HF
avoid salt, encourage exercise, keep vaccinations up to date
what are the 4 pillars of therapy in Heart failure
ARNI, BB, MRA, SGLT2i
what are ARNIs
angiotensin receptor neprilysin inhibitors
what are MRAs
mineralocorticoid receptor antagonists
what are SGLT2i
sodium-glucose co transporter 2 inhibitors
what does the presence of LBBB in HF lead to
abnormal contractile wave-front across the LV causing dyssynchronous contraction and worsening LV systolic function
what is it called when the LV doe not contact efficiently
Dyssynchronous Contraction
Cardiac resynchronisation therapy (CRT) leads to pacing the LV from where? and what does this do?
From the left lateral wall
- increases synchronous contraction and improved haemodynamics
what is involved in cardiac resynchronisation therapy
CRT-D implant
what is new in HF treatment (for mild HF)
Eplerenone
what is given in addition to BB when they are not enough
ivabradine
what is ivabradine
IF channel modulator
explain ivabradines function and mode of action
specifically binds to the funny channel
- slows HR
what condition does ivabradine not work in
Atrial Fibrillation
what does ivabradine not alter
ventricular repolarisation,
myocardial contraction,
Blood pressure
what do ARNIs do
Neprilysin inhibitor (NEPi)
- to enhance effects of naturetic peptides
- NEP inhibitor
- Vasodilatior
a. BP
b. Sympathetic tone
c. aldosterone levels
d. natrioresis/ diuresis
what do ARBs do
block renin angiotensin aldosterone system (RAAS)
- Valsartan
a. BP
b. Sympathetic tone
c. aldosterone levels
d. cellular growth
e. natriuresis
what do SGLT2i do
lower Blood glucose levels and BP through osmotic diuresis
increases urinary caloric loss with reductions in body weight
Reduces albuminuria possibly due to alterations in tubuloglomerular feedback
give me a HF drug summary
→ ACE Inhibitors
→ ARBs
→ Beta-blockers
→ Mineralocorticoid antagonists (Spironolactone, eplerenone)
→ Neprilysin inhibitors (salcubitril valsartan)
→ Sglt2 inhibitors (Dapagliflozin / Empagliflozin)
→ Diuretics (Frusemide/Bumetanide)
Digoxin
Exercise and SGLT2 inhibitors show MUCH PROMISE for…
HFpEF
what drugs helped diuresis in patient with ADHF
Ipragliflozin
in refractory end stage HF what must be done
review
control fluid retention - are the diuretics not working or ultrafiltration
IV inotropic/vasodilators during decomposition
consider resynchronization or mechanical assist devices or heart transplant
what are some reasons patients might need a heart transplant
- refractory cardiogenic shock
- documented dependence on IV inotropic support
- Peak VO2 <10 ml/kg/min
- severe symptoms of ischameia
- recurrent arrhythmias not responding to treatments
what are some contradictions to getting a heart transplant
Age
severe comorbidity
active infection
recent cancer
