Cardiac causes of SOB Flashcards
What are the main cardiac causes of SOB?
Heart failure
Cardiomyopathy
Constrictive pericarditis
Myocarditis
A 70-year old lady presents with dyspnoea, which has becoming worse over the last months. She also reports cough, productive of pink frothy sputum. On examination her pulse is irregularly irregular, and she has a high respiratory and heart rate. What is the most likely diagnosis?
Clue:
A Acute Coronary Syndrome
B Aortic stenosis
C Congestive Heart Failure
D Right Heart Failure
E Left Heart Failure
Answer: E Left Heart Failure
Chronic heart failure
Definition
Types And Basic concepts
Aetiology- Low output [LHF and RHF], High output
Risk factors
Symptoms- LHF, RHF and scoring
Signs- LHF, RHF
Investigations
Diagnosis [risk score]
Management- chronic, acute
Prognosis
Complications
Chronic heart failure
Definition
Long standing failure of heart to provide adequate circulation for requirements of body
Types and basic concepts
Low output HF CO is low and cannot meet body’s demands
High output HF CO is normal but body’s requirements have increased - less common
Right sided heart failure
Left sided HF
Congestive cardiac failure- both sided
Aetiology
Left HF-low output
Valvular
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Heart muscle - IHD, Cardiomyopathy, Myocarditis Arrhythmia -AF
Systemic
Drugs- cocaine, beta blocker. chemotherapy, alcohol
Hypertension
Amyloidosis
Right HF- low output
Left HF
Pulmonary- pulmonary hypertension, PE, chronic lung disease
Valvular- Tricuspid regurg, Pulmonary valve disease
High output heart failure [rare]- NAP MEALS
Nutritional deficiency-lack of thiamine
Anaemia
Pregnancy
Malignancy- multiple myeloma
Endocinne- hyperthyroidism
AV malformations
Liver cirhhosis
Sepsis
Risk factors
Increased age
Symptoms
Left heart failure
Generally resp symptoms because blood backs up into lungs
- Exertional dyspnoea
- Orthopnea
- Paroxysmal noctural dyspnoea
- Fatigue
- Nocturnal cough- usually with pink frothy sputum
- Wheeze
Right heart failure
Generally peripheral symptoms [blood backs up into body]
- Swelling [ankles, face, ascites]
- Weight gain [oedema]
- Fatigue
- Reduced exercise tolerance
- Anorexia
- Nausea
- Nocturia
Scoring of symptoms
New York Heart Association
Stage I: no symptoms
Stage II: symptoms on exertion
Stage III: symptoms on minimal exertion
Stage IV: symptoms at rest
Signs
Left HF
S3 gallop S4 if severe
Increased HR, RR
Irregularly irregular heart beat [AF]
Pulsus alternans- strong and weak beats
Displaced apex beat
Murmur [left sided]
LUNGS
fine end inspiratory bibasal crackles
Wheeze [cardiac asthma]
Right HF
Face- face swelling
Neck- raised JVP
Heart- TR murmur,
Increased HR, RR
Abdo- Ascites, hepatomegaly
Other- pitting oedema- ankles and sacrum
Investigations
Bedside- ECG
Bloods- FBC, U and E, LFT, TFT, BNP
Imaging- CXR Signs -ABCDE [see other flashcard] -
If BNP high- Do transthoracic echo with doppler- this is diagnostic gold standard - can indicate cause- MI, valvular disease - calculate ejection fraction
Diagnosis
Heart failure - Framingham criteria - More than two major, or one minor + one major [see other flashcard for criteria]
Management
Chronic:
- Conservative: smoking. diet, exercise etc.
- ARB/ACE inhibitors - first line
- Diuretic
- Beta blockers
- Digoxin [symptom control]
- Other to treat cause: ICD etc.
Types/classification of heart failure
- Acute vs Chronic
- Reduced ejection fraction [systolic] vs preserved ejection fraction [diastolic]
- Low output vs. high output
- Left vs right heart failure
What is cor pulmonale
Enlargement or failure of right ventricle due to increased resistance in pulmonary vascular bed/pressure in lungs
What is the sensitivity/specificity of BNP
Sensitive but not specific
What can a transthoracic echo with doppler show
- cause of HF - ejection fracture
What is seen on CXR with heart failure?
A-lveolar oedema B-Kerley B lines C-ardiomegaly D-ilated upper lobe vessels E- Pleural effusion- transudate
What ejection fraction is HF with reduced ejection fraction?
<40%
What is the pathology behind HF with reduced ejection fraction?
Inability of ventricles to contract normally
What ejection fraction is HF with preserved ejection fraction?
>50%
What is the pathology behind HF with preserved ejection fraction?
Inability of ventricles to dilate/relax/fill normally So even though heart contracts the same, not enough blood fills heart during diastole to have adequate stroke volume
Acute heart failure
Definition
Aetiology
Symptoms
Signs
Management
Complications
Prognosis
Acute heart failure
Definition
Rapid onset/worsening of HF signs and symptoms- requiring urgent evaluation and treatment Aetiology
- Decompensation of chronic heart failure
- due to
MI
infections
uncontolled HTN
thyroid- hypo/hyper
arrhythmias
- Acute coronary sydrome
Symptoms
Dyspnoea
Wheeze
Cough
Pink frothy sputum
Swelling
Symptoms of underlying condition
Signs
Increased HR, RR
Pulsus alternans [alternating strong and weak pulse]
Peripheral shutdown
Cyanosis
S3 gallop
Fine end inspiratory bibasal crackles
Management
Make patient sit up
High flow O2 via non rebreather mask [target is 94-98%]
Diuretic- IV furosemide 40-800mg -
Consider GTN infusion - if pulmonary oedema and SBP above 90
Consider CPAP - if sats dropping
Treat if cardiogenic shock with positive inotropes Complications
Pleural effusion
Renal failure
Acute exacerbation
Death
Prognosis
50% of severe HF patients die within 2 years
AHF - in hospital mortality- 2-20%
A 67-year-old woman presents to her GP complaining of increasing shortness of breath, which becomes worse when trying to sleep. She has a history of hypertension and hyperlipidaemia. On examination, her blood pressure is 148/83 mmHg and heart rate is 126 beats per minute. There is an audible S3 gallop and the jugular venous pressure is elevated 3 cm above normal. Which investigation would be best to confirm the diagnosis?
A ECG
B Brain natriuretic peptide (BNP)
C Endothelin levels
D Echocardiogram
E CXR
D Echocardiogram
A 62 year old man, 3 months after an MI presents with increasing shortness of breath. He is currently on aspirin, atenolol and simvastatin. An echocardiogram shows an ejection fraction of 30% in the left ventricle. What additional medication should he be given?
A Carvedilol
B Furosemide
C Digoxin
D Enalapril
E Morphine
D Enalapril ACEi/ ARB is first line
summary table of cardiomyopathy
ECHO findings
