Cardiac causes of SOB Flashcards
Define heart failure
Failure of heart to maintain cardiac output needed to meet body’s requirements.
Differentiate low and high output heart failure. Which is more common?
Low output: CO is low and fails to increase with exertion
High output: CO is normal but you have increased needs.
Give 3 valvular causes of LHF.
Give 4 heart muscle causes of LHF.
Give 3 systemic causes of LHF.
Valvular: aortic stenosis, aortic regurgitation, mitral regurgitation.
Heart muscle: Ischaemic heart disease, cardiomyopathy, myocarditis, arrhythmia.
Systemic: Hypertension, amyloidosis, drugs- cocaine, alcohol, BBs.
Give 1 heart related cause of RHF
Give 3 lung causes of RHF
Give 2 valvular causes of RHF
LHF
Lungs: Pulmonary hypertension -> cor pulmonale, PE, Chronic Lung disease (interstitial lung disease, pulmonary fibrosis, cystic fibrosis).
Heart valves: Tricuspid regurgitation, pulmonary valve disease.
What is the acronym for causes of high output heart failure?
High output HF presents initially with features of RHF and then LHF more apparent.
NAP MEALS:
- Nutritional: B1, thiamine
- Anaemia
- Pregnancy
- Malignancy - multiple myeloma
- Endocrine- hyperthyroidism
- AV malformations
- Liver cirrhosis
- Sepsis
Give 5 symptoms of LHF
- Exertional dyspnoea
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Nocturnal cough (+/- pink frothy sputum)
- Wheeze
Give 7 cardiac signs of LHF
Give 2 respiratory signs of LHF
Cardiac:
- Increased HR and RR
- Irregularly irregular heart beat
- Pulsus alternans- alternating strong and weak pulse
- Displaced apex beat
- S3 gallop rhythm- Kentucky- sound of blood hitting ventricle wall.
- S4- Tennessee, if severe HF, due to poor compliance of scarred ventricle.
- Murmur- AS, MR, AR
Respiratory:
- Fine end-inspiratory crackles at lung bases- pulmonary oedema
- Wheeze- cardiac asthma
Give 7 symptoms of RHF
- Swelling- ankles, facial engorgement, ascites
- Weight gain- due to oedema
- Fatigue
- Reduced exercise tolerance
- Anorexia
- Nausea
- Nocturia- as fluid returns from legs when patient lies down.
Symptoms of fluid congestion due to back pressure of venous system. Further compounded by salt and water retention due to activation of RAS by renal hypoperfusion.
Give 5 signs of RHF
- Face: swelling
- Neck: increased JVP.
- Heart/ chest: TR murmur, raised HR, raised RR.
- Abdomen: ascites, hepatomegaly
- Other: pitting oedema in ankles and sacrum
Give 3 differentials of a raised JVP.
- RHF
- Tricuspid regurgitation
- Constrictive pericarditis
Give the following investigations for heart failure:
- Bedside (1)
- Bloods (5)
- Imaging (2)
Bedside; ECG
Blood: FBC, U&E, LFTs, TFTs, BNP
Imaging: CXR, Transthoracic Echocardiogram (TTE)
What is BNP and how does its level (raised/ lowered) relate to diagnosis of heart failure?
What does it reduce?
What investigation should be done after high level found?
Brain Natriuretic peptide, released by cardiomyocytes in response to stretching. Reduces renal sodium reabsorption, reducing blood volume.
Low level means heart failure unlikely. High level indicates need for Transthoracic Echocardiogram (TTE)
TTE coupled with doppler can calculate ejection fraction- % of blood present in LV pumped during systole (normal 50-70%).
What does EF < 40% indicate?
What does EF > 50% indicate?
< 40: HF with reduced ejection fraction, HFrEF- systolic HF. Inability of ventricle to contract normally.
> 50: HF with preserved ejection fraction, HFpEF- diastolic HF. Inability of ventricle to relax and fill normally.
Give 5 features of HF on chest X-ray. What acronym is used?
ABCDE
- Alveolar oedema- batwing appearance
- B-lines, Kerley
- Cardiomegaly
- Dilated upper lobe vessels
- Effusion- pleural, transudative (no protein), after pulmonary oedema.
Which criteria is used to diagnose heart failure? What grading is needed for diagnosis?
Framingham criteria: >2 major or 1 major and 2 minor.
Give 3 conservative steps for management of heart failure.
- Smoking cessation
- Weight management
- Diet- reduce salt intake.
Give 5 steps in medical management for heart failure. Give drug names
- ACE inhibitors - enlalalpril, for all patients with LV dysfunction.
- BBs (carvedilol, bisoprolol), reduce O2 demand on heart. Synergistic effects with ACEi.
- Diuretics (furosemide, spironolactone, chlorothiazide), use if evidence of fluid retention, monitor electrolytes- spironolactone causes hyperkalaemia.
- Digoxin: +inotrope (increases heart contractility), helps improve symptoms.
- Other: hydralazine nitrate, cardiac resynchronisation, implantable defibrillator.
Give 3 features of chronic heart failure regarding:
- Progression
- Blood pressure
- Compensation
- Develops and progresses slowly
- Arterial pressure maintained until very late
- Periods of acute decompensation
Give 2 aetiologies of acute heart failure
- decompensation of previous chronic HF: MI, cardiac arrhythmias, infection, thyroid disease, uncontrolled HTN.
- Acute coronary syndrome- most common cause of acute new onset HF.
Give 6 features of HF history.
- Dyspnoea
- Cough
- Wheeze
- Pink frothy sputum
- Swelling of legs
- Symptoms of underlying condition
Give 6 examination findings of a HF patient.
- Raised HR and RR
- Pulsus alternans
- Cyanosis
- Peripheral shutdown
- S3 gallop rhythm
- Fine end inspiratory crackles
Give first 3 steps in patient with acute heart failure
- sit patient upright
- High-flow oxygen via non rebreathe mask, sats target 95-98%
- IV Furosemide 40-80mg
Give 2 complications of heart failure
- Pleural effusion
- Renal failure- long standing HF can lead to hypoperfusion
What is the 2 year prognosis for severe HF?
what is the hospital mortality for acute HF?
- 50% of sever HF patients die within 2 years.
- 2-20% mortality.
