Cardiac causes of SOB Flashcards
Risk factors for heart failure
Older men PMH of Heart disease – MI is strongest risk factor Diabetes Family history of heart disease Dyslipidaemia Drug abuse
What is heart failure?
Failure of heart to maintain CO (=HRxSV) needed for the body’s requirement
Compare acute and chronic HF
Acute
- rapid onset
- worsening sx and signs of HF
- urgent tx
Chronic
- long-term
- develops and progresses slowly
- can have periods of acute decompensation
Compare low and high output HF
Low output
- CO decrease so fails to match normal body demands thus normally appears on exertion
High output
- CO normal but high body demand thus occurs when heart fails to meet high demands so heart is overworked and strained
Causes of high output HF
NAP+MEALS: N utritional (thiamine def.) A naemia P regnancy M alignancy (muliple myeloma) E ndocrine (hyperthyroidism) A V malformations L iver cirrhoisis S epsis
Top ddx of increased JVP
1) RHF
2) Triscuspid regurgitation
3) Constrictive pericarditis
Sx of chronic RHF
*Due to fluid accumulation in periphery: Swelling (ankles, facial enlargement, ascites) Weight gain (oedema) Fatigue Reduced exercise tolerance Anorexia Nausea Nocturia
Sx of chronic LHF
*Due to fluid accumulation in lungs: Exertional dyspnoea Orthopnoea (SOB lying down) Paraoxysmal nocturnal dyspnoea (attack of SOB at night) Fatigue Wheeze Nocturnal cough +/- pink frothy sputum
Signs of chronic RHF
Face swelling Increased JVP Ascites +/- hepatomegaly TR murmur Increased HR and RR Pitting oedema in ankles and sacrum
Signs of chronic LHF
Increased HR and RR Fine end inspiratory crackles at lung bases (pulmonary oedema) Wheeze Irregularly irregular heart beat AS/AR/MR murmur S3; gallop rhythm S4; severe HF Displaced apex beat Pulsus alternans (alternating strong and weak beats)
Which heart failure can occur as cor pulmonale?
Pulmonary HTN => increased pressure in lungs/vascular resistance => enlarged RV => failure of RV => RHF
Causes of RHF
LHF
Heart valves: TR, pulmonary valve disease
Lungs: pulmonary HTN, PE, chronic lung disease (CF, pulmonary fibrosis, interstitial lung disease)
Causes of LHF
Systemic: HTN, amyloidosis, drugs (cocaine, BBs, alcohol)
Valvular: MR, AR, AS
Heart muscle: AF, IHD, cardiomyopathy, myocarditis
Ix for HF
Bedside: ECG
Bloods: FBC, U&Es, LFTs, TFTs, BNP*
Imaging: CXT, TTE w/ doppler*
Which ix is diagnostic for HF?
Transthoracic echocardiogram (TTE) with doppler
- calculates ejection fracture
- shows the % of blood present in LV when pumped during systole (n=50-70%)
- can indicate cause, i.e. MI or valvular disease
What can the results from a TTE show?
EF<40% => HFrEF
- systolic HF
- unable for ventricle to contract normally
EF>50% => HFpEF
- diastolic HF
- unable for ventricle to relax normally
Which bloods is most sensitive to HF?
Brain natriuretic protein (BNP)
- if high => TTE next step
- if low => HF unlikely
Highly sensitive but non-specific as increases whenever there is increased stretch to the heart
What may a CXT show if HF present?
A lveolar oedema B -lines (Kerley) C ardiomegaly D ilated upper lobe vessels E ffusion (pleural, transudative)
Which criteria is used for HF diagnosis and how?
Framingham Criteria
- must have 2+ major signs/sx present of 1 major and 2 minor
MAJOR includes
- acute pulm. oedema, wt loss, neck vein distention, cardiomegaly, increased central venous pressure, bilateral creptitations, PND, S3 gallop
MINOR includes
- bilateral ankle oedema, dyspnoea on ordinary exertion, tachycardia, pleural effusion, nocturnal cough, decrease in vital capacity by 1/3
Management of chronic HF
Conservative:
- smoking cessation, exercise, diet (reduce salt)
Medical:
1. ACEi - enalapril (improves survival + slows down progression)
2. BBs - carvedilol, bisoprolol (reduce O2 demand on heart, synergistic effect with ACEi)
3. Diuretics - furosemide, chlorothiazide, spironolactone (use if eveidence of fluid retention, monitor electrolytes)
4. Digoxin - positive inotrope (increase contractility, good for sx relief not overall survival)
5. Other - hydralazine nitrate, cardiac resynchronisation, implantable cardiac defib. (treat cause!)
How does acute HF typically present?
Hx
- dyspnoea, cough, wheeze, pink frothy sputum, swelling legs, sx of underlying condition
O/E
- pulsus alternans, increased HR + RR, cyanosis, peripheral shutdown, S3 gallop rhythm, fine end inspiratory crackles
Causes of acute HF
Decompensation of previous chronic HF
- MI, AF, infection, uncontrolled HTN
ACS
Mx for acute HF
- Sit patient up
- High-flow oxygen, non-rebreathable mask (target 94-98%)
- Furosemide 40-80mg IV
- GTN if pul. oedema + SBP >90mmHg
- Consider CPAP if sats dropping
- Treat cardiogenic shock if BP <90mmHg w/ +ve inotropes (dobutamine, digoxin)
Potential complications of acute HF
Pleural effusion
Renal failure
Acute exacerbation
Death
What’s the prognosis for acute HF?
50% of pts die within 2 years
Hospital mortality: 2-20%
What is cardiomyopathy?
Group of diseases where myocardium becomes structurally and functionally abnormal in the absence of coronary artery, valvular and congenital heart diseases
Primary => continued to myocardium
Secondary => part of systemic disease
How could cardiomyopathies present?
Hx
- sx of HF (SOB on exertion, fainting, dizziness, fatigue), sudden death in FHx
O/E
- inspiratory crackles, murmurs, S3, S4, HF signs (increased JVP, oedema)
Possible ix if suspected cardiomyopathy
Bloods, including BNP CXR ECG ECHO Cardiac catheritisation Non-invasive stress test *no single test diagnostic test for all types
Compare the four types of cardiomyopathy
Dilated
- ventricles enlarge thus weakening so cannot properly contract
Hypertrophic
- heart thickens inwards so may block blood flow out of ventricle
Arrhythmogenic right ventricular
- progressive fatty and fibrous replacement of ventricular myocardium
Restrictive
- ventricles become abnormally rigid and lack flexibility to expand as ventricles fill with blood
Restrictive cardiomyopathy summary card
Idiopathic, familial, systemic Signs: - increased JVP - *Kussmaul's sign (paradoxical increased JVP in inspiration due to restricted filling of the ventricles) - S3 - ascites/ankle oedema/hepatomegaly - asymptomatic to sx of HF
HOCM signs and symptoms card
Athletes with no PMH + syncopal episodes 50% familial (autosomal dominant) Sx: - sudden cardiac death (FHx) - angina, dyspnoea on exertion, palpitations, syncope Signs: - *ejection systolic murmur - *jerky carotic pulse - S4 - apex beat NOT displaced - double apex beat
HOCM ix findings card
ECHO => ventricular hypertrophy
ECG => left axis deviation, Q waves, signs of left ventricular hypertrophy
Dilated cardiomyopathy summary card
Associated with genes, alcohol, post-viral, autoimmune, haemochromatosis
Signs + sx:
- sx of HF, increased JVP, TR/MR murmur, displaced apex beat
Ix:
- CXR = globular heart
- ECHO = dilated ventricles
Arrhythmogenic right ventricular cardiomyopathy summary card
Autosomal dominant inherited
Initially asymptomatic then present w/ arrhythmias during exercise
Signs of left ventricular hypertrophy in ECG
deep S wave in V1/2
tall R wave in V5/6
S in V1 + R in V5/V6 >/=7 large squares
Signs and sx of constrictive pericarditis
(resembles restrictive cardiomyopathy)
Kussmaul’s sign
RHF sx: fluid congestion, increased JVP, dyspnoea
Causes of c pericarditis
Idiopathic
Infection (TB, bacterial: Pseudomonas/Staphylococci, viral)
Acute pericarditis
Cardiac surgery + radiation
Ix for c pericarditis
CXR = pericardial calcification
*ECHO = increased pericardial thickness
Cardiac CT/MRI
*distinguishes from restrictive cardiomyopathy
Presentation of myocarditis
<50 y.o. associated with acute ischaemic disease
- flu-like prodrome
- SOB
- palpitations
- chest pain worse when lying down
Causes of myocarditis
Inflammation of myocardium
- drugs (cocaine, penicillin, cephalosporins, digoxin, anti-epileptics)
- metals
- radiation
- infection
Ix for myocarditis
ECG = non-specfic ST changes, T-wave abnormal
Endomyocardial biopsy = diagnostic, not routinely performed
Cardiac biomarker = CK + troponins (exclude)
A 78-year-old woman is admitted with heart failure.
The underlying cause is determined to be aortic
stenosis. Which sign is most likely to be present?
A. Pleural effusion on chest x-ray
B. Raised jugular venous pressure (JVP)
C. Bilateral pedal oedema
D. Bibasal crepitations
E. Atrial fibrillation
D. Bibasal crepitations
A 60-year-old man presents to his GP with gradually
increasing fatigue and some exertional dyspnoea. Blood pressure is 118/74mmHg and pulse rate is 81/minute. There are no abnormal physical findings and on echocardiography the ejection fraction is 0.47. However, the clinical impression remains one of early heart failure. Which of the following circulating biomarkers would lend support to that conclusion?
A. Atrial natriuretic peptide
B. Brain natriuretic peptide
C. Endothelin
D. Noradrenaline
E. Adrenomedullin
B. BNP
A 55-year-old male presents with increasing exertional
dyspnoea, fatigue, weight loss and bone pain. Blood results reveal elevated calcium levels and normocytic anaemia. He is treated for heart failure. What is the underlying cause for his heart failure?
A. Hyperthyroidism
B. Malignancy
C. Thiamine deficiency
D. Meningitis
E. Paget’s disease of the bone
B. Malignancy
A 74 year old male with a 30 pack year smoking history is admitted to AMU. He has had 2 myocardial infarctions in the last 5 years. On examination he is producing frothy pink sputum, he has bilateral pitting oedema, bibasal crackles and oxygen saturations of 89%. Which of the following is most likely to be identified by auscultating the chest? A. Third heart sound B. Carotid bruit C. Ejection systolic murmur D. Pericardial rub E. Fourth heart sound
A. Third heart sound
A 74 year old man presents to AMU with a history of fatigue, breathlessness and has noticed his ankles to be swollen. On examination, he has an oedematous ankles, his JVP is raised and he has finger clubbing. When you ask about work, he says he used to work as a ship builder. He is diagnosed with acute heart failure. What is the most likely cause of his heart failure? A. Smoking B. Rheumatic Heart Disease C. Interstitial Lung Disease D. Aortic Stenosis E. Aortic Regurgitation
C. Interstitial Lung Disease
A 85 year old woman is seen in Heart Failure clinic for a review of her long term condition. She is currently taking enalapril and bisoprolol. Which other drug can be added to help control her symptoms? A. Spironolactone B. Amlodipine C. Salbutamol D. Morphine E. Omeprazole
A. Spironolactone
Regarding the management of acute heart failure,
which of these statements is not true?
A. The patient should be given a diuretic, such as IV furosemide.
B. High-oxygen is not always recommended
C. Opiate analgesia is always recommended
D. A vasodilator, such as nitrates, can be given
E. An ECG may not show an arrythmia
C. Opiate analgesia is always recommended
Which of these x-ray findings is most likely to be seen on a Chest X-ray of a patient with heart failure? A. Cardiothoracic ratio <50% B. Blunting of the costophrenic angles C. Air bronchograms D. Dilated lower lobe vessels E. Cannon-ball opacities
B. Blunting of the costophrenic angles
You are volunteering at a refugee camp in Calais and
you see a 10 year old boy who is acutely breathless, and has fatigue and feels nauseous . His mother tells you he has been having several episodes fevers, elbow pains and difficulty walking for the past 2 years, and has developed a rash. On examination, he has an ejection systolic murmur. He is treated for heart failure. What is the most likely underlying cause of his heart failure?
A. Cor pulmonale
B. Cystic Fibrosis
C. Familial cardiomyopathy
D. Rheumatic Heart Disease
E. Congenital heart disease
D. Rheumatic Heart Disease
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?
a) Acute Coronary Syndrome
b) Aortic stenosis
c) Congestive Heart Failure
d) Right Heart Failure
e) Left Heart Failure
e) Left Heart Failure
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
A 58 years old man has presents with chest pain and breathlessness, which is worse at night. When questioned, he reports 2 episodes of collapse in the past 3 months. His father died of a heart condition when he was 55, but he cannot recall details of the condition. On examination, he has a jerky carotid pulse. Given the most likely diagnosis, what is it most likely to be found on auscultation of the chest? a) Ejection systolic murmur b) Pericardial friction rub c) Mid-diastolic murmur d) Coarse crackles e) Pansystolic murmur
A. Ejection systolic murmur
A 55-years old man with a heavy history of alcohol abuse presents with breathlessness, which is worse on exertion. He also feels that his heart is racing at times and he complains that his ankles have been swollen. On examination the JVP is increased and the apex beat is displaced. CXR shows a globular heart. Which is the most likely cause of his heart failure? a) Myocarditis b) Hypertrophic Cardiomyopathy c) Dilated Cardiomyopathy d) Tricuspid Regurgitation e) Amyloidosis
C. Dilated cardiomyopathy
A 45-year-old woman complains of increasing shortness of breath on exertion for the previous 3–4 months. She also reports that her ankles have become more swollen during the same time period. She had apparently recovered from pericarditis about a year earlier. CXR shows pericardial calcification. The presumptive diagnosis is constrictive pericarditis. Which of the following signs would be consistent with this diagnosis?
a) Increased JVP on inspiration
b) Third heart sound
c) Fourth heart sound
d) Inspiratory crackles at lung bases
e) Loud first and second heart sounds
A. Increased JVP on inspiration
