Cardiac causes of SOB: Heart failure Flashcards
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
Aortic stenosis will first result in left ventricular failure as a result of increased ventricular pressure as the ventricle tries to pump blood across a narrowed valve. Initially the pressure load will cause a backlog of blood into the lungs, resulting in pulmonary oedema – the first sign of which will be bibasal crepitations (D) before enough fluid accumulates as pleural effusions visible on chest x-ray (A). Earlier signs of pulmonary oedema include upper lobe blood diversion and Kerley B lines as fluid infiltrates the interstitium. If the backlog continues back into the right heart, eventually signs of right-sided heart failure will be evident including raised JVP (B) and bilateral pedal oedema (C). Atrial fibrillation (E) may coexist with aortic stenosis, however it is more commonly associated as a result of mitral stenosis as the enlarged atrium disrupts the normal electrical pathways.
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. Brain natriuretic peptide
Brain natriuretic peptide (B) is considered to have the greatest power as a diagnostic biomarker of the given answer options. In established heart failure, high levels of endothelin (C) and noradernaline (D) in particular are associated with poor prognosis. All of the given answers, including atrial natriuretic peptide (A) and adrenomedullin (E), may be increased in heart failure.
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. HyperthyroidismB. MalignancyC. Thiamine deficiencyD. MeningitisE. Paget’s disease of the bone
B. Malignancy
Multiple Myeloma: Symptoms and presentation are consistent with malignancy. C – hypercalcaemia, R- renal failure, A-anaemia, B- bone lesions. Hence weight loss, bone pain, anaemia. Hyperthyroidism does cause weight loss but would not explain other symptoms
Thiamine deficiency – no other signs, history of alcoholism, peripheral neuropathy
Menigitis – no signs of infection
Paget’s disease – calcium is unaffected, high ALP
How can the aetiology/risk factors of heart failure be classified
- Heart valves
- Heart muscle (pump failure)
- Systemic
- Drugs
LHF: give examples of heart valve malfunctions
- aortic valve disease (AR - regurg, AS - stenosis)
2. Mitral regurgitation
How can the aetiology/risk factors of left heart failure be classified
- Heart valves
- Heart muscle (pump failure)
- Systemic
- Drugs
LHF: give example of pump (heart muscle) failure
- ischaemic heart disease
- MI
- cardiomyopathy e.g. hypertrophic (HOCM), dilated, restrictive
- myocarditis
- arrhythmias e.g. AF
How can the aetiology/risk factors of right heart failure be classified
- Lungs
- Heart valves
- Left heart failure
What is Cor Pulmonale
Enlargement and failure of the right ventricle due to increased pressure in the lungs/vascular resistance
RHF: give examples of lung pathologies
- pulmonary hypertension
- pulmonary embolus
- pulmonary valve disease
- chronic lung disease e.g. ILD, pulmonary fibrosis, CF
RHF: give examples of heart valve malfunctions
- tricuspid regurgitation
2. pulmonary valve disease
Give examples of high output states that can put strain on the heart causing heart failure
- AV malformations: abnormal connection between arteries anf veins
- Malignancy e.g. multiple myeloma
- Endocrine e.g. hyperthyroidism
- Pregnancy
- Nutritional e.g. vitamin B1/thiamine deficiency (beriberi)
- GI/Renal e.g. cirrhosis of the liver
- Anaemia
- Sepsis
Give examples of high output states that can put strain on the heart causing heart failure
NAP MEALS 1. Nutritional e.g. vitamin B1/thiamine deficiency (beriberi AV malformations: abnormal connection between arteries and veins 2. Anaemia 3. Pregnancy 4. Pregnancy 5. Malignancy e.g. multiple myeloma 6. Endocrine e.g. hyperthyroidism 7. Liver cirrhosis 8. Sepsis
Give examples of high output states that can put strain on the heart causing heart failure
NAP MEALS 1. Nutritional e.g. vitamin B1/thiamine deficiency (beriberi AV malformations: abnormal connection between arteries and veins 2. Anaemia 3. Pregnancy 4. Pregnancy 5. Malignancy e.g. multiple myeloma 6. Endocrine e.g. hyperthyroidism 7. Liver cirrhosis 8. Sepsis
What are the risk factors for heart failure
- older men
- PMH of heart disease - MI is the strongest risk factor
- diabetes
- family history of heart disease
- dyslipidaemia
- Drug abuse
What are the risk factors for heart failure
- older men
- PMH of heart disease - MI is the strongest risk factor
- diabetes
- family history of heart disease
- dyslipidaemia
- Drug abuse
Describe the epidemiology of heart failure
10% of >65 years olds, 1-3% general population
Describe the epidemiology of heart failure
10% of >65 years olds, 1-3% general population
Why do you get respiratory symptoms with left heart failure
LHF leads to fluid congestion in the lungs
Why do you get respiratory symptoms with left heart failure
LHF leads to fluid congestion in the lungs
What are the signs and symptoms of LHF
- exertional dyspnoea
2. orthopnoea (SOB when lying flat)
What are the symptoms of LHF
- exertional dyspnoea
- orthopnoea (SOB when lying flat)
- paroxysmal Nocturnal Dyspnoea (attacks of SOB/coughing at night, may wake patient up)
- fatigue
- Nocturnal cough (+/- pink frothy sputum)
- wheeze (cardiac asthma)
What are the clinical signs of LHF
Heart:
- increase HR and respiratory rate
- irregularly irregular heart beat
- displaced apex beat
- Gallop rhythm (S3) (Kentucky rhythm)
- murmur (AS, MR)
Lungs:
- Bibasal crackles
- wheeze
Why does RHF cause peripheral symptoms
fluid congestion in the system
What are the symptoms of RHF
- swelling - ankles, face, abdomen (ascities)
- fatigue
- weight gain (oedema)
- reduced exercise tolerance
- anorexia
- nausea
- nocturia
What are the clinical signs of RHF
Face/Neck
- raised JVP
- Facial swelling
Heart/Chest
- parasternal heave
- TR murmur
- increased HR and respiratory rate
Abdomen
- Ascities
- hepatomegaly
Other
1. pitting oedema in ankles/sacrum
What is an ECHO
heart ultrasound
allows us to look at the structure of the heart and function of heart (ejection fraction)
Ejection fraction =
stroke volume/end diastolic volume
How is heart failure classified in terms of ejection fraction
Normal = 50-70%
<40% = systolic heart failure
due to a decrease in stroke volume and a decrease in strength of contraction
> 50% = heart failure with preserved ejection fraction
due to abnormal diastolic function
Heart failure: features on a CXR
ABCDE Alveolar oedema B-line (Kerley) Cardiomegaly Dilated upper lobe vessels Effusion
What are the investigations for heart failure
- BNP (Brain natriuretic peptide): an increase indicated heart failure
- ECHO
to visualise heart
to determine ejection fraction
systolic heart failure vs HFpEF - CXR: ABCDE changes
What is the conservative treatment for chronic heart failure
smoking cessation
weight management - exercise
Diet - reduce salt intake
What is the medical management of chronic heart failure
- ACE inhibitors
enalapril, perindopril, ramipril
can use ARB if cough is an on-going problem, must monitor K+ - Beta blockers
bisoprolol, carvedilol - Diuretics
aldosterone antagonist e.g. spironolactone
loop diuretics e.g. furosemide
thiazide e.g. hydrochlorthiazide
Other than ACEi, BB and diuretics, what other drugs/therapies can be used
hydralazine + nitrate in afro Caribbean pts
Digoxin
positive iontrope
does not improve survival
Cardiac resynchronisation therapy
Aspirin
What to do if a patient comes into hospital presenting with acute heart failure
- Sit the patient up
- Oxygen
15L via non rebreath mask
SpO2 target = 94-98% - IV access and ECG
- Diuretic
Furosemide IV - Vasodilator
GTN spray 2 puff sublingual - analgesia
What are the complications of heart failure
- pleural effusion
- Renal failure
- acute exacerbations
- death
What is the prognosis of heart failure patients
50% sever heart failure patients die with 2 years
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?
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
