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MedEd Lectures > Cardiac causes of SOB: Heart failure > Flashcards

Cardiac causes of SOB: Heart failure Flashcards

1
Q

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

A

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.

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2
Q 
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
A

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.

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3
Q

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

A

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

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4
Q

How can the aetiology/risk factors of heart failure be classified

A
  1. Heart valves
  2. Heart muscle (pump failure)
  3. Systemic
  4. Drugs
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5
Q

LHF: give examples of heart valve malfunctions

A
  1. aortic valve disease (AR - regurg, AS - stenosis)

2. Mitral regurgitation

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6
Q

How can the aetiology/risk factors of left heart failure be classified

A
  1. Heart valves
  2. Heart muscle (pump failure)
  3. Systemic
  4. Drugs
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7
Q

LHF: give example of pump (heart muscle) failure

A
  1. ischaemic heart disease
  2. MI
  3. cardiomyopathy e.g. hypertrophic (HOCM), dilated, restrictive
  4. myocarditis
  5. arrhythmias e.g. AF
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8
Q

How can the aetiology/risk factors of right heart failure be classified

A
  1. Lungs
  2. Heart valves
  3. Left heart failure
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9
Q

What is Cor Pulmonale

A

Enlargement and failure of the right ventricle due to increased pressure in the lungs/vascular resistance

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10
Q

RHF: give examples of lung pathologies

A
  1. pulmonary hypertension
  2. pulmonary embolus
  3. pulmonary valve disease
  4. chronic lung disease e.g. ILD, pulmonary fibrosis, CF
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11
Q

RHF: give examples of heart valve malfunctions

A
  1. tricuspid regurgitation

2. pulmonary valve disease

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12
Q

Give examples of high output states that can put strain on the heart causing heart failure

A
  1. AV malformations: abnormal connection between arteries anf veins
  2. Malignancy e.g. multiple myeloma
  3. Endocrine e.g. hyperthyroidism
  4. Pregnancy
  5. Nutritional e.g. vitamin B1/thiamine deficiency (beriberi)
  6. GI/Renal e.g. cirrhosis of the liver
  7. Anaemia
  8. Sepsis
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13
Q

Give examples of high output states that can put strain on the heart causing heart failure

A 
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
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13
Q

Give examples of high output states that can put strain on the heart causing heart failure

A 
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
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14
Q

What are the risk factors for heart failure

A
  1. older men
  2. PMH of heart disease - MI is the strongest risk factor
  3. diabetes
  4. family history of heart disease
  5. dyslipidaemia
  6. Drug abuse
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14
Q

What are the risk factors for heart failure

A
  1. older men
  2. PMH of heart disease - MI is the strongest risk factor
  3. diabetes
  4. family history of heart disease
  5. dyslipidaemia
  6. Drug abuse
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15
Q

Describe the epidemiology of heart failure

A

10% of >65 years olds, 1-3% general population

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15
Q

Describe the epidemiology of heart failure

A

10% of >65 years olds, 1-3% general population

16
Q

Why do you get respiratory symptoms with left heart failure

A

LHF leads to fluid congestion in the lungs

16
Q

Why do you get respiratory symptoms with left heart failure

A

LHF leads to fluid congestion in the lungs

17
Q

What are the signs and symptoms of LHF

A
  1. exertional dyspnoea

2. orthopnoea (SOB when lying flat)

18
Q

What are the symptoms of LHF

A
  1. exertional dyspnoea
  2. orthopnoea (SOB when lying flat)
  3. paroxysmal Nocturnal Dyspnoea (attacks of SOB/coughing at night, may wake patient up)
  4. fatigue
  5. Nocturnal cough (+/- pink frothy sputum)
  6. wheeze (cardiac asthma)
19
Q

What are the clinical signs of LHF

A

Heart:

  1. increase HR and respiratory rate
  2. irregularly irregular heart beat
  3. displaced apex beat
  4. Gallop rhythm (S3) (Kentucky rhythm)
  5. murmur (AS, MR)

Lungs:

  1. Bibasal crackles
  2. wheeze
20
Q

Why does RHF cause peripheral symptoms

A

fluid congestion in the system

21
Q

What are the symptoms of RHF

A
  1. swelling - ankles, face, abdomen (ascities)
  2. fatigue
  3. weight gain (oedema)
  4. reduced exercise tolerance
  5. anorexia
  6. nausea
  7. nocturia
22
Q

What are the clinical signs of RHF

A

Face/Neck

  1. raised JVP
  2. Facial swelling

Heart/Chest

  1. parasternal heave
  2. TR murmur
  3. increased HR and respiratory rate

Abdomen

  1. Ascities
  2. hepatomegaly

Other
1. pitting oedema in ankles/sacrum

23
Q

What is an ECHO

A

heart ultrasound

allows us to look at the structure of the heart and function of heart (ejection fraction)

24
Q

Ejection fraction =

A

stroke volume/end diastolic volume

25
Q

How is heart failure classified in terms of ejection fraction

A

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

26
Q

Heart failure: features on a CXR

A 
ABCDE
Alveolar oedema
B-line (Kerley)
Cardiomegaly 
Dilated upper lobe vessels 
Effusion
27
Q

What are the investigations for heart failure

A
  1. BNP (Brain natriuretic peptide): an increase indicated heart failure
  2. ECHO
    to visualise heart
    to determine ejection fraction
    systolic heart failure vs HFpEF
  3. CXR: ABCDE changes
28
Q

What is the conservative treatment for chronic heart failure

A

smoking cessation
weight management - exercise
Diet - reduce salt intake

29
Q

What is the medical management of chronic heart failure

A
  1. ACE inhibitors
    enalapril, perindopril, ramipril
    can use ARB if cough is an on-going problem, must monitor K+
  2. Beta blockers
    bisoprolol, carvedilol
  3. Diuretics
    aldosterone antagonist e.g. spironolactone
    loop diuretics e.g. furosemide
    thiazide e.g. hydrochlorthiazide
30
Q

Other than ACEi, BB and diuretics, what other drugs/therapies can be used

A

hydralazine + nitrate in afro Caribbean pts

Digoxin
positive iontrope
does not improve survival

Cardiac resynchronisation therapy

Aspirin

31
Q

What to do if a patient comes into hospital presenting with acute heart failure

A
  1. Sit the patient up
  2. Oxygen
    15L via non rebreath mask
    SpO2 target = 94-98%
  3. IV access and ECG
  4. Diuretic
    Furosemide IV
  5. Vasodilator
    GTN spray 2 puff sublingual
  6. analgesia
32
Q

What are the complications of heart failure

A
  1. pleural effusion
  2. Renal failure
  3. acute exacerbations
  4. death
33
Q

What is the prognosis of heart failure patients

A

50% sever heart failure patients die with 2 years

34
Q 
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

A. Third heart sound

35
Q

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

C. Interstitial Lung Disease

36
Q 
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

A. Spironolactone

37
Q

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

A

C. Opiate analgesia is always recommended

38
Q

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
A

B Blunting of the costophrenic angles

39
Q

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
A

D Rheumatic Heart Disease

MedEd Lectures (15 decks)

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