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CARDIOVASCULAR > Cardiac failure > Flashcards

Cardiac failure Flashcards

1
Q

Define heart failure

A

Also known as congestive heart failure (CHF) and congestive cardiac failure (CCF), is when the heart is unable to pump sufficiently to maintain blood flow to meet the body’s metabolic needs.

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2
Q

Epidemiology

A

Heart failure is common: in the United Kingdom the prevalence is 1-2%. The average age at diagnosis is 75 years old.

Elderly population, incidence higher with age

In Europe and North America the most common causes are coronary artery disease, hypertension, and valvular disease.

Rare cause in Although Europe and North America (significant in Central/South America) –> Chagas disease

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3
Q

Systolic vs diastolic HF

A

Low output heart failure can be further classified into that caused by:
- pump failure
- arrhythmias
- excess after-load
- excess pre-load.

Pump failure may be caused by
1. diastolic dysfunction (impaired ventricular filling during diastole) or
2. systolic dysfunction (impaired myocardial contraction during systole).

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4
Q

Causes of systolic heart failure

A

Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
Infiltration (e.g. in haemochromatosis or sarcoidosis)

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5
Q

Causes of diastolic heart failure

A

Hypertrophic obstructive cardiomyopathy
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis

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6
Q

Define high output heart failure

A

Cardiac output is normal, but there is an increase in peripheral metabolic demands which exceed those that can be met with maximal cardiac output.

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7
Q

Causes of high-output heart failure (AAPPTT)

A

Anaemia
Arteriovenous malformation
Paget’s disease
Pregnancy
Thyrotoxicosis
Thiamine deficiency (wet Beri-Beri)

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8
Q

Clinical features of left heart failure

A
  1. Pulmonary congestion (pressure builds up behind the left heart i.e. in the lungs)
  2. systemic hypoperfusion (reduced left heart output).
    1. can push RV into failure, leading to CHF
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9
Q

Pulmonary congestion
1. Signs
2. Symptoms

A
  1. Tachypnoea
    Bibasal fine crackles on auscultation of the lungs
  2. Shortness of breath on exertion
    Orthopnoea
    Paroxysmal nocturnal dyspnoea
    Nocturnal cough (± pink frothy sputum)
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10
Q

Systemic hypoperfusion
1. Signs

A
  1. Cyanosis
    Prolonged capillary refill time
    Hypotension
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11
Q

Less common signs of LHF

A
  • Pulsus alternans (an alternating strong and weak pulse)
  • S3 gallop rhythm (produced by large amounts of blood striking a compliant left ventricle)
  • Features of functional mitral regurgitation - fatigue, shortness of breath and oedema
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12
Q

Clinical features of right heart failure

A
  1. venous congestion (pressure builds up behind the right heart)
  2. pulmonary hypoperfusion (reduced right heart output).
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13
Q

Venous congestion
1. Signs
2. Symptoms

A
  1. Raised JVP
    Pitting ankle/sacral oedema
    Tender smooth hepatomegaly
    Ascites
    Transudative pleural effusions (typically bilateral)
  2. Ankle swelling
    Weight gain
    Abdominal distension and discomfort,
    Anorexia/nausea.
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14
Q

NYHA classification of HF

A

classify severity of cardiovascular disability through severity of exertional dyspnoea limiting activity, or discomfort at rest.

  • Class I - no limitation in physical activity, activity does not cause undue fatigue, palpitation or dyspnoea
  • Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitation and/or dyspnoea.

Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary).

Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.

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15
Q

Investigations

A
  1. ECG - can reveal ischaemic changes or arrhythmias
  2. NT-proBNP
    - >2000ng/L the patient needs an urgent 2 week referral for specialist assessment and an ECHO.
    - 400-2000ng/L the patient should get a 6 week referral for specialist assessment and an ECHO.
  3. ECHO
  4. Bloods
  5. CXR
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16
Q

NT-proBNP

A

N-terminal pro-B-type natriuretic peptide

BNP is released by the ventricles in response to myocardial stretch.

BNP has a high negative predictive value, so if the BNP is not raised the diagnosis of congestive cardiac failure is highly unlikely.

If the BNP is raised, the patient should be referred for trans-thoracic echocardiogram.

SEE flashcard 30 for difference between BNP and NT-proBNP

17
Q

Echo

A

Ventricular dysfunction is normally measured by the ejection fraction.

<40% = heart failure is reduced ejection fraction

Greater than 40% but raised BNP = Heart failure with preserved ejection fraction

18
Q

Blood tests

A

U+Es to assess renal function (for medication) and to look for hyponatraemia
LFTs for hepatic congestion
TFTs to check for hyperthyroidism
Glucose and lipid profile to assess modifiable cardiovascular risk factors
BNP is significantly associated with a diagnosis of heart failuare

19
Q

CXR findings

A

A: Alveolar oedema (with ‘batwing’ perihilar shadowing)
B: Kerley B lines (caused by interstitial oedema)
C: Cardiomegaly (cardiothoracic ratio >0.5)
D: upper lobe blood diversion
E: Pleural effusions (typically bilateral transudates)
F: Fluid in the horizontal fissure

20
Q

Lifestyle modifications

A

Smoking cessation
Salt and fluid restriction (this improves mortality)
Supervised cardiac rehabilitation

21
Q

Pharmacological management

A
  1. ACE-inhibitor and beta-blocker (bisoprolol, carvedilol, or nebivolol) (these improve mortality)
    - Consider angiotensin receptor blocker (ARB) if intolerant to ACE inhibitors
    - Consider hydralazine and a nitrate if intolerant to ACE-I and ARB.
  2. Loop diuretics such as furosemide or bumetanide improve symptoms (but NOT mortality)
  3. If symptoms persist and NYHA Class 3 or 4 consider:
    - Aldosterone antagonists such as spironolactone or eplerenone. These drugs also improve mortality (2nd line)
    - for Afro-Caribbean patients - hydralazine and a nitrate
    - if in sinus rhythm and impaired ejection fraction - Ivabradine
    - Angiotensin receptor blocker
  4. Digoxin - useful in those with AF. This worsens mortality but improves morbidity.
22
Q

Surgical/device management options

A

Surgical/device management options
- ICD if
1. QRS interval <120ms, high risk sudden cardiac death, NYHA class I-III
2. QRS interval 120-149ms without LBBB, NYHA class I-III
3. QRS interval 120-149ms with LBBB, NYHA class I

23
Q

Surgical/device management options

A

Surgical/device management options
- ICD if
1. QRS interval <120ms, high risk sudden cardiac death, NYHA class I-III
2. QRS interval 120-149ms without LBBB, NYHA class I-III
3. QRS interval 120-149ms with LBBB, NYHA class II

24
Q

Initial Management of acute heart failure (pulmonary oedema)

A
  1. Sit the patient up
  2. Oxygen therapy (aiming saturations >94% in normal circumstances)
  3. IV furosemide 40mg or more (with further doses as necessary) AND close fluid balance (aiming for a negative balance)
  4. SC morphine - this is contentious with some studies suggesting that it might increase mortality by suppressing respiration
25
Q

Advanced management of acute heart failure (pulmonary oedema)

A

The following usually occurs in a high dependency or ITU setting.

  • CPAP - reduces hypoxia and may help push fluid out of alveoli
  • Intubation and ventilation
  • Furosemide infusion - continuous IV furosemide given over 24 hours to maximise diuresis
  • Dopamine infusion - Continuous IV dopamine given over 24 hours. It works by inhibiting sympathetic drive and thereby increasing myocardial contractility.
  • Intra-aortic balloon pump - if the patient is in cardiogenic shock
  • Ultrafiltration - If resistant to or contraindicated diuretics

Note that GTN infusion is no longer routinely used in acute heart failure

26
Q

Adverse effects of heart failure medications
Beta blockers
ACE inhibitors
Spironolactone
Furosemide
Hydralazine/nitrate
Digoxin

A

Beta blockers: Bradycardia, hypotension, fatigue, dizziness
ACE inhibitors: Hyperkalaemia, renal impairment, dry cough, lightheadedness, fatigue, GI disturbances, angioedema
Spironolactone: Hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/hair growth in women, changes in libido
Furosemide: Hypotension, hypoatraemia/kalaemia,
Hydralazine/nitrate: Headache, palpitation, flushing
Digoxin: Dizziness, blurred vision, GI disturbances

27
Q

Acute HF

A

sudden onset or worsening of the symptoms of heart failure
reduced cardiac output that results from a functional or structural abnormality.
Other causes: viral myopathy, toxins, viral dysfunction

28
Q

Most common precipitating causes of AHF

A

Acute coronary syndrome
Hypertensive crisis
Acute arrhythmia
Valvular disease

29
Q

HF-rEF vs HF-pEF

A

HF-rEF - HF with reduced Ejection fraction (<40%)
HF-pEF - HF with preserved Ejection Fraction (>40%)

Whilst the overlap is not perfect:
- HF-rEF patients typically have systolic dysfunction (impaired myocardial contraction during systole)
- HF-pEF patients have diastolic dysfunction (impaired ventricular filling during diastole).

30
Q

Difference between BNP and NT-proBNP

A

ProBNP (pro B-type natriuretic peptide) is secreted by cardiomyocytes in response to stretch and is quickly cleaved into 2 circulating fragments—the biologically active 32-amino acid C-terminal BNP (B-type natriuretic peptide) and the inert 76-amino acid NT-proBNP (N-terminal pro-BNP)

Raised levels
BNP - > 400 pg/ml (116 pmol/litre)
NT-proBNP - > 2000 pg/ml (236 pmol/litre)

31
Q

Factors which can increase BNP level

A

Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis

32
Q

Factors which can decrease BNP level

A

Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists

33
Q

Other treatments

A

Annual influenza vaccine
One-off pneumococcal vaccine
- If CKD or splenic dysfunction, every 5 years

CARDIOVASCULAR (20 decks)

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