Cardiac Failure Flashcards
Define Cardiac Failure
Inability of cardiac output to meet body’s demands despite NORMAL venous pressures
How can cardiac failure be classified by output?
Low output: Decreased output
High output: Increased demand
Which 5 conditions predispose to left heart failure?
IHD HTN Cardiomyopathy Aortic valve disease Mitral regurgitation
Which 7 conditions predispose to right heart failure?
Secondary to left heart failure (congestive cardiac failure)
Infarction
Cardiomyopathy
Pulmonary HTN/ embolus/ valve disease
Chronic lung disease
Tricuspid regurgitation
Constrictive pericarditis/ pericardial tamponade
Which 4 conditions predispose to biventricular failure?
Arrhythmia
Cardiomyopathy (dilated or restrictive)
Myocarditis
Drug toxicity e.g. Taxanes
Which 6 conditions predispose to high output cardiac failure?
Anaemia Beri beri Pregnancy Paget's disease Hyperthyroidism Arteriovenous malformation
Describe the epidemiology of cardiac failure
10% of >65 yrs
List 4 presenting symptoms of left heart failure
Dyspnoea (NYHA)
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue
What causes the presenting symptoms in left heart failure?
Pulmonary congestion
List 3 additional presenting symptoms in acute left ventricular failure
Wheeze
Cough
Pink frothy sputum
List 6 presenting symptoms in right heart failure
Swollen ankles Fatigue Increased weight (due to oedema) Reduced exercise tolerance Anorexia Nausea
What are 6 signs of left heart failure?
Tachycardia Tachypnoea Displaced apex beat Bilateral basal crackles S3 gallop (rapid ventricular filling) Pansystolic murmur (due to functional MR)
What are 5 additional signs in acute left ventricular failure?
Cyanosis Peripheral shutdown Pulsus alternans Wheeze (cardiac asthma) Fine crackles throughout lung
What are 5 signs in right heart failure?
Raised JVP Hepatomegaly Ascites Ankle/sacral pitting oedema Signs of functional tricuspid regurgitation
What bloods would be taken in cardiac failure?
FBC U+Es LFTs CRP Glucose TFTs
What bloods must also be taken in acute left ventricular failure?
ABG Troponin BNP Raised plasma BNP suggests cardiac failure Low plasma BNP excludes cardiac failure
What is seen on a CXR in acute LV failure?
Alveolar oedema (bats wing shadowing) Kerley B lines Cardiomegaly Upper lobe Diversion/ Dilated prominent upper lobe veins Pleural Effusion
What may be seen on an ECG in cardiac failure?
Normal
Ischaemic changes (pathological q waves, t wave inversion)
Arrhythmia or LV hypertrophy
What end diastolic pressures would you measure using a Swan-Ganz Catheter in cardiac failure ?
RA RV Pulmonary artery Pulmonary wedge LV
What is the management plan for all patients with acute heart failure?
IV loop diuretics e.g Furosemide/ Bumetanide
+/- O2: 94-98%
When should nitrates be given in management of acute heart failure?
If concomitant myocardial ischaemia, severe HTN, AR or MR
What is indicated in patients with acute heart failure and respiratory failure?
Continuous positive airway pressure (CPAP)
How does CPAP benefit patients in acute heart failure?
Increases intrathoracic pressure which reduces venous return to the heart + lowers preload
Also decreases afterload by decreasing pressure difference between LV + extra thoracic arteries
These pressure changes increase stroke volume + promote movement of fluid from interstitial fluid compartment into the intravascular fluid compartment reducing oedema + alleviating dyspnoea
How should patients with acute heart failure and hypotension/ cardiogenic shock be managed?
Inotropes e.g. Dobutamine
If severe LV dysfunction + potentially reversible cause of cardiogenic shock
Vasopressors e.g. Norepinephrine
If insufficient response to inotropes + evidence of end-organ hypoperfusion
Mechanical circulatory assistance: intra-aortic balloon counter pulsation or ventricular assist devices
What is the first line management for chronic heart failure?
ACEi + BB
Start one drug at a time
Which beta-blockers are licensed for use in chronic HF?
Bisoprolol
Carvedilol
Nebivolol
What is second line management of chronic heart failure? What needs to be monitored and why?
Aldosterone antagonist e.g. Spironolactone/ Eplerenone
Monitor K+ as ACEi + aldosterone antagonists can cause hyperkalaemia
What drug can be used second line in management of chronic heart failure with reduced ejection fraction?
SGLT-2 inhibitors: dapagliflozin, empagliflozin, canagliflozin
Reduce glucose reabsorption + increase urinary glucose excretion
What third line therapy can be initiated by a specialist for chronic HF?
Ivabradine
Sacubitril-valsartan
Digoxin
Hydralazine + Nitrate
Cardiac resynchronisation therapy
What is the criteria for using ivabradine?
Sinus rhythm >75 bpm
Left ventricular fraction <35%
What is the criteria for using sacubitril valsartan?
LV fraction <35%
Symptomatic on ACEi/ ARBs
Must have ACEi/ ARB washout period
What is the purpose of digoxin in heart failure? When in particular is it indicated?
Symptomatic relief due to inotropic properties
Strongly indicated if coexistent AF
In which patients is hydralazine and nitrate particularly indicated?
Afro-caribbean
What is the indication for cardiac resynchronisation therapy?
Widened QRS (LBBB)
What non-cardiac treatment should be offered in chronic heart failure?
Annual influenza vaccine
One-off pneumococcal vaccine
When treating chronic heart failure what else must you do?
TREAT THE CAUSE (e.g. HTN)
TREAT EXACERBATING FACTORS (e.g. anaemia)
What must be avoided when treating patients with heart failure?
Drugs that could adversely affect them due to systolic dysfunction:
NSAIDs
Non-dihydropyridine CCBs e.g. Diltiazem, Verapamil
List 3 possible complications of heart failure
Respiratory failure
Cardiogenic shock
Death
What is the prognosis for heart failure?
50% with cardiac failure die within 2 years
What conservative management advice is used for chronic heart failure?
Stop smoking
Stop drinking alcohol
Decrease salt intake
Optimise weight + nutrition
Describe left heart failure
Dysfunction associated with LV
Describe right heart failure
Dysfunction associated with the RV
Often a result of left-sided failure.
How can heart failure be classified by time course?
Acute: Rapid onset
Chronic: Slow onset
What are the 2 types of left heart failure?
Systolic: LV loses its ability to contract normally
Diastolic: LV loses its ability to relax normally
Why perform an echocardiogram in cardiac failure?
To assess ventricular contraction.
If LV ejection fraction < 40%: systolic dysfunction.
Diastolic dysfunction: reduced compliance leading to a restrictive filling defect.
When are nitrates particularly indicated in acute cardiac failure?
Severe HTN
Concurrent myocardial ischaemia/ regurgitant aortic/ mitral valve disease
What is the MOA of nitrates that benefits patients in acute cardiac failure?
Dilate coronary arteries, enhancing blood flow to myocardium
Vasodilatory effects reduce preload + afterload
