Cardiac Failure Flashcards by Soorya Thavaraj

Define Cardiac Failure?

Inability of the cardiac output to meet the body’s demands despite normal venous pressures

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What are the three types of Low Output Cardiac Failure (reduced cardiac output)?

Left Heart Failure
Right Heart Failure
Biventricular Failure

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What are some examples of Left Heart Failure?

Ischaemic Heart Disease
Hypertension
Cardiomyopathy
Aortic Valve Disease
Mitral Regurgitation

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What are some examples of right heart failure?

Secondary to left heart failure
Infarction
Cardiomyopathy
Pulmonary hypertension/embolus/valve disease
Chronic Lung Disease
Tricuspid Regurgitation
Constrictive Pericarditis/ pericardial tamponade

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What’s it called when right heart failure is secondary to left heart failure?

Congestive Cardiac Failure

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What are some examples of Biventricular Failure?

Arrhythmia
Cardiomyopathy (dilated or restrictive)
Myocarditis
Drug Toxicity

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What are some examples of High Output Cardiac Failure (increased demand)?

Anaemia 
Beri Beri
Pregnancy
Paget's Disease
Hyperthyroidism
Arteriovenous malformation

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What is the epidemiology of cardiac failure?

10% > 65 yrs old

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What are the presenting symptoms of Left Heart Failure?

Dyspnoea
Orthopnoea
Paroxysmal Noctural Dyspnoea
Fatigue

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What are the symptoms caused by in Left Heart Failure?

Pulmonary Congestion

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What is Dyspnoea divided based on?

Based on the New York Heart Association Classification

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What is the New York Heart Association Classification?

1 - no dyspnoea
2 - dyspnoea on ordinary activities
3 - dyspnoea on less than ordinary activites
4 - dyspnoea at rest

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What are some of the presenting symptoms of Acute Left Ventricular Failure?

Dyspnoea
Wheeze
Cough
Pink Frothy Sputum

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What are some of the presenting symptoms of Right Heart Failure?

Swollen ankles 
Fatigue 
Increased Weight (due to oedema)
Reduced Exercise tolerance
Anorexia
Nausea

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What are the signs of Left Heart Failure on physical examination?

Tachycardia
Tachypnoea
Displaced apex beat
Bilateral basal crackles
S3 gallop (caused by rapid ventricular filling)
Pansystolic murmur (due to functional mitral regurgiation)

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What are some of the signs of Acute Left Ventricular Failure on physical examination?

Tachypnoea 
Cyanosis 
Tachycardia
Peripheral Shutdown
Pulsus Alternans
Gallop Rhythm
Wheeze (cardiac asthma)
Fine crackles throughout lung

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What is Pulsus Alternans?

Arterial Pulse Waveforms showing alternating strong and weak beats
Sign of left ventricular systolic impairment

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What is the explanation for Pulsus Alternans?

In left ventricular dysfunction, ejection fraction significantly decreases leading to a reduction in stroke volume
This causes an increase in end-diastolic volume
This means that the left ventricle is stretched more for the next contraction
Due to Starling’s Law the increased stretch of the left ventricle caused by the increased end-diastolic volume following the previous beat leads to an increase in the strength of the myocardial contraction
This results in a stronger systolic pulse

What are the signs of Right Heart Failure on physical examination?

Raised JVP 
Hepatomegaly
Ascites 
Ankle/sacral pitting oedema 
Signs of functional tricuspid regurgitation

What bloods would you do in cardiac failure?

FBC 
U&amp;E 
LFTs 
CRP
Glucose 
Lipids 
TFTs

What tests would you do in Acute Left Ventricular Failure?

ABG
Troponin
BNP

Why do we do BNP in suspected cardiac failure?

Raised plasma BNP suggests diagnosis of cardiac failure

Low plasma BNP rules out cardiac failure (90% sensitivity)

What do we see in CXR in cardiac failure?

ABCDE

Alveolar shadowing
kerley B lines
Cardiomegaly
upper lobe Diversion
pleural Effusion

What might you see on an ECG in cardiac failure?

May be normal
May show ischaemic changes (pathological q waves, t wave inversion)
May show arrhythmia or left ventricular hypertrophy

What might you see on an Echocardiogram?

Assess ventricular contraction Systolic dysfunction = LV ejection fraction < 40% Diastolic dysfunction = decreased compliance of the myocardium leads to restrictive filling defect

How can we use Swan-Ganz Catheter in cardiac failure?

Allows measurement of right atrial, right ventricular, pulmonary artery, pulmonary wedge and left ventricular end-diastolic pressures

How do you treat cardiogenic shock?

This is severe cardiac failure with low BP Requires the use of inotropes (e.g. dobutamine) Managed in ITU

How do you treat pulmonary oedema?

Sit the patient up 60-100% Oxygen (and consider CPAP) Diamorphine (venodilator + anxiolytic) GTN infusion (venodilator ---> reduced preload) IV furosemide (venodilator and later diuretic effect Treat the cause (e.g. MI, arrhythmia)

What do we monitor when treating pulmonary oedema?

``` BP Resp Rate Oxygen Saturation Urine Output ECG ```

What's important to remember when treating Chronic Left Ventricular Failure?

Treat The Cause (e.g. hypertension) | Treat Exacerbating Factors (e.g. anaemia)

What can you use to treat chronic left ventricular failure?

``` ACE inhibitors Beta-Blockers Loop Diuretics Aldosterone Antagoniss Angiotensin Receptor Blockers Hydralazine and a Nitrate Digoxin N-3 Polyunsaturated Fatty Acids Cardiac Resynchronisation Therapy ```

How do ACE inhibitors work?

Inhibits renin-angiotensin system and inhibits adverse cardiac remodelling They slow down the progression of heart failure and improve survival

How do Beta-Blockers work?

Blocks the effects of a chronically activated sympathetic system Slows progression of heart failure and improves survival The benefits of ACE inhibitors and beta-blockers are additive

How do Loop Diuretics work?

Alongside dietary salt restriction, can correct fluid overload

How do Aldosterone Antagonists work?

``` Improves survival in patients with NYHA class III/IV symptoms on standard therapy Monitor K+ (as these drugs may cause hyperkalaemia) ```

How do Angiotensin Receptor Blockers work?

``` Improves survival in patients with NYHA class III/IV symptoms on standard therapy Monitor K+ (as these drugs may cause hyperkalaemia) ```

How can Hydralazine and a Nitrate be used?

May be added in patients (particularly Afro-Caribbeans) with persistent symptoms despite the use of ACE inhibitors and beta-blockers)

How is Digoxin used?

Positive Inotrope | Reduces hospitalisation but does NOT improve survival

How can N-3 Polyunsaturated Fatty Acids be used?

Provide a small beneficial advantage in terms of survival

How can Cardiac Resynchronisation Therapy be used?

Biventricular pacing improves symptoms and survival in patients with a left ventricular ejection fraction < 35%, cardiac dyssynchrony (QRS > 120 msec) and moderate-severe symptoms These patients are also candidates for implanatable cardioverter defibrillator (ICD) They may receive a combined device

What's important to remember when treating a patient with heart failure?

Avoid drugs that could adversely affect a patient with heart failure due to systolic dysfunction (e.g. NSAIDs, non-dihydropyridine CCBs)

What are the possible complications of cardiac failure?

Respiratory Failure Cardiogenic Shock Death

What is the prognosis for patient with cardiac failure?

50% with cardiac failure die within 2 years