Cardiac Failure Flashcards
Define Cardiac Failure?
Inability of the cardiac output to meet the body’s demands despite normal venous pressures
What are the three types of Low Output Cardiac Failure (reduced cardiac output)?
Left Heart Failure
Right Heart Failure
Biventricular Failure
What are some examples of Left Heart Failure?
Ischaemic Heart Disease Hypertension Cardiomyopathy Aortic Valve Disease Mitral Regurgitation
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
What’s it called when right heart failure is secondary to left heart failure?
Congestive Cardiac Failure
What are some examples of Biventricular Failure?
Arrhythmia
Cardiomyopathy (dilated or restrictive)
Myocarditis
Drug Toxicity
What are some examples of High Output Cardiac Failure (increased demand)?
Anaemia Beri Beri Pregnancy Paget's Disease Hyperthyroidism Arteriovenous malformation
What is the epidemiology of cardiac failure?
10% > 65 yrs old
What are the presenting symptoms of Left Heart Failure?
Dyspnoea
Orthopnoea
Paroxysmal Noctural Dyspnoea
Fatigue
What are the symptoms caused by in Left Heart Failure?
Pulmonary Congestion
What is Dyspnoea divided based on?
Based on the New York Heart Association Classification
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
What are some of the presenting symptoms of Acute Left Ventricular Failure?
Dyspnoea
Wheeze
Cough
Pink Frothy Sputum
What are some of the presenting symptoms of Right Heart Failure?
Swollen ankles Fatigue Increased Weight (due to oedema) Reduced Exercise tolerance Anorexia Nausea
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)
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
What is Pulsus Alternans?
Arterial Pulse Waveforms showing alternating strong and weak beats
Sign of left ventricular systolic impairment
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&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
