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Yr 3 Acute Care and Trauma > cardiac failure > Flashcards

cardiac failure Flashcards

1
Q

definitoon of cardiac failure

A

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

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2
Q

defintion of acute cardiac failure

A

new onset acute/decompensation of HF,

characterized by pulmonary and/or peripheral oedema

with or without signs of peripheral hypoperfusion.

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3
Q

definition of chronic cardiac failure

A

Develops or progresses slowly. Venous congestion is common but arterial pressure is well maintained until very late.

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4
Q

systolic HF

A

inability of the ventricle to contract normally = reduced CO, EF <40%

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5
Q

diastolic HF

A

inability of ventricle to relax and fill normally = increased filling pressures.

Typically EF is >50% – HFpEF (heart failure with preserved EF).

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6
Q

low output HF

A

Cardiac output is low and fails to raise normally with exertion.

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7
Q

high output HF

A

rare.

output is normal or increased in the face of increased needs.

Failure occurs when cardiac output fails to meet these needs.

will occur with a normal heart, but earlier in heart disease

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8
Q

aetiology of low output LHF

A
  • ischemic heart disease,
  • HTN,
  • cardiomyopathy,
  • aortic valve disease,
  • mitral regurg,
  • fluid overload
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9
Q

aetiology of low output RHF

A
  • secondary to LHF,
  • infarction,
  • cardiomyopathy,
  • pul HTN/embolus/valve disease,
  • chronic lung disease (cor pulmonale),
  • tricuspid regurg,
  • constrictive pericarditis/pericardial tamponade,
  • pul stensosis
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10
Q

aetiology of low output biventricular failure

A

arrthmia,

cardiomyopathy (dilated/restrictive),

myocarditis,

drug toxicity

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11
Q

aetiology of low output pump failure

A

systolic +/ diastolic HF,

reduced HR (B blockers, heart block, post MI),

negatively inotropic drugs (eg most antiarrhythmic agents).

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12
Q

aetiology of high output HF

A

anaemia

beriberi

pregnancy

Paget’s disease

hyperthyroidism

arteriovenous malformation

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13
Q

aetiology of systolic HF

A

IHD, MI, cardiomyopathy

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14
Q

aetiology of diastolic HF

A

ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardio myopathy, obesity

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15
Q

what is congestive cardiac failure

A

when R and L ventricular failure occur together

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16
Q

effect of preload and afterload on HF

A

Excessive preload = ventricular dilatation - exacerbates pump failure.

Excessive afterload = ventricular muscle thickening (ventricular hypertrophy), = stiff walls and diastolic dysfunction.

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17
Q

epidemiology of HF

A

1–3% of the general population;

~10% among elderly patients (>65)

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18
Q

sx of LHF

A

symptoms caused by pulmonary congestion

Dyspnoea (New York Heart Associationclassification):

  • none
  • on ordinary activities
  • on less than ordinary activities
  • at rest

poor exercise tolerance

orthopnoea

paroxysmal nocturnal dyspnoea

fatigue

nocturia

cold peripheries

weight loss

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19
Q

sx of acute LVF

A

Dyspnoea,

wheeze,

cough

pink frothy sputum

20
Q

sx of RHF

A
  • swollen ankles
  • ascites
  • fatigue
  • increased weight (from oedema)
  • reduced exercise tolerance
  • anorexia
  • nausea
  • facial engorgement
  • epistaxis
21
Q

sx of high output HF

A

initially features of RVF;

later LV F becomes evident.

22
Q

signs of LHF

A

tachycardia

tachypnoea

displaced apex beat (LV dilatation)

bilateral basal crackles

3rd heart sound - gallop rhythm: rapid ventricular filling

pansystolic murmur (functional mitral regurg)

23
Q

signs of acute LVF

A

tachypnoea

cyanosis

tachycardia

peripheral shut down

pulsus alternans

gallop rhythm

wheeze ‘cardiac asthma’

fine crackles throughout the lung

24
Q

signs of RHF

A

raised JVP

hepatomegaly

ascites

anklesacral pitting

oedema

signs of functional tricuspid regurg

25
Q

general signs of HF

A

cyanosis

low BP

narrow pulse pressure

RV heave - pul hypertension

severity graded by New York Classification

26
Q

Ix for HF

A

bloods

CXR

ECG

echo

Swan-Ganz catheter

if BNP and ECG normal - unlikely HF, if either not normal - need echo

27
Q

bloods for HF

A

FBC, UE, LFT, CRP, glucose, lipid, TFT

in acute LVF - ABG, troponin, BNP

  • raised Plasma BNP suggests the diagnosis of cardiac failure.
  • A low plasma BNP rules out cardiac failure (90% sensitivity).
28
Q

CXR in acute LVF

A

cardiomegaly (heart >50% of thoracic width)

prominent upper lobe vessels

pleural effusion

interstitial oedema - kerley B lines

perihilar shadowing - Bat’s wings

fluid in fissures

29
Q

ECG in HF

A

may be normal

ischemic changes

arrhythmia

MI

LVH - seen in hypertension

30
Q

echo for HF

A

assess ventricular contraction

MI

If left ventricular ejection fraction (LVEF)<40%: systolic dysfunction.

Diastolic dysfunction: reduced compliance leading to a restrictive filling defect.

31
Q

Swan-Ganz catheter

A

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

32
Q

complications of HF

A

resp failure

cardiogenic shock

death

33
Q

Px of HF

A

Fifty per cent of patients with severe heart failure die within 2 years.

34
Q

Mx of acute LVF

A

medical emergency

cardiogenic shock - severe cardiac failure, low BP = need inotropes eg dopamine, dobutamine and should be managed in ITU

pul oedema

  • Sit up patient, 60–100% O2 and consider CPAP
  • diamorphine (venodilator and anxiolytic effect)
  • GTN infusion - reduce preload
  • IV furosemide if fluid overloaded (venodilator and later diuretic effect)
  • monitor BP, RR, sats, urine output, ECG
  • treat cause
35
Q

Mx of chronic LVF

A
  • treat cause - eg HTN
  • treat exacerbating factors eg anaemia, thyroid disease, infection, raised BP
  • stop smoking, drinking, eat less salt, optimise weight
  • Annual ’flu vaccine, one-off pneumococcal vaccine.
  • ACEi
  • B blocker
  • loop diuretic eg furosemide and salt restriction to treat fluid overload
  • aldosterone antagonists
  • angiotensin receptor blockers
  • hydralazine and a nitrate (visodilators) - reduce mortality
  • digoxin - positive inotrope - reduces hospitalisation, doesnt improve survival
  • n-3 polyunsaturated fatty acids - benefit mortality
  • cardiac resynchronisation therapy
  • Avoid drugs that can adversely affect patients with heart failure due to systolic dysfunction,e.g. NSAIDs, non-dihydropyridine calcium channel blockers (i.e. diltiazem and verapamil).
36
Q

why ACEi for HF

A

e.g. enalapril, perindopril, ramipril:

Inhibit intracardiac renin-angiotensin system which may contribute to myocardial hypertrophy and remodelling.

slow progression of the heart failure and improve survival, improve sx

if LV systolic dysfunction

SE - high K

37
Q

why B blocker for HF

A

bisprolol or carvedilol

Block the effects of chronically activated sympathetic system

slow progression of the heart failure and improve survival

The benefits of ACEinhibitors and b-blockers are additive.

38
Q

why loop diuretics for HF

A

reduce Sx

SE - reduce K, renal impairment

Monitor U&E and add K+-sparing diuretic (eg spironolactone)

if K+<3.2mmol/L = predisposition to arrhythmias, concurrent digoxin therapy, or pre-existing K+-losing conditions.

if refractory oedema - consider adding thiazide eg metolazone

39
Q

aldosterone antagonists in HF

A

spirinolactone/eplerenone

improve survival in pts with classification 3 or 4

use if still Sx, or post MI with LV systolic dysfunction

Monitor K+ (may cause hyperkalaemia).

  • May be used to assist in the management of diuretic-induced hypokalaemia.
40
Q

ARB in HF

A

candesartan

added in pts with persistent symptoms despite ACE inhibitors and B blockers

monitor K+ may cause hyperkalaemia

41
Q

hydralazine and a nitrate in HF

A

May be added in patients (particularly in Afro-Caribbeans) with persistent symptoms despite therapy with an ACE inhibitor and b-blocker

42
Q

cardiac resynchronisation therapy in HF

A

Biventricular pacing improves symptoms and survival in patients with LVEF <=35%, cardiac dyssynchrony (QRS>120msec) and moderate to severe symptoms despite optimal medical therapy.

Most patients who meet these criteria are also candidates for an implantable cardiac defibrillator (ICD) and receive a combined device.

43
Q

digoxin in HF

A

helps sx even if in sinus rhythm

give in pts with LV systolic dysfunction of still sx or signs when have standard therapy (inc ACEi or B blocker) or AF

monitor UE - low K = risk toxicity

44
Q

Mx of intractable HF

A
  • reassess cause
  • switch furosemide to butmetanide
  • minimal exertion
  • Na and fluid restriction
  • metolazone and IV furosemide
  • opiates and IV nitrates - relieve sx
  • weigh daily
  • frequent UE - beware low K

in extremis - IV ionotropes

consider cardiac resynchronisation, LV assist device or transplant

45
Q

palliative care for HF

A

treat/prevent co-morbidities eg flu vaccine

good nutrition

tackly dyspnoiea, nausea, constipation, and low mood

opiates - pain and dyspnoea

ox

46
Q

L ventricular assist devices

A

bridging therapy while waiting for heart transplant

pump force blood through tubing from LV to aorta

Yr 3 Acute Care and Trauma (6 decks)

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