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cardiology > Cardiac failure (acute & chronic) > Flashcards

Cardiac failure (acute & chronic) Flashcards

1
Q

Define cardiac failure

A

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

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2
Q

Aetiology of cardiac failure

2 types of cardiac failure

A

Low output cardiac failure - reduced CO

High output cardiac failure - increased demand

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3
Q

Aetiology of low output cardiac failure

3 types

A

Left heart failure
Right heart failure
Biventricular failure

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4
Q

Aetiology of low output cardiac failure - left heart failure

5

A 
Ischaemic heart disease
Hypertension
Cardiomyopathy
Aortic valve disease
Mitral regurgitation
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5
Q

Aetiology of low output cardiac failure - right heart failure
(7)

A

Secondary to left heart failure (= congestive cardiac failure)
Infarction
Cardiomyopathy
Pulmonary hypertension/embolus/valve disease
Chronic lung disease
Tricuspid regurgitation
Constrictive pericarditis/pericardial tamponade

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6
Q

Aetiology of low output cardiac failure - biventricular failure
(4)

A

Arrhythmia
Cardiomyopathy (dilated or restrictive)
Myocarditis
Drug toxicity

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7
Q

Aetiology of high output cardiac failure

6

A 
Anaemia
Beri beri
Pregnancy 
Paget's disease
Hyperthyroidism 
Arteriovenous malformation
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8
Q

Epidemiology of cardiac failure

A

10% >65 yrs old

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9
Q

Presenting symptoms of left heart failure

4

A 
(symptoms caused by pulmonary congestion)
Dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea 
Fatigue
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10
Q

Presenting symptoms of acute left ventricular failure

4

A

Dyspnoea
Wheeze
Cough
Pink frothy sputum

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11
Q

Presenting symptoms of right heart failure

6

A 
Swollen ankles
Fatigue
Increased weight (due to oedema)
Reduced exercise tolerance
Anorexia
Nausea
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12
Q

New York Heart Association classification of dyspnoea

4

A

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

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13
Q

Signs of left heart failure on physical examination

6

A

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

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14
Q

Signs of acute left ventricular failure on physical examination
(8)

A 
Tachypnoea
Cyanosis
Tachycardia
Peripheral shutdown
Pulsus alternans
Gallop rhythm 
Wheeze (cardiac asthma)
Fine crackles throughout lung
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15
Q

Signs of right heart failure on physical examination

5

A 
Raised JVP
Hepatomegaly
Ascites
Ankle/sacral pitting oedema 
Signs of functional tricuspid regurgitation
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16
Q

Definition & aetiology of pulses alternans

1 +4

A

Arterial pulse waveforms showing alternating strong & weak beats
Sign of left ventricular systolic impairment
In left ventricular dysfunction, ejection fraction significantly decreases —> reduced stroke volume
Left ventricle is stretched more for next contraction due to increased end-diastolic volume of previous beat —> increased strength of myocardial contraction (Starling’s law)
Results in stronger systolic pulse

17
Q

Investigations for cardiac failure

5 groups

A 
Bloods
CXR
ECG
Echocardiogram
Swan-Ganz catheter
18
Q

Investigations for cardiac failure - bloods

7 + 3 acute ventricular

A 
FBC
U&Es
LFTs
CRP
Glucose
Lipids
TFTs

ABG
Troponin
BNP -
Raised plasma BNP suggest diagnosis of cardiac failure
Low plasma BNP rules out cardiac failure (90% sensitivity)

19
Q

Investigations for cardiac failure - CXR

5

A 
ABCDE
Alveolar shadowing
Kerley B lines
Cardiomegaly
Upper lobe diversion
Pleural effusion
20
Q

Investigations for cardiac failure - ECG

3

A

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

21
Q

Investigations for cardiac failure - echocardiogram

3

A

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

22
Q

Investigations for cardiac failure - Swan-Ganz catheter

A

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

23
Q

Management of acute left ventricular failure

2 groups

A

Treating cardiogenic shock

Treating pulmonary oedema

24
Q

Management of acute left ventricular failure - cardiogenic shock
(3)

A

Severe cardiac failure w/ low BP
Requires use of inotropes (e.g. dobutamine)
Managed in ITU

25
Q

Management of acute left ventricular failure - pulmonary oedema
(7)

A

Sit patient up

60-100% oxygen (consider CPAP)

Diamorphine (venodilator + anxiolytic)

GTN infusion (venodilator —> reduced preload)

IV furosemide (venodilator + later diuretic effect)

Monitor 
BP
resp rate
oxygen saturation
urine output
ECG

Treat the cause (e.g. MI, arrhythmia)

26
Q

Management of chronic left ventricular failure

2 general + 9

A

Treat the cause (e.g. hypertension)
Treat the exacerbating factors (e.g. anaemia)

ACE inhibitors

β-blockers

Loop diuretics

Aldosterone antagonists

Angiotensin receptor blockers

Hydralazine & a nitrate

Digoxin

N-3 polyunsaturated fatty acids

Cardiac resynchronisation therapy

(Avoid drugs that could adversely affect patient w/ heart failure due to systole dysfunction - e.g. NSAIDS, non-dihydropyridine CCBs)

27
Q

Management of chronic left ventricular failure - ACE inhibitors
(2)

A

Inhibit renin-angiotensin systen & inhibit adverse cardiac remodelling
Slow down progression of heart failure & improve survival

28
Q

Management of chronic left ventricular failure - β blockers

3

A

Block effects of chronically activated sympathetic system
Slow progression of heart failure & improve survival
Benefits of ACE inhibitors & β-blockers are additive

29
Q

Management of chronic left ventricular failure - loop diuretics

A

Alongside dietary salt restriction, can correct fluid overload

30
Q

Management of chronic left ventricular failure - aldosterone antagonists
(2)

A 
Improve survival in patients w/ NYHA class III/IV symptoms on standard therapy
Monitor K+ (these drugs may cause hyperkalaemia)
31
Q

Management of chronic left ventricular failure - angiotensin receptor blockers
(2)

A

May be added in patients w/ persistent symptoms despite use of ACE inhibitors & β-blockers
Monitor K+ (these drugs may cause hyperkalaemia)

32
Q

Management of chronic left ventricular failure - hydralazine & a nitrate

A

May be added in patients (particularly Afro-Caribbeans) w/ persistent symptoms despite use of ACE inhibitors & β-blockers

33
Q

Management of chronic left ventricular failure - digoxin

2

A

Positive inotrope

Reduces hospitalisation but does NOT improve survival

34
Q

Management of chronic left ventricular failure - N-3 polyunsaturated fatty acids

A

Provide small beneficial advantage in survival

35
Q

Management of chronic left ventricular failure - cardiac resynchronisation therapy
(3)

A

Biventricular pacing improves symptoms & survival in patients w/ left ventricular ejection fraction <35%, cardiac desynchrony (GRS >120 ms) & moderate severe symptoms
Also candidates for implantable cardioverter defibrillator (ICD)
May receive a combined device

cardiology (31 decks)

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