Cardiac Failure - Acute Heart Failure Flashcards
Acute left ventricular failure (ALVF) occurs when an acute event results in the left ventricle being unable to move blood efficiently through the left side of the heart and into the systemic circulation. What is the incidence of (ALVF)?
1 - 20,000 cases per 100,000
2 - 2000 cases per 100,000
3 - 200 cases per 100,000
4 - 20 cases per 100,000
3 - 200 cases per 100,000
Equally likely in men and women
What age does the incidence of acute left ventricular failure (ALVF) typically peak at?
1 - >70
2 - >60
3 - >50
4 - >40
1 - >70
Stroke volume (SV) is the volume of blood ejected from the heart per beat. How do we calculate SV?
1 - SVR / EDV
2 - SVR / ESV
3 - EDV - ESV
4 - EDV - EF
SVR = systemic vascular resistance
ESR = end systolic volume
EDV = end diastolic volume
EF = ejection fraction
3 - EDV - ESV
EDV = volume of blood in the fully relaxed left ventricle (LV) after diastolic filling. Occurres at the end of diastolic filling and heard at S1 closure of mitral and tricuspid valves
ESV = volume of blood blood remaining in left ventricle following LV contraction. Occurres at the end systole and heard at S2 closure of aortic and pulmonary valves
- EDV = 120ml was in the LV after filling
- ESV = 50ml was left in LV after LV contraction
- 120 - 50 = 70ml was pumped out of the LV
Ejection fraction (EF) is a measure of left ventricular function. How can we calculate EF?
1 - EF = HR x SV
2 - EF = (HR / SVR) x 100
3 - EF = (SV / EDV) x 100
4 - EF = (SV / ESV) x 100
SV = stroke volume
HR = heart rate
EDV = end diastolic volume
ESV = end systolic volume
3 - EF = (SV / EDV) x 100
Normal EF = >55%
- 40-50% is borderline heart failure
- <40% is systolic heart failure
The frank starling mechanism is useful to understand the relationship between systolic and diastolic function. What does the frank starling mechanism show?
1 - increased atrium filling means more ventricular contraction
2 - increased ventricular stretching results in greater stroke volume (SV)
3 - increased ventricular stretching results in reduced preload
4 - reduced ventricular filling increased afterload
2 - increased ventricular stretching results in greater stroke volume
- like a rubber band, the more the stretch the ventricle in diastole = a greater contract force and a larger SV in systole
- reduced stretching due to a dilated or weak left ventricle will cause a reduction in the SV
All of the following can occur in acute left ventricular failure (ALVF), but which is typically the first sign?
1 - increased LV diastolic pressure
2 - increased end diastolic volume
3 - reduced ejection fraction
4 - reduced SV
4 - reduced SV
- weak heart so decreased left ventricle contractility
In acute left ventricular failure (ALVF), stroke volume is decreased due to a weakened left ventricle (LV), causing more blood to remain in is left in the LV at the end of systole. Which of the following can this then cause?
1 - increased left atrium (LA) pressure
2 - increased pulmonary venous pressure
3 - pulmonary oedema
4 - all of the above
4 - all of the above
- More blood in LV means increased pressure in the LA to force blood into LV
- increased pressure in pulmonary veins needed to overcome pressure in LA
- fluid backs up into the lungs causing pulmonary oedema
Decompensated chronic heart failure is the leading cause of acute left ventricular failure (ALVF). Which of the following is NOT a typical cause of this?
1 - ACS / IHD
2 - Hypertensive crisis (bilateral renal artery stenosis)
3 - Toxins
4 - Acute arrhythmia
5 - Valvular disease
6 - Iatrogenic (e.g., aggressive IV fluids in a frail elderly patient with impaired left ventricular function)
7 - Sepsis
3 - Toxins
De novo = 1st time
- Typically occurs in patients with no known heart failure, but have other health conditions that damage their heart. Most common is ischaemia that causes increased cardiac filling pressures and myocardial dysfunction
De-novo, meaning 1st time occurs in patients with no known heart failure, but have other health conditions that can lead to acute left ventricular failure (ALVF). Which of the following is NOT a typical cause of this?
1 - ACS / IHD
2 - Viral myopathy
3 - Toxins
4 - Valvular dysfunction
1 - ACS / IHD
Acute left ventricular failure (ALVF) can cause dyspnoea. Does this then cause type 1 or 2 respiratory failure?
- Type 1 respiratory failure
Essentially low oxygen
<8kPa with normocapnia
All of the following may be observed during the examination of a patient with Acute left ventricular failure (ALVF), EXCEPT which one?
1 - Bradycardia
2 - Tachypnoea
3 - Hypertension (RAAS activation)
4 - Valvular heart disease with murmur
5 - 3rd heart sound on auscultation
6 - Bilateral basal crackles (pulmonary oedema)
7 - Raised JVP (increased RA pressure)
8 - Peripheral oedema
1 - Bradycardia
Tachycardia is more common
In severe cases ALVF can lead to cardiogenic shock and hypotension
An S3 heart sound is caused by the rapid deceleration of blood against a stiff ventricle during early diastolic filling.
JVP and peripheral oedema are most common in right sided heart failure
The following are key symptoms of Acute left ventricular failure (ALVF), EXCEPT which one?
1 - Breathlessness, worse by exertion
2 - RUQ pain and mass
3 - Dry cough (may be frothy white/pink)
4 - Orthopnoea
5 - Paroxysmal nocturnal dyspnoea
6 - Peripheral oedema
7 - Fatigue
2 - RUQ pain and mass
Hepatomegaly is NOT a common symptom
Orthopnoea = breathlessness when lying flat, patients often sleep with lots of pillows
Paroxysmal nocturnal dyspnoea = being woken by the feeling of drowning/severe SOB when asleep
Which blood test has the best sensitivity for detecting heart failure early and is now the 1st line test for heart failure?
1 - brain natriuretic peptide (BNP)
2 - troponin
3 - creatine Kinase MB
4 - N-terminal pro b-type natriuretic peptide (NT-proBNP)
4 - N-terminal pro b-type natriuretic peptide (NT-proBNP)
Typically released by left ventricle due to excessive fluid, stretching and strain
- Longer half life so remains in blood for longer
- Better sensitivity to detect heart failure early
N-terminal pro b-type natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) are released from the left ventricle in response to heart strain. What do these 2 hormones then do?
1 - signal the heart to slow contractions
2 - reduce ADH release by hypothalamus
3 - reduce aldosterone release by adrenal glands
4 - reduce Na+ and H2O retention in kidney
4 - reduce Na+ and H2O retention in kidney
Normal levels of N-terminal pro b-type natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) are:
- NT-proBNP = <400 pg/ml (47 pmol/litre)
- BNP = <100 pg/ml (29 pmol/litre)
High levels = specialist assessment including transthoracic echocardiography <2 weeks
Raised levels = specialist assessment including transthoracic echocardiography <6 weeks
Referral is based on NT-proBNP = <400 pg/ml and BNP levels
Very high NT-proBNP and BNP = poor prognosis