Cardiac failure (CV) Flashcards
Define cardiac failure.
Inability of the cardiac output to meet the body’s demands, despite normal venous pressures
Which age group is cardiac failure most common in?
> 65 years old
What are the three types of cardiac failure?
- left heart failure (systolic + diastolic)
- right heart failure
- congestive heart failure - left HF + right HF
What are the two types of left heart failure?
- systolic heart failure
- diastolic heart failure
Define systolic heart failure.
HFrEF <40%, unable to pump blood
What are some causes of systolic heart failure? (4)
DAMI:
- dilated cardiomyopathy
- arrhythmias
- myocarditis
- ischaemic heart disease
What heart sound is heard in systolic heart failure?
- S3
- rapid filling of ventricles at start of diastole - normal variant in young and athletes due to strong atrial contraction
- abnormal in left-sided HF usually due to mitral regurgitation –> over-filled LA = when mitral valve opens in diastole a lot of blood rapidly empties into ventricle - sign of systolic HF, usually with MR
Define diastolic heart failure.
HFpEF >50%, heart cannot relax and properly fill with blood
What are some causes of diastolic heart failure? (4)
- hypertrophic obstructive cardiomyopathy
- restrictive cardiomyopathy
- constrictive pericarditis
- cardiac tamponade
What heart sound is heard in diastolic heart failure?
- S4
- atrial-kick near the end of diastole as the atria contract hard trying to force blood into a ‘stiff non-compliant ventricle’ - classically associated with diastolic HF
- pure diastolic HF is rare, whereas pure systolic and mixed HF are more common = S3 much more common in HF
What are some causes of right heart failure? (4)
LIPT(on iced tea will give you heart failure):
- secondary to Left HF (congestive HF)
- Infarction
- Pulmonary hypertension
- Tricuspid regurgitation
How can you categorise cardiac failure? (4)
- acute
- chronic
- low output state - low cardiac output
- high output state - NORMAL heart unable to pump enough blood to meet metabolic needs of the body
What conditions can cause a high output state - cardiac failure? (4)
- anaemia
- Beri-Beri –> thiamine deficiency
- pregnancy
- hyperthyroidism
What are the clinical features of high output state cardiac failure? (3)
Heart failure with fluid overload:
- acute breathlessness with no associated pain
- bilateral pitting oedema
- elevated JVP
What are the clinical features of left heart failure? (6)
- dyspnoea
- orthopnoea
- paroxysmal nocturnal dyspnoea
- bibasal crackles on inspiration
- pink frothy sputum - due to pulmonary oedema
- wheeze
When are inspiratory vs expiratory bibasal crackles heard?
- inspiratory - left HF
- expiratory - lung fibrosis
What is an early sign of LV failure?
S3 gallop rhythm
Why do patients get pulmonary symptoms in left heart failure?
Fluid accumulation in lungs –> pulmonary oedema
What are the clinical features of right heart failure? (4)
- swollen ankles - peripheral oedema
- raised JVP
- hepatomegaly - pulsatile liver edge on palpation
- ascites
Why do patients get swollen signs in right heart failure?
Fluid accumulates in peripheries as it is congested backwords (into systemics)
Why do you get different types of symptoms in left vs right heart failure?
- left HF - fluid build up in lungs as left heart not functioning properly
- right HF - fluid build up in peripheries as right heart not working properly
What is the first-line investigation for heart failure?
BNP - raised in heart failure - sensitive but not specific
What drug types can cause a falsely low BNP? (5)
- ACEi
- ARBs
- beta blockers
- diuretics
- aldosterone antagonists
What investigation is diagnostic for heart failure?
Transthoracic echocardiogram - done if BNP is raised for confirmation of heart failure
What can you calculate from transthoracic echocardiogram in heart failure?
- ejection fraction
- EF<40% = HFrEF –> systolic dysfunction
- EF>50% = HFpEF –> diastolic dysfunction
What would you see on CXR in heart failure? (5)
ABCDE
- Alveolar shadowing (oedema)
- Kerley-B lines (horizontal lines in lung periphery that extend to pleural surface; thickened, oedematous interlobular septa due to pulmonary oedema)
- Cardiomegaly
- Dilated upper lobe vessels due to diversion of blood to upper lobe
- pleural Effusion - notching of costophrenic angles, meniscus sign
What are Kerley-B lines seen on CXR in heart failure?
- horizontal lines in lung periphery that extend to pleural surface
- thickened, oedematous interlobular septa due to pulmonary oedema
What other investigations are done in heart failure? (3)
- ECG
- ABG
- bloods -
- rule out anaemia
- look for hyperthyroidism - may led to high-output HF and cause hypervolaemic hyponatraemia, managed by fluid restriction
How is clinical diagnosis of heart failure made?
Framingham criteria: 2+ majors, or 1 major + 2 minors:
Major:
- paroxysmal nocturnal dyspnoea
- bibasal crepitations
- S3 gallop
- cardiomegaly
- increased central venous pressure
- weight loss
- neck vein distension
- acute pulmonary oedema
- hepatojugular reflex
Minor:
- bilateral ankle oedema
- dyspnoea on exertion
- tachycardia
- decrease in vital capacity by 1/3
- nocturnal cough
- hepatomegaly
- pleural effusion
What is the management plan for acute heart failure? (4)
Treat pulmonary oedema - SOMF:
- Sit patient up
- Oxygen
- Morphine
- IV Furosemide (loop diuretic - inhibits Na/K/Cl cotransporter in thick ascending LoH, can cause hypokalaemia)
What electrolyte imbalance can furosemide (loop diuretic used in HF) cause?
Hypokalaemia
How do we manage acute HF if the patient is in cardiogenic shock e.g. hypotension <85mmHg?
Give inotropes - dobutamine
How do you manage acute right heart failure?
May do fluid challenge
What do you do if acute heart failure is not responding to treatment?
Consider CPAP
What is the management plan for chronic heart failure (HFrEF)?
- 1st line: ACEi (ramipril) + beta blocker (bisoprolol)
- 2nd line: aldosterone antagonist (spironolactone) - given alongside 1st-line Rx in those with HFrEF if they continue to have symptoms
- if there are troublesome side effects of spironolactone e.g. gynaecomastia, give eplerenone
- can give SGLT-2 inhibitors alongside this
What medication is contraindicated in heart failure?
Rate-limiting CCBs e.g. verapamil or diltiazem
What broad pharmacological interventions are advised for heart failure? (2)
- annual influenza vaccine
- one-off pneumococcal vaccine
What conservative management is there for heart failure? (3)
- daily weights
- fluid restriction
- catheter/fluid balance
Describe the prognosis of heart failure.
50% with heart failure die within 2 years
What is the NYHA classification of cardiac failure?
- stage I - no limitation on ordinary physical activity
- stage II - normal at rest, ordinary physical activity causes breathlessness
- stage III - normal at rest, less than ordinary physical activity causes breathlessness
- stage IV - symptoms at rest
