Cardiac Shortness of Breath Flashcards
1
Q
What causes breathlessness?
What are the 3 reasons why this might occur?
A
breathlessness is caused by insufficient oxygen delivery to respiring tissues
- not enough oxygen reaching the lungs
- e.g. asthma, COPD, anaphylaxis
- not enough oxygen getting into the blood
- e.g. issues with exchange surfaces leading to V/Q mismatch
- e.g. pulmonary oedema, pulmonary fibrosis
- not enough oxygen reaching the rest of the body
- e.g. due to issues with the heart, anaemia or shock
2
Q
A
C - right heart failure secondary to tricuspid regurgitation
- infective endocarditis is a common reason for someone younger presenting with a HF picture
- swelling of the ankles / face and raised JVP are signs of RIGHT HF
- pansystolic murmur is associated with tricuspid regurgitation
3
Q
What is the definition of heart failure?
A
- the failure of the heart to maintain the cardiac output required to meet the body’s demands
- CO = the volume of blood pumped by the heart in one minute
- this means that not enough oxygen reaches the rest of the body
4
Q
What are the 3 different ways in which heart failure can be classified?
A
- acute or chronic
- left or right
- high output state or low output state
5
Q
What is cardiac output measured relative to?
A
cardiac output is measured relative to the body’s metabolic demands
- sometimes CO can be normal, but there is still HF present as it is not enough to meet the body’s demands at that time
6
Q
How is chronic and acute heart failure defined?
What causes acute HF?
A
Chronic heart failure:
- long term condition in which the heart fails to maintain an adequate circulation for the needs of the body
Acute heart failure:
- rapid onset symptoms and signs of heart failure, which require urgent management
- this is caused by acute coronary syndrome OR a decompensation of chronic HF
- the patient is usually gasping for breath
7
Q
What are the only 2 causes of acute heart failure?
A
- acute coronary syndrome
- e.g. an MI that damages the myocardium
- decompensation of chronic heart failure
- chronic heart failure suddenly gets worse for some reasion
8
Q
Why is it important to distinguish right and left heart failure from each other?
What is congestive heart failure?
A
- the signs and symptoms of HF depend on which side of the heart is affected
- congestive heart failure occurs when BOTH LHF + RHF are present
- in CHF, the patient usually has LHF to begin with, pressure then backs up into the pulmonary circulation and into the right heart, leading to subsequent RHF
9
Q
What is the difference between low output state and high output state heart failure?
A
Low output state:
- the heart fails to pump in response to normal exertion
- this leads to reduced cardiac output
High output state:
- cardiac output is normal, but the body has higher metabolic demands
- e.g. pregnancy, anaemia, hyperthyroidism
10
Q
What are the 3 different aetiologies of chronic left HF?
What are examples of these?
A
Valvular:
- there is a problem with the aortic or mitral valves
- aortic stenosis
- aortic regurgitation
- mitral regurgitation
Muscular:
- the heart muscle is not performing properly, which reduces CO
- ischaemic heart disease
- cardiomyopathy
- myocarditis
- arrhythmias (AF)
Systemic:
- hypertension
- amyloidosis
- drugs - e.g. cocaine, chemo
11
Q
How can hypertension eventually lead to chronic left HF?
A
- the left heart pumps blood into the aorta
- if there is systemic hypertension, there is increased pressure within the aorta
- there is increased afterload, which can cause pressure to back up into the left heart and eventually cause HF
12
Q
What are the 2 possible categories of causes of chronic right HF?
What are examples of each?
A
Lungs:
- pulmonary hypertension (cor pulmonale) is the main cause of RHF
- it can also be caused by pulmonary embolism and chronic lung disease
- e.g. cystic fibrosis or interstitial lung disease
Valvular:
- problems with the tricuspid and pulmonary valves
- tricuspid regurgitation
- pulmonary valve disease
13
Q
What mnemonic can be used to remember the causes of chronic high output HF?
A
- caused by conditions that require a higher CO, which puts a strain on the heart
- NAP MEALS
- N - nutritional (B1 / thiamine deficiency)
- A - anaemia
- P - pregnancy
- M - malignancy
- E - endocrine (hyperthyroidism)
- A - AV malformations
- L - liver cirrhosis
- S - sepsis
14
Q
Why can anaemia and hyperthyroidism lead to chronic high output heart failure?
A
- in anaemia, the blood is not carrying enough oxygen so the heart needs to pump harder to compensate for this
- in hyperthyroidism, there is an increased basal metabolic rate, which increases metabolic demands of the body
15
Q
What types of symptoms result from left and right HF and why?
A
LHF:
- fluid accumulates in the lungs, leading to respiratory symptoms
RHF:
- fluid accumulates in the peripheries, leading to swelling signs
16
Q
What are the respiratory symptoms associated with LHF?
A
-
dyspnoea
- paroxysmal nocturnal dyspnoea (PND)
- exertional dyspnoea
- orthopnoea
-
nocturnal cough (+/- pink frothy sputum)
- pink frothy sputum is more associated with acute left HF
- fatigue
17
Q
What are good questions to ask for assessing SOB, orthopnoea and PND?
A
Shortness of breath:
- How far are you able to walk before getting breathless?
- How many flights of stairs?
Orthopnoea:
- Have you noticed anything making the SOB worse?
- What about lying down?
PND:
- Do you ever wake up at night gasping for air?
- How many pillows do you sleep with at night? Has this changed recently?
18
Q
What are the heart signs associated with LHF?
A
- increased HR and RR
- irregularly irregular heartbeat
- pulsus alternans
- displaced apex beat
- S3 gallop rhythm
- S4 in severe heart failure
- murmur in AS, MR and AR
19
Q
What is pulsus alternans?
A
a physical finding on arterial pulse waveform that shows alternating strong and weak beats
it indicates left ventricular systolic impairment
20
Q
What are the lung signs associated with LHF?
A
- fine end-inspiratory crackles at the lung bases which suggests pulmonary oedema
- wheeze which suggests cardiac asthma
21
Q
What are the symptoms of RHF?
A
- fatigue
- reduced exercise tolerance
- anorexia
- nausea
- nocturia
22
Q
What are the signs associated with RHF?
A
- facial swelling
- elevated JVP
- increased HR and RR
- ascites and/or hepatomegaly
- ankle and sacral pitting oedema
- there may be a murmur present if there is an underlying valve disorder
23
Q
What are the bedside, bloods and imaging investigations performed in HF?
A
-
ECG is performed at the bedside
- this rules out more acute causes, like MI
- FBC, U&Es, LFTs, TFTs and BNP
- FBC rules out anaemia
- TFTs rule out hyperthyroidism
- imaging involves CXR and transthoracic echo (TTE)
- TTE is the gold standard for diagnosing HF
24
Q
Is BNP sensitive or specific?
How is it used in diagnosing HF?
A
- if BNP is low then HF is very unlikely
- if BNP is high then a TTE is performed to diagnose HF
- BNP is sensitive but not specific
- it is not specific as it can be raised by other heart conditions
- HF can only be diagnosed by TTE
25
What is the diagnostic test for HF?
**transthoracic echocardiogram (TTE) coupled with doppler**
doppler allows you to visualise blood flow
26
Why can TTE with doppler be used to diagnose HF?
* visualising the **structure and function** of the heart may show the **_cause of HF_**
* e.g. underlying valve abnormalities
* can calculate the **_ejection fraction (EF)_**
* this is the % of blood present in the LV that gets pumped during systole
* normal is **50-70%**
27
What type of HF is present if ejection fraction (EF) is \< 40%?
What does this indicate?
**_HF with reduced ejection fraction_**
(previously known as systolic HF)
this indicates the **inability** of the ventricle to **_contract normally_**
28
What type of heart failure is present when EF \> 50%?
What does this indicate?
**_HF with preserved ejection fraction_**
(previously called diastolic HF)
this indicates the **inability** of the ventricle to **_relax and fill normally_**
29
What are the A - E signs of heart failure on CXR?
* A - **alveolar oedema**
* B - **Kerley B lines**
* C - **cardiomegaly**
* D - **dilated upper lobe vessels** + **diverted upper lobe**
* E - **effusion** (transudative pleural effusion)
30
What criteria are used to make a clinical diagnosis of HF?
* clinical diagnosis can be made using the **_Framingham Criteria_**
* there must be **2+ majors** OR **1 major + 2 minors**
31
What are the 4 stages involved in the management of chronic HF?
* treat the **_underlying cause_**
* treat the **_exacerbating factors_**
* **_lifestyle modifications_**
* smoking cessation
* reduced salt diet
* increased exercise
* **_drugs_** (ABD):
* ACE inhibitors
* beta-blockers
* diuretics
32
When are ACE inhibitors given to patients?
What are examples and what can be done if they are not tolerated?
* given to all patients with **_LV dysfunction_**
* enalapril, perindopril, ramipril
* can switch to **_ARBs_** if they are not tolerated
* this is usually due to a **chronic cough**
33
Why are beta-blockers given in heart failure?
What are examples?
* they **slow down the heart** and **_reduce the oxygen demand_**
* e.g. bisoprolol, carvedilol
* they are particularly useful when someone has a **coronary artery disease** that has resulted in heart failure
34
When are diuretics given in heart failure?
What are the different types?
* these are given when there is evidence of **_fluid retention_**
* **loop diuretics** - e.g. furosemide
* **aldosterone antagonists** - e.g. spironolactone
35
What medication is considered in Afro-Caribbean patients with HF?
hydralazine + nitrates
36
What is cardiac resynchronisation therapy?
it aims to improve the timings of contraction of the atria and ventricles
37
What are the 5 steps in the emergency management of acute HF?
* sit the patient **upright**
* give **_60 - 100% oxygen_**
* give **_IV diamorphine_** 2.5 - 5 mg
* **_GTN infusion_**
* give **_IV furosemide_** 40 - 80 mg
* this is a loop diuretic which causes massive diuresis and helps get rid of fluid
38
What mnemonic can be used to remember the stages of treatment of acute HF?
DMONS
* D - diuretics
* M - morphine
* O - oxygen
* N - nitrates
* S - sit-up
(not in order)
39
What are the potential complications of acute HF?
* **respiratory failure**
* **_renal failure_** (due to hypoperfusion)
* acute exacerbations
* death
40
What is the prognosis like for acute heart failure?
* prognosis is very poor and worse than most malignancies
* 50% of patients with severe HF die within 2 years
41
E - alveolar oedema
this is due to LHF causing pulmonary oedema
42
What is the definition of cardiomyopathy?
Who tends to be affected?
* a group of diseases in which the **_myocardium_** becomes **structurally** and **functionally abnormal**
* in the absence of coronary artery diease, valvular disease and congenital heart disease
* it can affect **young people**
43
What is the difference between primary and secondary cardiomyopathy?
* primary is **confined to the _myocardium_**
* secondary is part of a **_systemic disease_**
44
What are the 4 types of cardiomyopathy?
* normal
* dilated
* hypertrophic
* restrictive
45
What happens in dilated cardiomyopathy?
* the ventricle becomes **_larger_**
* the ventricle walls become **_thinner_** and **_weaker_**
* the dilated ventricle is less effective at pumping blood
46
What happens in hypertrophic cardiomyopathy?
* cardiac muscle has **hypertrophied** and become **_thicker_**
* the thickened myocardium is **_stiffer_** and less effective at pumping blood
* the excess cardiac muscle also **invades into the ventricle** and blocks it off slightly
47
What happens in restrictive cardiomyopathy?
* there is the **same amount of muscle** present as in a normal heart
* the myocardium has become infiltrated with something which makes it **_more rigid_** and less effective at pumping blood
* a stiff myocardium also has **impaired relaxation**, so the ventricle cannot fill with as much blood
48
What are the key points to pick up in the history of someone with a cardiomyopathy?
* they often have symptoms of **_heart failure_**
* SOB on exertion
* fainting
* fatigue
* **_sudden death_** is often the first presentation
* there is often a **_family history_**
49
What is a very important question to ask in the history if cardiomyopathy is suspected?
* " Is there any family history of **sudden, unexplained cardiac death** at a **young age**?*
* i.e. under 50 "*
50
What signs might be present on examination of someone with a cardiomyopathy?
signs of heart failure:
* respiratory crackles
* heart murmurs
* S3 and S4
51
What investigations are performed in someone with suspected cardiomyopathy?
* there is **no single diagnostic test** for all types
* **_ECHO_** is performed as this is good at visualising the **structure** of the heart
* bloods can be done, including **BNP**
* as well as CXR, ECG, cardiac catheterisation, stress test
52
What is the pathophysiology involved in dilated cardiomyopathy?
What "Law" is relevant to explain the consequence of this?
* ventricles **enlarge** and become **_dilated_**
* **walls** of ventricles become **_thinner and weaker,_** meaning contractions are not as effective
* cardiac output is reduced
* the **_Law of Laplace_** states that ***increased radius** leads to **reduced ventricular pressure***
* reduced ventricular pressure results in reduced CO
53
What are the risk factors for dilated cardiomyopathy?
* **alcohol**
* can occur post-viral infection
* genetic
* haemochromatosis
54
How does someone with dilated cardiomyopathy present?
* they will have signs and symptoms of **heart failure**
* **_displaced apex beat_**
* this occurs as the ventricles become larger, shifting the position of the apex
* **tricuspid regurgitation** / **mitral regurgitation** murmur
* **S3** heart sound
55
What investigations are performed in dilated cardiomyopathy and what might they show?
* CXR shows a large, **_globular heart_**
* Echo will show a **dilated ventricle**
56
What is involved in the pathophysiology of hypertrophic cardiomyopathy?
* the myocardium **thickens _inwards_**
* **increased stiffness** of thicker muscle affects the pumping
* thickened muscle **disrupts electrical conduction** and causes **_arrhythmia_**
57
What happens if hypertrophic cardiomyopathy progresses to hypertrophic obstructive cardiomyopathy (HOCM)?
* the thickened myocardium starts to **_obstruct the outflow of blood_** from the ventricle
58
What is particularly important to ask about in hypertrophic cardiomyopathy?
What is the classical presentation?
* **_family history_** is very important as 50% cases are familial (autosomal dominant)
* classic presentation is of a **young, healthy person** who **_suddenly collapses_** and often **dies**
59
What are the symptoms associated with obstructive cardiomyopathy?
* usually **asymptomatic**
* **_sudden cardiac death_** is often the first presentation
* may have some cardiac symptoms:
* angina
* dyspnoea on exertion
* palpitations
* syncope
60
What are the signs associated with obstructive cardiomyopathy?
* **_ejection systolic_ murmur**
* the muscle is obstructing the outflow of blood
* this is the same murmur as **aortic stenosis** as blood is struggling to leave the ventricle
* **_jerky carotid pulse_**
* **_double apex beat_** but not displaced
* muscle is growing inwards, so the apex is not displaced as the position of the ventricle is not changing
* **S4 heart rhythm**
61
What investigations are performed in hypertrophic cardiomyopathy?
What would they show?
***_ECG:_***
* Q waves
* left axis deviation
* signs of left ventricular hypertrophy
***_Echo:_***
* shows ventricular hypertrophy
* this is asymmetrical septal hypertrophy
62
What is involved in the pathophysiology of restrictive cardiomyopathy?
* the ventricles become **_abnormally rigid_** and **lose flexibility**
* there is **_impaired ventricular filling_** during diastole
* reduced preload leads to **reduced blood flow** (cardiac output) and **backing up of blood**
63
What are the different causes of restrictive cardiomyopathy?
* the **infiltrative "osis" diseases**:
* sarcoidosis
* amyloidosis
* haemochromatosis
* familial
* idiopathic
* it is rarer than dilated or hypertrophic cardiomyopathy
64
What are the signs and symptoms associated with restrictive cardiomyopathy?
* it is **asymptomatic** or has **heart failure symptoms**
* often there are **_RHF signs_**:
* raised JVP
* S3 heart sound
* ascites / peripheral oedema
* hepatomegaly
* **_Kussmaul's sign_** is positive
* this is a paradoxical **rise in the JVP during inspiration**
* (usually the JVP should fall during inspiration)
65
What happens in arrhythmogenic right ventricular cardiomyopathy?
* there is **_progressive fatty and fibrous replacement_** of the ventricular myocardium
* this is an **inherited** autosomal dominant condition
66
What happens in Takotsubo cardiomyopathy?
* there is **_sudden weakening_** of the heart muscle after a **_significant stressor_**
* also known as ***"broken heart syndrome"***
67
What is constrictive pericarditis?
* **chronic _inflammation_ of the pericardium** with **_thickening_** and **_scarring_**
* the pericardium is the **outer sheath** that acts to protect the heart
* when it is damaged, it becomes **_less compliant_**, meaning the heart is **less able to fill with blood** and **maintain CO**
68
What are the causes of constrictive pericarditis?
* idiopathic
* infectious - TB, bacterial and viral
* **acute pericarditis**
* cardiac surgery & radiation
69
What are the signs and symptoms of constrictive pericarditis?
* they are similar to **restrictive cardiomyopathy**
* the difference is which layer of the heart is being affected
* **_RHF presentation_** with **raised JVP** and **oedema**
* **_Kussmaul's sign_** present
70
What investigations are performed in constrictive pericarditis and what do they show?
* **CXR** shows **_pericardial calcification_**
* this is not very specific as other heart diseases can cause calcification
* **Echo** shows **_increased pericardial thickness_**
* this can differentiate it from restrictive cardiomyopathy
* cardiac CT / MRI
71
What is the difference in the way in which restrictive cardiomyopathy and constrictive pericarditis can be "cured"?
* restrictive cardiomyopathy does not have a cure
* constrictive pericarditis can be cured via surgical removal of the pericardium in a **pericardectomy**
72
What is myocarditis?
What can cause this?
* it is **_inflammation of the myocardium_**
* sometimes called inflammatory cardiomyopathy
* it can affect the electrical conduction system, leading to **arrhythmias**
***_Causes:_***
* infections
* **__****_Coxsackie B virus_** is the most common cause in Europe
* if this infection becomes severe, it can lead to **dilated cardiomyopathy**
* drugs - especially **cocaine**
* metals
* radiation
73
What are the signs and symptoms associated with myocarditis?
* **flu-like prodrome**
* relevant as a virus is the most likely cause
* **_chest pain_** that is worse when lying down
* **shortness of breath**
* **palpitations**
74
What investigations are performed in myocarditis and what might these show?
***_ECG:_***
* this shows **non-specific ST** and **T wave changes**
***_Cardiac biomarkers:_***
* **creatinine kinase** and **troponin**
* these are measured to ensure it is the myocardium that is diseased and **_not the pericardium_**
* CK and troponin will NOT be raised in pericarditis
***_Endomyocardial biopsy:_***
* this is diagnostic but not routinely performed
* only really performed when suspected myocarditis is not responsive to treatment
75
B - arrhythmia
* this is a classic example of **_hypertrophic cardiomyopathy_**, which causes **obstructed blood flow** from the heart
* in HOCM with obstructed blood flow, there is usually some sort of **warning symptoms**
* e.g. breathlessness on exertion / fainting
* **_arrhythmia is the most common reason for death_** from HOCM as the thick muscle does not conduct electricity as well
* the heart will start beating abnormally and then suddenly stop
76
E - chest pain
this is an acute presentation with chest pain that is worse when lying down
77
A - Echo
* if a patient has **features of RHF** and **Kussmaul's sign**, this could be either **_restrictive cardiomyopathy_** or **_constrictive pericarditis_**
* the only way to tell the difference between these conditions is with Echo
78
