Cardiology - Heart Failure Flashcards
How can Heart Failure be classified by ejection fraction?
Patients with heart failure have have a normal or abnormal left ventricular ejection fraction (LVEF) as measured by echocardiography.
Heart failure with reduced ejection fraction is typically defined as having a LVEF of less <35 to 40%.
Above this is defined as heart failure with preserved ejection fraction.
How can heart failure be defined using systole and diastole and how does this overlap with ejection fraction.
Systole - Impaired myocardial contraction.
Normally this is the same as HF-rEF.
Diastole - impaired ventricular filling.
Normally the same as HF - pEF.
Give examples of systolic heart failure causes
Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
arrhythmias
Give examples of causes of diastolic heart failure
Hypertrophic obstructive cardiomyopathy
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive Pericarditis.
Give some causes of high output heart failure
- Anaemia
- Arteriovenous malformation (haemangioma?)
- Thyrotoxicosis
- Pregnancy
- Pagets Disease
- Paget’s disease is associated with rapid bone formation and resorption that can lead to increased blood flow within bone and the surrounding limb tissue
- Thiamine deficiency.
- (Wet beriberi causes right-sided heart failure and pulmonary hypertension with high cardiac output due to vasodilation. The vasodilation of wet beriberi is caused by adenosine production and opening of the arteriovenous shunt in the arterioles of the somatic musculature.)
A 68 year old man has been suffering from frequent cough: which is worse at night and associated with pink/frothy sputum.
In the day time he is comfortable at rest, but gets ‘puffed’ when gets up to get a snack from the fridge.
He is investigated and found to have chronic heart failure secondary to aortic stenosis. What New York Heart Association (NYHA) classification of heart failure does this man fall under?
Class III
YHA Class I
- no symptoms
- no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
NYHA Class II
- mild symptoms
- slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
NYHA Class III
- moderate symptoms
- marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
NYHA Class IV
- severe symptoms
- unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
Patient with a history of MI presents with:
- dyspnoea
- cough: may be worse at night and associated with
- orthopnoea
- paroxysmal nocturnal dyspnoea
- bibasal crackles on examination
- signs of right-sided heart failure: raised JVP, ankle oedema and hepatomegaly
You examine and perform a blood test mesuring N-terminal pro-B-type natriuretic peptide (NT‑proBNP).
The levels are reported as 850.
How should this patient be followed up.
Seen by a HF specialist and have transthoracic echocardiography within 6 weeks:
Explanation:
- N-terminal pro-B-type natriuretic peptide (NT‑proBNP)
- High levels = > 2000 pg/ml (236 pmol/litre)
- Raised levels - 400-2000 pg/ml (47-236 pmol/litre)
- Normal levels < 400 pg/ml (47 pmol/litre)
- Patients with a High NT-proBNP should be seen by a specialist and have Transthoracic echocardiography within 2 weeks
- Patients with raised levels should be seen within 6 weeks.
Other investigations to perform include:
- ECG
- chest X-ray
- blood tests:
- renal function profile
- thyroid function profile
- liver function profile
- lipid profile
- glycosylated haemoglobin (HbA1c)
- full blood count
- urinalysis
- peak flow or spirometry.
A patient with chronic heart failure and an ejection fraction <40 is currently taking carvedilol 25mg BD and Ramipril 5mg BD but is still symptomatic with SOB and ankle oedema. What drug would you start them on next? What would you want to monitor?
Spironolactone 25-50mg OD
OR
Eplerenone 50mg (start at 25mg and titrate up over 4 weeks)
Monitor potassium as ACEi and Mineralocorticoid receptor antagonists can cause hyperkalaemia
Explanation
- The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
- generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first
- beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.
- ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction
- Second-line treatment is an aldosterone antagonist
- these are sometimes referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and eplerenone
- it should be remembered that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored
Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
Other treatments
offer annual influenza vaccine
offer one-off pneumococcal vaccine
A patient with heart failure is started on sacubitril-valsartan, what drugs should be stopped with a washout period prior?
ACEi or ARB
What are the conditions required to be eligible for treatment with ivabradine?
criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%
A patient with a background of chronic heart failuire presents with SOB.
On examination they have bibasal crackles and reduced air entry bibasally.
Their SATS are 89% on room air.
HR 109
BP 120/80
A chest xray shows – bilateral pulmonary venous congestion, interstitial oedema and cardiomegaly
What would be the 5 step management for this condition?
High flow oxygen
IV Furesemide
IV nitrates
Morphine
CPAP
