Cardiology - Heart Failure Flashcards
What are the causes of heart failure?
- ischaemic heart disease (most common)
- hypertension
- valvular heart disease
- atrial fibrillation
- HIV
Presentation of chronic heart failure.
- breathlessness worsened by exertion
- cough (frothy white / pink sputum)
- orthopnoea
- paroxysmal nocturnal dyspnoea
- peripheral oedema
What is paroxysmal nocturnal dyspnoea?
The experience that patients have of suddenly waking at night with a severe attack of shortness of breath and cough.
What are the mechanisms behind which paroxysmal nocturnal dyspnoea arises?
- As patient’s sleep lying flat, fluid settles across a large surface area of their lungs.
- During sleep, the respiratory centre is less responsive, meaning respiratory rate and effort lessens. This allows the patient to develop more significant pulmonary congestion and hypoxia before waking up and feeling very unwell.
- During sleep, circulating adrenaline lessens, meaning the myocardium is more relaxed and cardiac output worsens.
How should heart failure be investigated?
- U&Es (renal function, baseline and diuretic effect)
- FBC (anaemia)
- LFTs (commencing ACEi or ARB)
- TFTs
- ferritin and transferrin
- NT-proBNP
- CXR
- echocardiogram
What are the xray findings consistent with heart failure?
- cardiomegaly
- ?pleural effusions
- perihilar shadowing / consolidation
- alveolar oedema
- air bronchograms
- increased with of vascular pedicle
What are the echocardiogram findings consistent with heart failure?
- dilated poorly contracting left ventricle (systolic dysfunction)
- stiff, poorly relaxing left ventricle (diastolic dysfunction)
- valvular heart disease
- atrial myxoma
- pericardial disease
What lifestyle modifications should be advised to a patient with heart failure?
- smoking cessation
- alcohol restriction
- salt restriction
- fluid restriction
- yearly flu and pneumococcal vaccine
What is the first line medical treatment of chronic heart failure?
ABAL:
- ACE inhibitor (ramipril) (or ARB if not tolerated)
- Beta-blocker (bisoprolol)
- Aldosterone antagonist (spironolactone) (if not controlled with A and B)
- Loop diuretics (furosemide) (sx improvement)
Patient’s should have their U&Es monitored closely whilst on diuretics, ACEi and aldosterone antagonists, as these classes of medication may cause electrolyte disturbances.
What is left bundle branch block (LBBB)?
A conduction delay within the left bundle that means impulses travel first through the right bundle branch to the RV, and then to the LV via the septum.
What ECG changes are consistent with LBBB?
Lateral leads (I, aVL, V5, V6):
- absent Q wave
- prolonged QRS
- “M shaped”, notched or monophasic R waves
- RS complex (small R wave, deep S wave)
V1:
- RS complex (small R wave, deep S wave)
- QS complex (deep Q/S wave, no preceding R wave
What complex device therapy is available for heart failure?
- cardiac resynchronisation pacemaker (CRT) if LBBB
- implantable cardiac defibrillators (ICDs*)
*Primary or secondary prevention of cardiac arrest.
What is acute left ventricular failure?
Occurs when the left ventricle is unable to adequately move blood through the left side of the heart, causing a backlog of blood in the left atrium, pulmonary veins and lungs.
As vessels are engorged with blood, hydrostatic pressure increases an this can lead to pulmonary oedema. This interferes with normal gas exchange in the lungs, causing oxygen desaturation.
What are the triggers for acute left ventricular failure?
- iatrogenic (e.g. aggressive IV fluids)
- sepsis
- myocardial infarction
- arrhythmias
Presentation of acute LVF.
- rapid onset breathlessness
- worsened by lying flat
- improves on sitting up
- cough (frothy white / pink sputum)
