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Yr 4 - CCC > Cardiology: Heart Failure > Flashcards

Cardiology: Heart Failure Flashcards

1
Q

What does chronic heart failure refer to?

A

Refers to the clinical features of impaired heart function, specifically the function of the left ventricle to pump blood out of the heart and around the body.

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2
Q

What does impairmed LV function result in?

A

1) Results in a chronic backlog of blood waiting to flow into and through the left side of the heart (has just been oxygenated by the lungs).

2) The left atrium, pulmonary veins and lungs experience an increased volume and pressure of blood.

3) They start to leak fluid and cannot reabsorb excess fluid from the surrounding tissues, resulting in pulmonary oedema.

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3
Q

Define ejection fraction

A

The ejection fraction is the percentage of blood in the left ventricle squeezed out with each ventricular contraction.

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4
Q

What ejection fraction is considered normal?

A

An ejection fraction above 50% is considered normal.

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5
Q

Define a reduced ejection fraction

A

When the ejection fraction is less than 50%.

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6
Q

Define heart failure with preserved ejection fraction

A

When someone has the clinical features of heart failure but an ejection fraction greater than 50%.

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7
Q

What is HF with preserved ejection fraction a result of?

A

This is the result of diastolic dysfunction, where there is an issue with the left ventricle FILLING with blood during diastole (the ventricle relaxing).

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8
Q

Causes of chronic HF?

A

1) IHD
2) Valvular heart disease (commonly aortic stenosis)
3) HTN
4) Arrhythmias (commonly AF)
5) Cardiomyopathy

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9
Q

What type of valve defect typically causes chronic HF?

A

Aortic stenosis

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10
Q

What type of arrhythmia typically causes chronic HF?

A

AF

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11
Q

Key symptoms of chronic HF?

A
  • SOB (worsened by exertion)
  • Cough (may produce frothy white/pink sputum)
  • Orthopnoea (ask about pillows)
  • Paroxysmal nocturnal dyspnoea
  • Peripheral oedema
  • Fatigue
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12
Q

What may a cough produce in chronic HF?

A

frothy white/pink sputum

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13
Q

What is orthopnoea?

A

breathlessness when lying flat, relieved by sitting or standing

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14
Q

Signs on examination in chronic HF?

A

1) Tachycardia

2) Tachypnoea

3) HTN

4) Murmurs on auscultation (indicating valvular heart disease)

5) 3rd heart sound on auscultation

6) Bilateral basal crackles (sounding “wet”) on auscultation of the lungs, indicating pulmonary oedema

7) Raised JVP

8) Peripheral oedema of the ankles, legs and sacrum

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15
Q

Auscultation of lung findings in chronic HF?

A

Bilateral basal crackles (sounding ‘wet’)

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16
Q

Cause of bilateral basal crackles in chronic HF?

A

pulmonary oedema

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17
Q

Cause of raised JVP in chronic HF?

A

caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck

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18
Q

What is paroxysmal nocturnal dyspnoea (PND)?

A

Describes the experience that patients have of suddenly waking at night with a severe attack of shortness of breath, cough and wheeze.

They may describe having to sit on the side of the bed or walk around the room, gasping for breath.

They may feel suffocated and want to open a window to get fresh air. Symptoms improve over several minutes.

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19
Q

What is required for establishing a diagnosis of chronic HF?

A

1) Clinical assessment (history and exam)

2) N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test

3) ECG

4) Echocardiogram

Other investigations:
1) Bloods for anaemia, renal function, thyroid function, liver function, lipids and diabetes

2) Chest x-ray and lung function tests to exclude lung pathology

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20
Q

1st line investigation in HF?

A

NT-proBNP

(N.B. BNP and NT-proBNP can be used in HF diagnosis)

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21
Q

Example BNP/NTproBNP results:

A

Normal:
a) BNP: <100
b) NT-proBNP: <400

Raised:
a) BNP: 100-400
b) NT-proBNP: 400-2000

High:
a) BNP: >400
b) NT-proBNP: >2000

‘High’ –> arrange specialist assessment (including transthoracic echocardiography) within 2 weeks

‘Raised’ –> arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks

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22
Q

What is BNP?

A

B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain.

Very high levels are associated with a poor prognosis.

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23
Q

What factors increase BNP levels?

A

1) Left ventricular hypertrophy

Ischaemia

2) Tachycardia

3) Right ventricular overload

4) Hypoxaemia (including pulmonary embolism)

5) GFR < 60 ml/min

6) Sepsis

7) COPD

8) Diabetes

9) Age > 70

10) Liver cirrhosis

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24
Q

What factors decrease BNP levels?

A

1) Obesity
2) Diuretics
3) ACE inhibitors
4) Beta-blockers
5) Angiotensin 2 receptor blockers
6) Aldosterone antagonists

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25
Q

What classification system is used to grade the severity of symptoms related to heart failure?

A

New York Heart Association (NYHA)

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26
Q

Describe class I of the NYHA

A

a) no symptoms
b) no limitation on activity

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27
Q

Describe class II of the NYHA

A

Comfortable at rest but symptomatic with ordinary activities

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28
Q

Describe class III of the NYHA

A

Comfortable at rest but symptomatic with any activity

Marked limitation of physical activity

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29
Q

Describe class IV of the NYHA

A

severe symptoms

unable to carry out any physical activity without discomfort

symptomatic at rest

30
Q

The urgency of the referral and specialist assessment depends on the NT-proBNP result.

What result should be seen and have an echocardiogram within 2 weeks?

A

Above 2000 ng/litre

31
Q

Additional management steps in HF?

A
  • Annual influenza vaccine
  • One off pneumococcal vaccine
  • COVID vaccine
  • Stop smoking
  • Optimise treatment of co-morbidities
  • Written care plan
  • Cardiac rehabilitation (a personalised exercise programme)
32
Q

1st line medical management of chronic HF?

A

1) ACEi (as high as tolerated)
+
2) Beta blocker (as high as tolerated)
+
3) Loop diuretic e.g. furosemide or bumetanide

33
Q

What 3 beta-blockers are licensed to treat heart failure in the UK?

A

1) bisoprolol
2) carvedilol
3) nebivolol

34
Q

What can be added in the management of chronic HF if symptoms are not controlled with ACEi and beta blocker?

A

Aldosterone antagonist e.g. spironolactone or eplerenone

35
Q

What should be monitored in patients taking ACEi and aldosterone antagonists?

A

Both can cause hyperkalaemia

36
Q

What can be used in the management of chronic HF if ACEi are not tolerated?

A

An angiotensin receptor blocker (ARB) (e.g., candesartan)

37
Q

Who should ACEi be avoided in?

A

Avoid ACE inhibitors in patients with valvular heart disease until initiated by a specialist.

38
Q

When are aldosterone antagonists used in chronic HF?

A

Aldosterone antagonists are used when there is a reduced ejection fraction and symptoms are not controlled with an ACEi and beta blocker.

39
Q

Additional specialist treatments in patients with heart failure?

A
  • SGLT2 inhibitor (e.g., dapagliflozin)
  • Sacubitril with valsartan (brand name Entresto)
  • Ivabradine
  • Hydralazine with a nitrate
  • Digoxin
40
Q

What surgical procedure may be done in severe HF?

A

1) Cardiac resynchronisation therapy (CRT)

2) Heart transplant

41
Q

At what EF is CRT considered?

A

<35%

42
Q

What does Cardiac resynchronisation therapy (CRT) involve?

A

CRT involves biventricular (triple chamber) pacemakers, with leads in the right atrium, right ventricle and left ventricle.

The objective is to synchronise the contractions in these chambers to optimise heart function.

43
Q

What is acute LV failure?

A

Acute left ventricular failure 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.

44
Q

Define cardiac output

A

the volume of blood ejected by the heart per minute.

Cardiac output = stroke volume x HR

45
Q

Define stroke volume

A

Stroke volume is the volume of blood ejected during each beat.

46
Q

What is pulmonary oedema?

A

Pulmonary oedema is where the lung tissue and alveoli are filled with interstitial fluid.

This interferes with normal gas exchange in the lungs, causing shortness of breath and reduced oxygen saturation.

47
Q

What is acute LV failure often the result of?

A

decompensated chronic heart failure.

48
Q

Give some triggers for acute LV failure

A

1) Iatrogenic (e.g., aggressive IV fluids in a frail elderly patient with impaired left ventricular function)

2) Myocardial infarction

3) Arrhythmias

4) Sepsis

5) Hypertensive emergency (acute, severe increase in blood pressure)

49
Q

What should you consider in frail patients presenting with breathlessness and desaturation in the hospital setting?

A

Ask yourself how much fluid that patient has been given and whether they will be able to cope with that amount.

Example: an 85 year old patient with CKD and aortic stenosis is prescribed 2 litres of fluid over 4 hours and then starts to drop her oxygen saturation.

Give a dose of IV furosemide

50
Q

Management of fluid overloaded patients?

A

IV furosemide

51
Q

Presentation of acute LVF?

A

1) Acute SOB (exacerbated by lying flat and improves on sitting up)

2) Looking and feeling unwell

3) Cough with frothy white or pink sputum

52
Q

What type of resp failure does acute LVF cause?

A

Type 1 (low O2 without raised CO2)

53
Q

Exam signs in acute LVF?

A

1) Raised respiratory rate
2) Reduced oxygen saturations
3) Tachycardia
4) 3rd heart sound
5) Bilateral basal crackles (sounding “wet”) on auscultation of the lungs
6) Hypotension in severe cases (cardiogenic shock)

There may also be signs and symptoms related to the underlying cause, for example:
- Chest pain in acute coronary syndrome
- Fever in sepsis
- Palpitations with arrhythmias

54
Q

If patients with acute LVF also have right sided heart failure, what signs may you see?

A

1) Raised JVP

2) Peripheral oedema (ankles, legs, sacrum)

55
Q

Investigations in acute LVF?

A

1) Clinical assessment (history and examination, starting with an ABCDE approach in any acutely unwell patient)

2) ECG to look for ischaemia and arrhythmias

3) Bloods for anaemia, infection, kidney function, BNP, and consider troponin if suspecting myocardial infarction

4) Arterial blood gas (ABG)

5) Chest x-ray

6) Echocardiogram

56
Q

What is BNP?

A

B-type natriuretic peptide (BNP) is a hormone released from the heart ventricles when the cardiac muscle (myocardium) is stretched beyond the normal range

57
Q

What does a raised BNP indicate?

A

A raised BNP blood result indicates the heart is overloaded beyond its normal capacity to pump effectively.

58
Q

Action of BNP?

A

1) Relax the smooth muscle in blood vessels

2) This reduces systemic vascular resistance, making it easier for the heart to pump blood through the system.

3) BNP also acts on the kidneys as a diuretic to promote water excretion in the urine - reduces the circulating volume, helping to improve the function of the heart in someone that is fluid-overloaded.

59
Q

Is BNP sensitive or specific?

A

Sensitive (but not specific)

60
Q

Causes of raised BNP?

A

Tachycardia
Sepsis
Pulmonary embolism
Renal impairment
COPD

61
Q

Purpose of an echo in acute LVF?

A

Echocardiography is helpful in assessing the function of the left ventricle and any structural abnormalities in the heart

62
Q

What is a key measure of LV function?

A

Ejection fraction

63
Q

What defines cardiomegaly on a CXR?

A

Classified as a cardiothoracic ratio of more than 0.5

I.e. when the diameter of the widest part of the heart (the widest part of the cardiac silhouette) is more than half the diameter of the widest part of the lung fields.

64
Q

CXR findings in acute LVF?

A

1) Cardiomegaly

2) Upper lobe venous diversion

Fluid leaking from oedematous lung tissue can cause:
1) Bilateral pleural effusions
2) Fluid in interlobar fissures (between the lung lobes)
3) Fluid in the septal lines (Kerley lines)

65
Q

What is upper lobe venous diversion?

A

1) Usually, when standing erect, the lower lobe veins contain more blood, and the upper lobe veins remain relatively small.

2) In acute LVF, there is such a back-pressure that the upper lobe veins also fill with blood and become engorged. This is referred to as upper lobe diversion.

3) This is visible as increased prominence and diameter of the upper lobe vessels on a chest x-ray.

66
Q

How does upper lobe venous diversion present on a CXR?

A

increased prominence and diameter of the upper lobe vessels on a chest x-ray.

67
Q

Management of patients with acute LVF?

Mneumonic: SODIUM

A

Hospital admission

S - Sit up
O - Oxygen (sats <95%)
D - Diuretic e.g. IV furosemide
I - IV fluids should be STOPPED
U - Underlying causes need to be identified and treated (e.g., myocardial infarction)
M - Monitor fluid balance

68
Q

What does fluid balance monitoring involve?

A

monitoring the fluid intake (oral and IV), urine output, U&Es and body weight.

69
Q

What are ionotropes?

A

Inotropes are medications that alter the contractility of the heart

Positive ionotropes –> act to increase contractility (increases cardiac output and mean arterial pressure)

70
Q

Who are positive ionotropes used in?

A

They are used in patients with a low cardiac output, for example, due to acute heart failure, recent myocardial infarction or following heart surgery.

71
Q

What are vasopressors?

A

Vasopressors are medications that cause vasoconstriction (narrowing of blood vessels).

This increases the systemic vascular resistance and, consequently, mean arterial pressure (MAP).

72
Q
A

Yr 4 - CCC (53 decks)

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